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Early rheumatoid arthritis — ABIM Board MCQ

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HardRheumatology/Allergy/ImmunologyEarly rheumatoid arthritisABIM Board

A 61-year-old woman with rheumatoid arthritis remains moderately active on maximally tolerated methotrexate. Four months ago she was hospitalized with bacterial pneumonia and bacteremia. She now asks about escalation. Which approach best reflects the recent serious infection?

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Correct answer: E — Add sulfasalazine and hydroxychloroquine to methotrexate

The best answer is “Add sulfasalazine and hydroxychloroquine to methotrexate”. In a patient with a serious infection within the preceding year, ACR guidance conditionally favors adding conventional synthetic DMARDs over a biologic or targeted synthetic agent. The aim is still treat-to-target, but infection risk changes the escalation pathway. Glucocorticoid escalation itself increases serious infection risk.

Reference: 2021 American College of Rheumatology Guideline for Treatment of Rheumatoid Arthritis: https://pmc.ncbi.nlm.nih.gov/articles/PMC9273041/