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Rheumatoid arthritis — MCCQE Part 1 MCQ

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MediumJoint PainRheumatoid arthritisMCCQE Part 1

A 50-year-old woman has 4 weeks of symmetric MCP and PIP synovitis, morning stiffness lasting more than 2 hours, elevated ESR, and positive RF and anti-CCP. Rheumatology assessment confirms active moderate rheumatoid arthritis. Pregnancy is excluded, baseline blood counts and renal and liver function are acceptable, and there is no methotrexate contraindication. Which disease-modifying strategy is best?

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Correct answer: D — Start a conventional DMARD promptly; oral methotrexate is an appropriate first-line option

Option D is best. Active rheumatoid arthritis should be treated to target with a conventional disease-modifying antirheumatic drug promptly rather than waiting for structural damage. Oral methotrexate is an appropriate first-line option in this patient because the stem establishes specialist confirmation, suitable baseline testing, moderate disease activity, and no contraindication. The ACR strongly favours methotrexate over hydroxychloroquine or sulfasalazine and conditionally over leflunomide in DMARD-naive moderate-to-high activity, while still requiring individualized shared decision-making. Hydroxychloroquine is generally favoured for low disease activity rather than this presentation. Glucocorticoids may sometimes be used briefly as bridging therapy, while NSAIDs relieve symptoms but do not replace disease-modifying treatment.

Reference: Canadian Rheumatology Association, current guideline hub: https://rheum.ca/resources/publications/ ; American College of Rheumatology RA treatment guideline: https://rheumatology.org/api/asset/blt9e44ccb701e1918c/ra-guideline-2021.pdf