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TNF inhibitor contraindication — SCE Rheumatology MCQ

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ModerateRheumatological PharmacologyTNF inhibitor contraindicationSCE Rheumatology

A 42-year-old woman with severe rheumatoid arthritis has failed methotrexate and sulfasalazine. She has a previous episode of optic neuritis and MRI evidence of demyelinating disease. TB and hepatitis screens are negative. A biologic is required. What is the most appropriate biologic?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Use a non-TNF biologic such as rituximab after assessment

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · A = shown as D · C = shown as E

Use a non-TNF biologic such as rituximab after assessment is best because TNF inhibitors are generally avoided in demyelinating disease, so a non-TNF biologic is preferred when biologic therapy is required. A is less suitable because certolizumab is also a TNF inhibitor; C is less suitable because infliximab is a TNF inhibitor; D is less suitable because etanercept is a TNF inhibitor; E is less suitable because negative infection screening does not address demyelination risk. Clinical pearl: contraindications can override the usual first biologic sequence.

Reference: BSR bDMARD safety guideline 2019; NICE RA technology appraisals