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Difficulty: EasyRheumatology and Immunology

A 45-year-old woman presents to the clinic reporting pain and swelling in her wrists and the knuckles of both hands for the past 3 months. She mentions that her joints feel extremely stiff when she wakes up, typically taking about two hours to loosen up. Physical examination reveals tender, boggy swelling of the bilateral metacarpophalangeal and proximal interphalangeal joints. Initial laboratory testing is notable for an elevated erythrocyte sedimentation rate and a positive rheumatoid factor. Which of the following is the most appropriate initial disease-modifying pharmacotherapy for this patient?

  1. MethotrexateAnswer
  2. B
    Ibuprofen
  3. C
    Prednisone
  4. D
    Allopurinol
  5. E
    Ceftriaxone

Answer

Methotrexate
Methotrexate is the universally accepted first-line conventional synthetic disease-modifying antirheumatic drug (DMARD) for patients with newly diagnosed rheumatoid arthritis. It should be initiated promptly to slow disease progression and prevent permanent joint damage.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and laboratory findings.
The patient has chronic, symmetric polyarthritis of the small joints of the hands accompanied by prolonged morning stiffness and a positive rheumatoid factor.
These classic findings strongly establish a diagnosis of rheumatoid arthritis.
2
Determine the goals of medical management for the diagnosed condition.
The goal is to provide immediate symptomatic relief while promptly initiating therapy to slow or prevent structural joint damage.
Untreated rheumatoid arthritis inevitably leads to irreversible joint destruction and significant disability.
3
Identify the standard first-line disease-modifying therapy.
Methotrexate is the widely recommended initial agent.
Guidelines advise starting a conventional synthetic disease-modifying antirheumatic drug (DMARD) as soon as rheumatoid arthritis is diagnosed, with methotrexate being the anchor drug.

Key Concept

Rheumatoid arthritis is typically treated initially with methotrexate, a conventional synthetic disease-modifying antirheumatic drug (DMARD), to prevent irreversible joint destruction.
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Topics

Rheumatology and Immunology

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