A 45-Year-Old Woman Comes to the Office Due to Progressive

A 45-year-old woman comes to the office due to progressive stiffness, pain, and swelling of the joints in the hands and wrists for the past 3 months.  The symptoms are worse when she wakes up and gradually improve after several hours.  The patient also feels fatigued but has had no skin rashes, oral lesions, or fever.  She recently began taking chlorthalidone for hypertension and takes no other medications.  She works in a daycare center.  The patient drinks alcohol occasionally and does not use tobacco or illicit drugs.  Her mother had "arthritis" in her older age, and her sister has systemic lupus erythematosus.  Temperature and other vital signs are within normal limits.  Physical examination shows warmth, swelling, and tenderness of the second and third proximal interphalangeal joints, the metacarpophalangeal joints, and the wrists of both hands.  The remainder of the examination shows no abnormalities. A week later, the patient returns to the office and says that her symptoms have improved with the prescribed treatment.  Laboratory results are as follows:
Hand x-rays reveal mild periarticular osteopenia and early erosions of the proximal interphalangeal and metacarpophalangeal joints.  Which of the following is the most appropriate next step in management of this patient?

A) Add low-dose oral glucocorticoid
B) Continue nonsteroidal anti-inflammatory drug only
C) Initiate methotrexate
D) No additional intervention necessary
E) Tumor necrosis factor inhibitor therapy