A 37-year-old woman comes to the physician with pain in her hand joints lasting several months. She feels she is clumsy in the morning because her hands are stiff and tender. Four weeks ago the patient was treated for knee pain and swelling with naproxen. Her past medical history is otherwise unremarkable.
Joint examination shows warmth, swelling, and tenderness in the proximal interphalangeal and metacarpophalangeal joints and both wrists. X-rays show periarticular osteopenia and erosions of the proximal interphalangeal and metacarpophalangeal joints.
Laboratory results are as follows:

The patient is treated with nonsteroidal anti-inflammatory therapy with significant symptomatic relief.
Which of the following is the most appropriate next step in management of this patient?

Question

A 37-year-old woman comes to the physician with pain in her hand joints lasting several months.  She feels she is clumsy in the morning because her hands are stiff and tender.  Four weeks ago the patient was treated for knee pain and swelling with naproxen.  Her past medical history is otherwise unremarkable.
Joint examination shows warmth, swelling, and tenderness in the proximal interphalangeal and metacarpophalangeal joints and both wrists.  X-rays show periarticular osteopenia and erosions of the proximal interphalangeal and metacarpophalangeal joints.
Laboratory results are as follows:

The patient is treated with nonsteroidal anti-inflammatory therapy with significant symptomatic relief.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has moderate rheumatoid arthritis (RA). Moderate or severe RA usually includes a combination of the following factors, as seen in this patient:5 Inflamed jointsElevated inflammatory markersPositive rheumatoid factor or anticyclic citrullinated peptide antibodiesEvidence of joint inflammation on plain radiography5 Inflamed joints Elevated inflammatory markers Positive rheumatoid factor or anticyclic citrullinated peptide antibodies Evidence of joint inflammation on plain radiography Generally less potent, nonbiologic agents, such as sulfasalazine and hydroxychloroquine, are used for mild disease, whereas methotrexate alone or in combination with other disease-modifying antirheumatic drugs (DMARDs) is used for patients with moderate to severe disease. Once moderate to severe disease has been identified, DMARD therapy should be initiated as soon as possible to avoid disease progression and irreversible joint destruction, which frequently occur in the early stages. (Choice A) Tumor necrosis factor (TNF) inhibitors, such as etanercept, are DMARDs commonly used in patients who are unable to tolerate methotrexate or used in combination with methotrexate in patients who do not improve sufficiently on methotrexate alone. (Choice B) Nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids may be used as adjuncts to therapy to more rapidly reduce pain and inflammation but should not be used without DMARD therapy as they do not halt disease progression. (Choice D) Rituximab therapy has been used in patients resistant to usual DMARD therapy (methotrexate alone or in combination with a TNF inhibitor). It has been shown to be effective when other therapies fail, but it would not be a first-line therapy. (Choice E) Sulfasalazine and hydroxychloroquine are DMARDs that are used in patients with mild disease or combined with methotrexate in patients with highly active disease, but these are not used alone in patients with moderate or severe disease. Educational objective: Patients with rheumatoid arthritis should be started on disease-modifying antirheumatic drugs as soon as possible. Hydroxychloroquine and sulfasalazine are options for mild disease, and methotrexate is commonly the initial drug of choice for moderate and severe disease. __________ References: Rheumatoid arthritis-early diagnosis and disease management. (http://www.ncbi.nlm.nih.gov/pubmed/23964304) My treatment approach to rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/22766086)

A 37-Year-Old Woman Comes to the Physician with Pain in Her