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Rheumatoid arthritis biologic escalation — SCE Rheumatology MCQ

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HardRheumatoid arthritisRheumatoid arthritis biologic escalationSCE Rheumatology

A 62-year-old man with established rheumatoid arthritis takes methotrexate 25 mg weekly and sulfasalazine 1 g twice daily. He remains symptomatic with DAS28 5.8, CRP 31 mg/L and ultrasound power Doppler synovitis in both wrists. Chest radiograph is normal, hepatitis B/C and HIV tests are negative, and interferon-gamma release assay is negative. What is the most appropriate biologic or targeted treatment?

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Correct answer: E — Add a TNF inhibitor in combination with methotrexate

In active RA despite conventional DMARDs, UK pathways usually use a biologic or targeted synthetic DMARD with methotrexate where tolerated; a TNF inhibitor is a standard early biologic option. Rituximab is often used after inadequate response to a TNF inhibitor or where TNF inhibition is unsuitable. Long-term steroids and hydroxychloroquine monotherapy would not address high disease activity adequately.

Reference: NICE NG100; BSR biologic DMARD safety guideline