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Question 5#

A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?

A) Prednisone 60 mg per day should be started
B) The patient should be evaluated for disease-modifying antirheumatic therapy
C) A nonsteroidal anti-inflammatory drug should be added to aspirin
D) The patient’s prognosis is highly favorable
E) The patient should receive a 3-month trial of full-dose nonsteroidal anti-inflammatory agent before determining whether and/or what additional therapy is indicated

Correct Answer is B

Comment:

The patient has more than four of the required signs or symptoms of RA, including morning stiffness, swelling of the wrist or MCP, simultaneous swelling of joints on both sides of body, subcutaneous nodules, and positive rheumatoid factor. Subcutaneous nodules and anti-CCP antibodies are poor prognostic signs for the activity of the disease, and disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, antimalarials, sulfasalazine, leflunomide, antiTNF agents, or a combination of these drugs should be instituted. Methotrexate has emerged as a cornerstone of most disease-modifying regimens, to which other agents are often added. Low-dose corticosteroids (eg, prednisone 7.5 mg a day or less) have recently been shown to reduce the progression of bony erosions and, although controversial, are useful additions to DMARD therapy. High-dose steroids, however, should be avoided. Use of anti-inflammatory doses of both aspirin and nonsteroidals together is not desirable because it will increase the risk of side effects. Given the aggressive nature of this woman’s rheumatoid arthritis and negative prognostic signs, use of DMARDs is indicated. Significant joint damage has been shown by MRI to occur quite early in the course of disease.