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Initial RA Treatment — SCE Rheumatology MCQ

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EasyRheumatoid ArthritisInitial RA TreatmentSCE Rheumatology

A 40-year-old woman has newly diagnosed rheumatoid arthritis with symmetrical MCP and PIP joint synovitis, 2 hours of morning stiffness, an elevated CRP, positive anti-CCP antibodies and a DAS28-ESR of 5.8. She is not pregnant, is not planning pregnancy and has no contraindication to methotrexate. Which is the most appropriate initial disease-modifying treatment strategy in UK practice?

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Correct answer: D — Start oral methotrexate, escalate as tolerated and consider short-term glucocorticoid bridging

The correct answer is D. She has highly active, anti-CCP-positive RA and requires prompt disease-modifying treatment. NICE recommends first-line cDMARD monotherapy with oral methotrexate, leflunomide or sulfasalazine; methotrexate is an appropriate anchor drug here, with dose escalation as tolerated. A short-term oral, intramuscular or intra-articular glucocorticoid bridge may be considered while the cDMARD takes effect. Treatment should follow a treat-to-target strategy, aiming for remission—particularly given her anti-CCP positivity—and disease activity should be monitored regularly. Biological or targeted synthetic DMARDs are not routine first-line UK treatment before an adequate cDMARD strategy. Hydroxychloroquine monotherapy is principally an alternative for mild or palindromic disease. Paracetamol and NSAIDs may relieve symptoms but do not prevent structural progression and must not replace prompt DMARD therapy.

Reference: National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management (NG100), sections 1.2 and 1.4, 2018, amended 2024. https://www.nice.org.uk/guidance/ng100/chapter/Recommendations