Rheumatology Question of the Week: 56-year-old female with rheumatoid arthritis and osteoporosis

As we begin #RheumatologyWeek, here is a rheumatology question from our ABIM question vault, which will be high-yield for those of you studying for the ABIM, Family Medicine, or USMLE Step exams. Even if you’re not preparing for any exam, give it your best shot and then see below for the answer. You’ll likely expand your Knowmedge in the process.

Question of the Week: Rheumatology edition

A 56-year-old female has persistent rheumatoid arthritis. She is currently on methotrexate, hydroxychloroquine, and etanercept, which was added six months ago. She continues to have pain in bilateral hands and wrists. Prednisone 5mg daily is added and provides only minor relief. The patient’s only other medical history is osteoporosis for which she takes vitamin D, alendronate and calcium supplements.

Physical exam shows metacarpophalangeal (MCP) joint tenderness bilaterally. Labs indicate elevated ESR, positive anti-CCP, and positive rheumatoid factor. Xray of hands bilaterally shows erosive lesions present.

Which of the following is the most appropriate next step in the patient’s management?

A. Add infliximab

B. Discontinue etanercept and add infliximab

C. Start NSAIDs

D. Increase prednisone to 10mg per day

E. Discontinue methotrexate and start sulfasalazine

Rheumatology Practice Question Explanation
This patient has osteoporosis so we would not want to increase the dose of steroids. If one anti-TNF alpha inhibitor is not working, discontinuing it and changing to another usually controls symptoms. Choice B (Discontinue etanercept and add infliximab) is the correct answer.

You do not want to place the patient on two anti-TNF alpha inhibitors because this can lead to an increased risk of infections.

Choice C (Start NSAIDs) is not correct since NSAIDs are used for mild rheumatoid arthritis. This patient in on several medications for rheumatoid arthritis and still has symptoms that are not controlled.

Choice D (Increase prednisone to 10 mg/day) is incorrect also since this patient has a history of osteoporosis. Increasing prednisone is contraindicated since prednisone is a medication notorious for causing bone loss.

Choice E (Discontinue methotrexate and start sulfasalazine) is an incorrect answer choice. Methotrexate is used for moderate rheumatoid arthritis treatment. Sulfasalazine, on the other hand, is used for mild rheumatoid arthritis symptoms. Doing this, therefore, would be the incorrect measure to take at this time.

Question reviewed: May 3, 2020

A Perdriger. Infliximab in the treatment of rheumatoid arthritis. Biologics. 2009; 3: 183–191. Published online 2009 Jul 13. doi: 10.2147/btt.2009.3099


You can find additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault.

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