Q64) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. X-ray of the wrist and hands reveal erosions in the proximal phalanges and ulnar styloid process. The most appropriate next step in management :
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine