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RA Combination csDMARD — RACP Adult Medicine MCQ

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ModerateRheumatologyRA Combination csDMARDRACP Adult Medicine

A 60-year-old man with RA on methotrexate 25 mg/week subcutaneously has a DAS28 of 3.8 (moderate activity) at 6 months. He has no erosions and no poor prognostic factors (RF negative, anti-CCP negative, no erosions). What is the most appropriate next step before escalating to biologics?

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Correct answer: B — Sulfasalazine alone

Before escalating to biologic DMARDs (which require PBS failure of ≥2 csDMARDs in Australia), combination csDMARD therapy should be tried. Adding sulfasalazine (± hydroxychloroquine) to methotrexate (triple therapy) is effective and may avoid the need for biologics. Triple therapy (MTX + SSZ + HCQ) has been shown to be non-inferior to MTX + anti-TNF in some trials (RACAT, tREACH).

Reference: ARA – 2024 – RA Treatment; EULAR 2022; PBS Criteria