Question of the Week # 64

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 :

A. Prednisone

B. Start NSAID and follow-up in one month.

C. Start NSAID and Methotrexate

D. Start Infliximab

E. Start NSAID and Hydroxychloroquine

7 Responses

  1. C. Start NSAID and methotrexate ; Rheumatoid artheritis

  2. c

  3. E, RF negative mild RA can be treated with E

  4. ccccc

  5. C

  6. Ans. C

    This patient has severe rheumatoid arthritis. He has all the criteria for the diagnosis of RA ( morning stiffness > 1hr, symmetricity, hand joint involvement, more than 3 joints, +ve CCP and bony erosions). His disease can be classified as “severe” because he has high ESR, high CCP and most importantly, he has erosive bony disease.

    Therapy depends on severity at the time of diagnosis ( in early RA) :-
    Mild RA : NSAID alone can be started first. NSAID does not prevent disease progression or erosive bone disease. If symptoms persist or progress while on NSAIDS or if no remission occurs after six weeks on NSAID therapy, a disease modifying agent must be added ( DMARD). For mild disease, a less toxic DMARD such as Hydroxychloroquine or Sulfasalazine must be used initially ( not methotrexate).

    Moderate RA : NSAID + less toxic DMARD such as hydroxychloroquine should be started from the time of diagnosis.

    Severe RA : An NSAID along with a more potent DMARD such as Methotrexate should be started together as initial therapy. NSAID alone should not be used as sole therapy in severe RA as it will not prevent disease progression. In patients who can not be started on MTX ( for contraindications), a TNF alpha inhibitor such as leflunomide or etanercept must be started as initial DMARD.

    Ans. A is incorrect. Prednisone is usually used for treating RA flares.

    Ans. B is incorrect. This option is appropriate if the patient is determined to have early, mild RA. Patients can be started on NSAID alone and follow up in 1 month to see if there is remision. If disease is still present, DMARD must be added.

    Ans. D is incorrect. This option is appropriate if the patient is determined to have early, severe RA and if the patient can not be started on DMARD such as methotrexate

    Ans. E is incorrect. This option is appropriate if the patient is determined to have early, mild RA or moderate RA. Patients can be started on NSAID alone in mild RA and follow up in 1 month to see if there is remision. If the disease is still present, a mildly toxic DMARD must be added such as hydroxychloroquine or sulfasalazine.

  7. C

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