Case Study: Active Rheumatoid arthritis

A 28-year-old woman has noted pain and swelling of her hands and wrists for six months. She has discomfort with walking, notes fatigue and difficulty using the keyboard at work and is having difficulty caring for her 2-year-old baby. She has been taking diclofenac 150 mg/day. Her exam shows tenderness and swelling of her PIP, MCP joints and wrist joints, as well as knee swelling. The MTP joints are also tender on squeeze. The labs include a negative rheumatoid factor, sed rate of 45 mm/hour and Hct of 36.

 

Radiograph.

 

Which of the following would you do now?

• Repeat rheumatoid factor.
• Order MRI of hands.
• Start prednisone 30 mg/day.
• Talk to her about starting methotrexate therapy.
• Refer to occupational therapy.

Answer: Talk to her about starting methotrexate therapy and refer to occupational therapy.

Explanation: This patient has active RA and needs to be started on a DMARD therapy. A referral to occupational therapy for a hand evaluaton, including hand exercises and adaptive equipment and splints, is also indicated to help improve her activity level.

The decision about starting a DMARD is not dependent on laboratory findings such as the rheumatoid factor status, acute phase response or the radiographic appearance. You should not wait for the presence of erosions as the indication to start a DMARD. The decision about starting a DMARD should be based on the clinical activity of the disease. Which DMARD you recommend should take into account disease activity, functional status, life style issues and the underlying health status of the patient. For this young woman, the DMARD methotrexate is appropriate based on the disease activity and functional disability.

There is no indication to order an MRI to look for erosions since the decision to start a DMARD should be made based on clinical activity. Similarly, it does not matter if you do a repeat rheumatoid factor because it will not impact on the decision to start a DMARD. Steroids might be added to the regimen, but the dose is too high to use as a bridge while you wait for the methotrexate to work.