A 56-year-old woman comes to the office with her daughter to discuss knee pain, which has been ongoing for several years. The patient has a high tolerance for pain and has previously refused to see a doctor for her condition. Lately, the pain has been affecting the patient's daily activities, and she spends most of the day sitting in a chair. The knee pain and stiffness are more pronounced on the right side and are worse in the morning but gradually improve by the afternoon. She takes no medications. Review of systems is positive for fatigue. Vital signs are within normal limits. BMI is 31 kg/m². Lower extremity examination shows that both knees are swollen and tender but more so on the right side. The patient is unable to fully flex or extend the right knee. There is mild, bilateral atrophy of the quadriceps. Radiographs of the knees reveal osteopenia of the distal femur, multiple periarticular erosions, and soft tissue swelling. Which of the following is the best long-term management for the most likely diagnosis in this patient?

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11ec25c8_d13d_fc26_bc81_49a74771dcfa_MD0003_00 The 2 most prevalent forms of arthritis are osteoarthritis (OA) and rheumatoid arthritis (RA), and individuals may have both conditions concurrently. OA is much more common and characteristically involves the knees, hips, and distal finger joints. RA, an inflammatory arthritis, typically involves the metacarpophalangeal, proximal interphalangeal, and wrist joints. However, any joint may be affected. This patient has multiple clinical and radiographic features suggestive of RA: Her prolonged morning stiffness, systemic symptoms (ie, fatigue), and soft tissue swelling involving multiple joints are more consistent with RA than OA; she also has X-ray findings that favor a diagnosis of RA over OA, including periarticular erosions (seen here on hand x-rays), distal osteopenia, and soft tissue swelling. periarticular erosions Additional evaluation of patients with suspected RA should include inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), which are typically elevated in RA but normal in OA. Cyclic citrullinated peptide antibodies are present in most patients with RA and can help confirm the diagnosis; rheumatoid factor should also be tested but has lower specificity. Initial management of RA includes nonsteroidal anti-inflammatory drugs and systemic glucocorticoids (eg, prednisone) to acutely reduce pain; however, these interventions do not alter the long-term prognosis and are inadequate for definitive therapy (Choice C). As soon as possible after the diagnosis is made, disease-modifying antirheumatic drugs (DMARDs) should be initiated to slow disease progression; first-line options include methotrexate, a folate antimetabolite that is cost-effective and well tolerated by most patients. Alternate options include sulfasalazine, leflunomide, and hydroxychloroquine. (Choice B) Nonpharmacologic interventions for OA include regular exercise and weight loss; knee braces may reduce pain in some patients but are unlikely to alter the long-term course of the condition. However, none of these interventions are adequate treatment for RA. (Choice D) Total knee arthroplasty is most commonly performed for patients with advanced OA. It is occasionally needed for patients with severe deformity due to RA, but early initiation of DMARD therapy may eliminate the need for later joint replacement. (Choice E) Urate-lowering therapy is indicated for long-term treatment of gout. Gout commonly affects the knee but typically causes episodic symptoms with brief but severe inflammatory changes (eg, redness, warmth, swelling). X-rays in early gout are generally normal, although chronic findings include punched-out erosions with an overhanging rim of cortical bone ("rat bite" lesion). punched-out erosions Educational objective: Clinical findings that favor the diagnosis of rheumatoid arthritis (RA) over osteoarthritis include prolonged morning stiffness, systemic symptoms, and soft tissue swelling. Other characteristic findings in RA include periarticular erosions on x-ray, elevated inflammatory markers, and positive cyclic citrullinated peptide antibodies or rheumatoid factor. Disease-modifying antirheumatic drugs (eg, methotrexate) slow disease progression and should be initiated on diagnosis. References: Early diagnosis and treatment of rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/29759122) Conventional radiology in rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/28774455)

A 56-Year-Old Woman Comes to the Office with Her Daughter