A 45-year-old woman presents to the clinic with a 6-month history of joint pain and morning stiffness lasting over an hour. She reports swelling in her wrists and fingers, which improves somewhat with activity throughout the day. She endorses fatigue and denies fever, rashes, dry mouth, or dry eyes. Past medical history is significant for hypothyroidism which is treated with levothyroxine. Family history is unremarkable. She drinks two glasses of wine per week and does not smoke cigarettes. Vital signs are within normal limits. Physical examinatioin reveals synovial thickening in the metacarpophalangeal joints and swelling in the wrist joints bilaterally. Laboratory tests reveal an elevated erythrocyte sedimentation rate, elevated C-reactive protein, positive rheumatoid factor, and elevated anti-cyclic citrullinated peptide (anti-CCP) antibodies. Radiographs of the hands show early erosive changes.
Which of the following is the most appropriate initial treatment for this patient?
C) Methotrexate
The clinical features of rheumatoid arthritis (RA) can be diverse. Morning stiffness is the hallmark of the disease, particularly when it lasts for more than an hour. Joint pain and swelling predominantly affects the small joints of the hands and feet. Constitutional symptoms may include fatigue, myalgias, and unintentional weight loss. Common laboratory findings include elevated acute phase reactants, positive rheumatoid factor (RF), and anti-cyclic citrullinated (CCP) antibodies. Radiographs of the affected joints may reveal joint space narrowing and bony erosions as later manifestations of RA. Patients diagnosed with rheumatoid arthritis should be treated with disease-modifying antirheumatic drugs (DMARDs) as soon as possible because much of the joint damage that results in disability begins early in the course of the disease. Methotrexate is recommended as first-line therapy for DMARD-naive patients due to its efficacy in controlling disease activity and preventing joint damage.
Answer choice A: Hydroxychloroquine, is incorrect. While hydroxychloroquine is a DMARD used in rheumatoid arthritis, it is generally considered less effective than methotrexate for initial treatment in moderate to severe cases.
Answer choice B: Leflunomide, is incorrect. Leflunomide is another DMARD that can be used in rheumatoid arthritis, but methotrexate is typically preferred as the first-line agent.
Answer choice D: Nonsteroidal anti-inflammatory drugs (NSAIDs), is incorrect. NSAIDs can help with symptom relief but do not prevent joint damage and are not considered DMARDs.
Answer choice E: Sulfasalazine, is incorrect. Sulfasalazine is a DMARD that can be used in rheumatoid arthritis, but methotrexate is the preferred first-line treatment.
Key Learning Point
Patients diagnosed with rheumatoid arthritis should be treated with disease-modifying antirheumatic drugs (DMARDs) as soon as possible because much of the joint damage that results in disability begins early in the course of the disease. Methotrexate is recommended as first-line therapy for DMARD-naive patients.
