A 51-year-old woman comes to the office for a follow-up visit. The patient was initially evaluated 3 weeks ago for bilateral wrist and hand pain that had been occurring for 2 months. She was prescribed ibuprofen and now reports satisfactory improvement in the symptoms. Medical history includes obesity, hyperlipidemia, and major depressive disorder. She is postmenopausal. The patient occasionally drinks alcohol but does not use tobacco or illicit drugs. Vital signs are within normal limits. Physical examination shows decreased swelling and tenderness of bilateral wrists and metacarpophalangeal and proximal interphalangeal joints compared to 3 weeks ago. Laboratory studies show that the erythrocyte sedimentation rate is 52 mm/h, and anticitrullinated peptide antibodies are positive. Low-dose methotrexate therapy is planned. Obtaining which of the following is most appropriate prior to starting this therapy in this patient?

Question

A 51-year-old woman comes to the office for a follow-up visit.  The patient was initially evaluated 3 weeks ago for bilateral wrist and hand pain that had been occurring for 2 months.  She was prescribed ibuprofen and now reports satisfactory improvement in the symptoms.  Medical history includes obesity, hyperlipidemia, and major depressive disorder.  She is postmenopausal.  The patient occasionally drinks alcohol but does not use tobacco or illicit drugs.  Vital signs are within normal limits.  Physical examination shows decreased swelling and tenderness of bilateral wrists and metacarpophalangeal and proximal interphalangeal joints compared to 3 weeks ago.  Laboratory studies show that the erythrocyte sedimentation rate is 52 mm/h, and anticitrullinated peptide antibodies are positive.  Low-dose methotrexate therapy is planned.  Obtaining which of the following is most appropriate prior to starting this therapy in this patient?

Quizplus · Accepted Answer

11ec25c8_d521_9ef9_bc81_878ab912266c_MD0003_00 This patient has rheumatoid arthritis (RA), presenting with symmetric polyarthritis affecting the metacarpophalangeal joints, proximal interphalangeal joints, and wrists, along with elevated inflammatory markers (eg, C-reactive protein, erythrocyte sedimentation rate). The diagnosis of RA is primarily based on clinical findings, but serologic markers (eg, rheumatoid factor, cyclic citrullinated peptide antibodies) can assist in diagnosis and are associated with higher risk of extraarticular manifestations (eg, rheumatoid nodules). Patients with RA can be treated acutely with glucocorticoids (eg, prednisone) or nonsteroidal anti-inflammatory drugs (eg, ibuprofen), but these treatments provide only symptomatic relief and do not alter the long-term joint destruction of RA. For this reason, disease-modifying antirheumatic drugs (DMARDs), which do improve long-term joint function, are initiated as soon as practical after diagnosis. Methotrexate is the preferred first-line DMARD for most patients with RA. Its effects are mediated by inhibition of dihydrofolate reductase, which causes cellular folate depletion leading to impaired DNA synthesis. Methotrexate can cause significant hepatotoxicity, which can range from mild elevations in hepatic aminotransferases to chronic liver disease and cirrhosis. Serum liver studies should be checked prior to initiation of methotrexate and periodically during treatment. Patients should avoid alcohol intake. Much of the toxicity of methotrexate, including hepatotoxicity, can be mitigated by concurrent administration of folic (or folinic) acid, which does not reduce the effectiveness of the drug. (Choice A) Hydroxychloroquine is an antimalarial DMARD that is generally well tolerated. Long-term use is associated with potential retinal injury, and patients should have regular ophthalmologic evaluation while on treatment. Methotrexate is not associated with retinopathy. (Choice B) Sulfasalazine is an occasionally used DMARD that can cause hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency. This effect is not seen with methotrexate, which causes anemia via bone marrow suppression. (Choices C and E) Tumor necrosis factor inhibitors (eg, etanercept, infliximab) are biologic DMARDs (large-molecule agents produced primarily by recombinant DNA technology) that are used for patients who fail first-line therapy. They are associated with significant immune suppression, which can lead to reactivation of latent tuberculosis; therefore, pretesting with an interferon gamma release assay is recommended. They may also be associated with an increased risk of heart failure, and some experts advise pretreatment echocardiography for patients with ventricular dysfunction. Educational objective: Methotrexate therapy for rheumatoid arthritis is associated with hepatotoxicity. Serum liver studies should be checked prior to initiation and periodically thereafter. Much of the toxicity of methotrexate, including hepatotoxicity, can be mitigated by concurrent administration of folic acid, which does not reduce the effectiveness of the drug.

A 51-Year-Old Woman Comes to the Office for a Follow-Up