Question of the Week # 67, 68

Q67) A 44 year old woman 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. She denies any fever or weightloss. She reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, she has symmetrical involvement of both the wrists and two of her left proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows normal ESR, negative rheumatoid factor, and a negative anti-CCP antibody. X-ray of the wrist and hands reveal mild joint space narrowing with only very small peripheral erosions. 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

Q68) The patient in the above question is started on appropriate therapy. He returns to your clinic in 1 month for regular follow up and his disease is well controlled with near complete remission. The most important next step in follow up of this patient :

A. DEXA scan in 1 year
B. PPD placement
C. Check hepatitis B serology
D. Ophthalmology referral at 3 months
E. Liver function tests

15 Responses

  1. e and d

  2. c ande.methotrexate .lft has be done in 4 to 6 weeks

  3. e

    d

  4. c and d

  5. i meant, c and e

  6. picked nsaid and check up in one month but then the follow up question made no sense so I looked up the answer and i wasn’t sure why they didn’t begin simple nsaids first since there was no elevated esr
    no weight loss
    I was just thinking that the DMARD was giving too soon …
    i guess that means I have to go read LOL

  7. C and E

  8. its E and D… E because it is moderate RA (small peripheral erosions, negative lab work, normal ESR).. because u are starting on Hydroxychloroquine u want to follow up opthalmology.. thats my reasoning

  9. C. Start NSAID and Methotrexate

  10. E. Liver function tests

  11. E,E

    • sorry the answer is E,D

  12. E,D

  13. c and e. MTB2 start DMARD with any sign of erosive joint involvement
    erosive defined as:
    joint space narrowing (as seen here in this patient),
    physical deformity of joints,
    and x ray abnormalities.

    Methotrexate is first line in RA. Hydroxychloroquine becomes an option if methotrexate alone or in combination with anti TNF alpha or rituximab fails.

  14. Thank you Dr. Archer for providing the question.
    My answer is E and D.
    E bc the patient has moderate RA (see below)
    D bc Hydroxychloroquine can lead to retinopathy (long term use) thus ophthalmology referral is needed.

    Proof of Moderate RA: “X-ray of the wrist and hands reveal mild joint space narrowing with only very small peripheral erosions.”
    Cartilage doesn’t show up on xray, but cartilage loss is revealed by a narrowing of joint space.

    Side note:
    -Methotrxate is related to hepatotoxicity – check LFTS for patients receiving MTX
    -TNF Blocker such as infliximab can reactivate latent TB- thus PPD Placement

    Below classification and treatment of RA is taken from #63 and#64 respectively.

    Mild RA : no extra-articular manifestations, no bony erosions or joint cartilage loss.

    Moderate RA : Elevated ESR, Positive RF or positive Anti – CCP antibodies, radiographic changes such as osteopenia or small peripheral erosions and minimal joint space narrowing, no extra-articular disease.

    Severe RA : imaging studies showing bony erosions and loss of cartilage, high titers of RF or Anti-CCP, presence of extra-articular manifestations, Anemia of chronic disease, Hypoalbuminemia.

    Treament-

    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.

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