Ace the Case: A 55-Year-Old Man With RA and Increasing Joint Symptoms After Methotrexate Use

Issue: September 2018

Mr. J., a 55-year-old retired fireman, was diagnosed with rheumatoid arthritis (RA) 8 years ago (seropositive for both rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP]) and started on therapy with methotrexate (MTX) 17.5 mg weekly.

During a routine evaluation last week, Mr. J. complained of increasing joint symptoms over the past 3 months and, more recently, morning stiffness lasting an average of 3 hours. The patient also has adult-onset diabetes mellitus (AODM) and hypercholesterolemia.

Family history: AODM, atherosclerotic cardiovascular disease (ASCVD)

Lifestyle: Cigarette smoker (40 packs/year but quit 2 years ago)

Medications: MTX 17.5 mg weekly; metformin; atorvastatin

Physical examination: 8 swollen joints; 6 tender joints

Laboratory tests: Disease Activity Score- 28, 5.3; Crohn’s Disease Activity Index, 25

EKG: Evidence of subclinical myocardial infarction (MI)
Stress echo: Normal function
Carotid ultrasound: Significant plaque
Hand films: Marginal erosions at proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints

After the addition of prednisone 5 mg/day failed to improve Mr. J.’s flare-of-joint signs and symptoms and morning stiffness, his rheumatologist suggested use of a biologic. However, Mr. J. has a strong fear of needles and asked for alternatives. Which of the following would you recommend?

A. Increase dosages of prednisone to 10 mg/day and MTX to 20 mg/week

B. Add adalimumab, etanercept, or abatacept to regimen

C. Add tofacitinib to regimen

D. Add sulfasalazine and hydroxychloroquine to regimen

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Learning Objectives:

Upon successful completion of this educational activity, the participant will be better able to assess the management of rheumatoid arthritis in individuals refractory to methotrexate.

Overview

Author(s)/Faculty: Gregg Silverman, MD
Source: Healio Rheumatology Education Lab
Type: Monograph
Articles/Items: 4
Release Date: 7/15/2018
Expiration Date: 7/14/2019
Credit Type: CME/ABIM MOC
Number of Credits: 0.25
Cost: Free
Providers: Vindico Medical Education

CME Information

Provider Statement: This continuing medical education activity is provided by Vindico Medical Education.
Support Statement: There is no commercial support for this activity.
Target Audience: The intended audience for this activity is rheumatologists, dermatologists, and other health care professionals.