Which of the following statements is correct?
a. Prednisone 60 mg per day should be started
b. The patient has RA and 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 antiinflammatory agent before determining whether and/or what additional therapy is indicated.
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 gold, antimalarials, sulfasalazine, methotrexate, leflunamide, anti-TNF agents, or a combination of these drugs should be instituted. Methotrexate has emerged as a cornerstone of most diseasemodifying regimens, to which other agents are often added. Low-dose corticosteroids have recently been shown to reduce the progression of bony erosions and, although controversial, are considered by some to be appropriate disease-modifying agents for long-term therapy. Use of antiinflammatory 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, delay in initiating DMARDs is contraindicated. Significant joint damage has been shown by MRI to occur quite early in the course of disease.