A 48-year-old woman comes to the physician because of pain in her hands for the last 6 months. She also has joint stiffness every morning that lasts several hours. The patient has no weight loss, fever, chest pain, or back pain. Examination of her joints shows mild swelling and tenderness of several proximal interphalangeal joints, metacarpophalangeal joints, and both wrists. There are no skin rashes or mucosal lesions. No lymph nodes are palpable.
Laboratory results are as follows:

X-ray of the hands reveals periarticular osteopenia and mild erosions of the proximal interphalangeal and metacarpophalangeal joints. She is started on naproxen and returns for follow-up 2 weeks later with marked improvement in her symptoms.
Which of the following is the best next step in the management of this patient?

Question

A 48-year-old woman comes to the physician because of pain in her hands for the last 6 months.  She also has joint stiffness every morning that lasts several hours.  The patient has no weight loss, fever, chest pain, or back pain.  Examination of her joints shows mild swelling and tenderness of several proximal interphalangeal joints, metacarpophalangeal joints, and both wrists.  There are no skin rashes or mucosal lesions.  No lymph nodes are palpable.
Laboratory results are as follows:

X-ray of the hands reveals periarticular osteopenia and mild erosions of the proximal interphalangeal and metacarpophalangeal joints.  She is started on naproxen and returns for follow-up 2 weeks later with marked improvement in her symptoms.
Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec193a_9939_4ec7_853d_afe821aa6fd2_MD0002_00 This patient has characteristic features of rheumatoid arthritis (RA): synovitis, evidence of systemic inflammation, and chronic, symmetric polyarticular joint pain and stiffness. Although rheumatoid factor is typically positive in RA, many patients have rheumatoid factor-negative ("seronegative") RA and generally have a somewhat less aggressive course. Other inflammatory markers that are useful in the diagnosis of RA include anti-cyclic citrullinated peptide antibodies and C-reactive protein. Patients with RA can have rapid relief of symptoms with nonsteroidal anti-inflammatory drugs or glucocorticoids. However, anti-inflammatory drugs alone do not prevent the long-term synovial injury and joint destruction of RA (Choices A and E). For this reason, patients with RA should be initiated promptly on disease-modifying antirheumatic drugs (DMARDs), which reduce the long-term joint damage and functional impairment of RA. Early initiation is associated with a more effective drug response than late initiation. Typical first-line DMARDs include hydroxychloroquine, methotrexate, sulfasalazine, and leflunomide. These drugs are well-tolerated, relatively inexpensive, and generally easy to administer. (Choice B) Febuxostat is a xanthine oxidase inhibitor approved to lower uric acid in patients with gout, which is characterized by acute attacks of monoarticular arthritis, usually in the lower extremities. This patient has a chronic polyarticular arthritis that is unrelated to uric acid. (Choice C) Patients with unusually severe disease or who fail first-line therapy may benefit from large-molecule DMARDs ("biologics") such as infliximab, adalimumab, or etanercept. These often require parenteral administration. Educational objective: Many patients with rheumatoid arthritis (RA) will have rheumatoid factor-negative ("seronegative") RA and may have rapid relief of symptoms with nonsteroidal anti-inflammatory drugs or glucocorticoids. However, they should be initiated promptly on disease-modifying antirheumatic drugs to prevent long-term joint damage and functional impairment. __________ References: Rheumatoid arthritis: a clinical overview of new diagnostic and treatment approaches. (http://www.ncbi.nlm.nih.gov/pubmed/23574518) Rheumatoid arthritis - early diagnosis and disease management. (http://www.ncbi.nlm.nih.gov/pubmed/23964304)

A 48-Year-Old Woman Comes to the Physician Because of Pain