A 46-year-old woman comes to the office for follow-up of rheumatoid arthritis. The patient was diagnosed 2 years ago and started on treatment with prednisone and methotrexate; she had a good initial response to treatment, and the oral glucocorticoid was gradually tapered. However, her symptoms have progressively worsened over the last several months, despite increases in the methotrexate dose. The patient continues to have hand stiffness and pain lasting 2-3 hours every morning and increasing knee and ankle pain. She takes frequent doses of acetaminophen and ibuprofen but her symptoms still significantly restrict her daily activities. Medical history is otherwise unremarkable. The patient does not use tobacco, alcohol, or illicit drugs. Physical examination shows symmetric swelling and tenderness of the proximal small hand joints, wrists, and knees. Blood cell count shows mild normochromic, normocytic anemia with normal leukocyte and platelet counts. Erythrocyte sedimentation rate is 55 mm/hr. Hand x-ray reveals periarticular osteopenia and mild joint erosions.
After discussion of treatment options, tumor necrosis factor inhibitor therapy is planned. Which of the following tests is most appropriate prior to beginning the treatment?

Question

A 46-year-old woman comes to the office for follow-up of rheumatoid arthritis.  The patient was diagnosed 2 years ago and started on treatment with prednisone and methotrexate; she had a good initial response to treatment, and the oral glucocorticoid was gradually tapered.  However, her symptoms have progressively worsened over the last several months, despite increases in the methotrexate dose.  The patient continues to have hand stiffness and pain lasting 2-3 hours every morning and increasing knee and ankle pain.  She takes frequent doses of acetaminophen and ibuprofen but her symptoms still significantly restrict her daily activities.  Medical history is otherwise unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.  Physical examination shows symmetric swelling and tenderness of the proximal small hand joints, wrists, and knees.  Blood cell count shows mild normochromic, normocytic anemia with normal leukocyte and platelet counts.  Erythrocyte sedimentation rate is 55 mm/hr.  Hand x-ray reveals periarticular osteopenia and mild joint erosions. 
After discussion of treatment options, tumor necrosis factor inhibitor therapy is planned.  Which of the following tests is most appropriate prior to beginning the treatment?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0c1_815d_8f63_83d0cf5446ec_MD0005_00 The primary treatment goals in rheumatoid arthritis are to control the acute synovitis and to slow or stop the chronic progression of joint destruction. A number of disease-modifying antirheumatic drugs have been shown to slow progression of the disease, but no single treatment regimen is ideal for every patient. The choice of therapy depends on individual patient factors and potential toxicity of the different drugs. Methotrexate is commonly chosen for initial therapy and can be combined with a limited course of oral glucocorticoids (eg, prednisone) for rapid symptom relief. For patients who have persistent or recurrent symptoms despite methotrexate therapy, large-molecule anticytokine agents ("biologics") are often considered. However these agents, primarily tumor necrosis factor (TNF) inhibitors (eg, infliximab, etanercept), are associated with an increased risk for opportunistic infections, especially reactivation of tuberculosis. Therefore, patients should be screened for latent tuberculosis with a tuberculin (purified protein derivative) skin test or interferon-gamma release assay prior to treatment. (Choice A) Long-term glucocorticoid therapy is associated with accelerated bone loss. Although this patient's initial treatment with systemic glucocorticoids may warrant DXA screening, this is not needed prior to initiating TNF inhibitor therapy. (Choice B) TNF inhibitors have been reported to cause worsening of heart failure and are relatively contraindicated in patients who have symptomatic heart failure at baseline. However, there is no clear evidence for increased risk of incident heart failure, and pretreatment echocardiography is not needed. (Choice D) High rheumatoid factor titers are associated with more aggressive disease and greater risk for extra-articular manifestations (eg, pulmonary disease). However, titers do not reliably correlate with disease activity and are not needed to determine choice of therapy. (Choice E) Elevated serum immunoglobulin levels can be due to monoclonal (eg, multiple myeloma) or polyclonal immune activation. Polyclonal hypergammaglobulinemia is common in rheumatoid arthritis, but serum immunoglobulins are not assayed routinely in management. Educational objective: Tumor necrosis factor inhibitors are large-molecule antirheumatic agents that are commonly used in patients with rheumatoid arthritis who fail first-line therapy. However, they are associated with increased risk for opportunistic infections, including reactivation of latent tuberculosis. Patients should be screened with a tuberculin skin test or interferon-gamma release assay prior to treatment. References: The risk of tuberculosis in patients with rheumatoid arthritis treated with tumor necrosis factor-a antagonist: a metaanalysis of both randomized controlled trials and registry/cohort studies. (http://www.ncbi.nlm.nih.gov/pubmed/26472414)

A 46-Year-Old Woman Comes to the Office for Follow-Up of Rheumatoid