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Fibromyalgia — SCE Rheumatology MCQ

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HardOsteoarthritis and soft tissue rheumatologyFibromyalgiaSCE Rheumatology

A patient with rheumatoid arthritis has DAS28 6.0 driven by 22 tender joints and very high patient global score, but no swollen joints, normal CRP, no power-Doppler synovitis and widespread allodynia with unrefreshing sleep. What is the best next step?

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Reveal the answer and explanation

Correct answer: C — Assess and treat probable fibromyalgia before cycling biologics, while monitoring RA objectively

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

A is correct. Composite activity scores can be inflated by fibromyalgia, pain sensitisation, fatigue and mood even when objective synovitis is absent. EULAR advises establishing whether persistent symptoms reflect inflammation before further DMARD cycling and addressing non-inflammatory drivers in parallel. B combines advanced therapies in an unsafe, unsupported way. C uses glucocorticoid response as a substitute for diagnostic reassessment. D overinterprets one quiet assessment and risks an RA flare by withdrawing effective treatment. E confuses analgesia with disease modification and exposes the patient to opioid harm. The answer does not dismiss symptoms as “non-organic”: it validates severe nociplastic pain while preventing unnecessary immunosuppression and maintaining structured examination and imaging when clinically indicated.

Reference: EULAR points to consider for difficult-to-treat rheumatoid arthritis: https://pmc.ncbi.nlm.nih.gov/articles/PMC8761998/