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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateTreat-to-TargetRheumatoid arthritisSCE Rheumatology

A 46-year-old woman with anti-CCP-positive erosive rheumatoid arthritis is treated with subcutaneous methotrexate 20 mg weekly and adalimumab. Before adalimumab was started, her DAS28-CRP was 5.8 despite intensive conventional DMARD therapy. She has subsequently remained glucocorticoid-free and in clinical remission for 8 months, with DAS28-CRP values between 2.1 and 2.4. At this review, she has no tender or swollen joints, CRP is 2 mg/L and DAS28-CRP is 2.2. She reports no inflammatory morning stiffness or functional deterioration, and treatment is well tolerated. As part of an observational study, ultrasound demonstrates grade 1 power Doppler signal at two metacarpophalangeal joints without clinically detectable synovitis. There are no new radiographic erosions. Which is the most appropriate treat-to-target management plan?

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

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Correct answer: E — Continue the current DMARD regimen and base subsequent adjustments on clinical composite disease activity

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

Her baseline anti-CCP positivity and erosions make clinical remission the preferred target because of the increased risk of radiographic progression. She has achieved that target consistently: there is no clinical synovitis, CRP is normal and DAS28-CRP remains below 2.6. NICE advises against using ultrasound for routine monitoring of rheumatoid arthritis disease activity. Furthermore, randomised strategy evidence found that incorporating ultrasound remission into treatment decisions increased treatment intensity without improving clinical or radiographic outcomes. The isolated low-grade power Doppler finding therefore does not justify DMARD escalation or switching. B and C are plausible responses to subclinical synovitis but would treat imaging rather than the recommended clinical target; either could be appropriate if clinically active disease emerged and the relevant treatment sequence supported escalation or switching. D and E recognise that she is in sustained remission, but step-down is premature. NICE recommends considering cautious dose reduction or drug withdrawal only after the treatment target has been maintained for at least 1 year without glucocorticoids. She has maintained remission for only 8 months. The current regimen should therefore be continued, with ongoing clinical assessment and rapid access if disease activity recurs.

Reference: Rheumatoid arthritis in adults: management — Recommendations (Published 11 July 2018; relevant recommendations amended 2024) — https://www.nice.org.uk/guidance/NG100/chapter/recommendations Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial (2016) — https://www.bmj.com/content/354/bmj.i4205