Question of the Week # 63

Q63) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning  and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender.  Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody.  The most appropriate next step in management :

A. Start etanercept

B. Start Ibuprofen and follow-up in one month.

C. Start Ibuprofen and Methotrexate

D. Obtain plain x-rays of hands and wrists

E. Obtain anti-nuclear antibodies

11 Responses

  1. b/c

  2. c

  3. d

  4. d. first we have to look for erosion and xray changes . then treat

  5. D, then C

  6. Answer. D

    The patient has the criteria for the diagnosis of Rheumatoid Arthritis. Once Rheumatoid arthritis is diagnosed, some baseline imaging study to evaluate the hands and the wrists must be performed. This will help to assess the severity of the disease at the time of initiation of therapy and also, for comparision with post treatment radiographs to evaluate response to the therapy . Plain radiographs of the hands and wrists are appropriate. Further managements depends upon the baseline severity of the disease at the time of diagnosis.

    Mild RA : less than 6 inflamed joints, no extra-articular manifestations, no bony erosions or joint cartilage loss.
    Moderate RA : Elevated ESR, Positive RA or positive Anti – CCP antibodies, radiographic changes such as osteopenia or small peripheral erosions and minimal joint space narrowing, no extra-articular disease.
    Severe RA : imaging studies showing bony erosions and loss of cartilage, high titers of RF or Anti-CCP, presence of extra-articular manifestations, Anemia of chronic disease, Hypoalbuminemia.

    Ans. A is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study.

    Ans. B is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study. This option is appropriate if the patient is determined to have early, mild RA. Imaging must be performed to assess if this is mild or severe RA.

    Ans. C is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study. This option is correct if the patient is determined to have early, severe RA. Imaging must be performed to assess if this is mild or severe RA.

    Ans. E is incorrect. The clinical criteria and positive anti-ccp suggest rheumatoid arthritis in this patient. There is no reason to obtain ANA.

  7. D

  8. thanks dr red .

  9. Thx Dr.Red—very good question

  10. Thank you Dr Archer for providing the answer to this question.
    I would like to add something with your permission.
    In addition to doing a joint X-ray, I would do a baseline chest X-Ray since this patient already falls in the moderate to severe disease category. This will give me a head start for initiating TB regimens if necessary.

    ‘6 Extra Boats & Cars’ stands for :
    6 or higher ACR* 2010 score, Extraarticular findings like subcutaneous nodules, hypoalbuminemia, anemia of chronic disease, Bone erosions, and Cartilage loss (interpreted radiologically as loss of joint space)

    *American College of Rheumatology (ACR) established criteria for classification of rheumatoid arthritis in 2010. To diagnose rheumatoid arthritis RA, we must have a score of 6 or higher.
    It’s easy to remember in Dr Archer’s format, anything less than 6 extra boats and cars is mild disease. but 6 in ACR 2010 represents a score not necessarily determined by or equivalent to 6 joint involvement. A patient may have 10 large joint involvement and still score 1. I think Dr Archer meant ACR score of 6 or less means mild disease.

    For practical purposes, Mild disease does not get DMARD, only pain relief and anti-inflammatory trial (sulfasalazine, minocycline, or hydro chloroquine) This question highlights a very crucial step in treatment of RA. ( i.e – X- Ray of affected joints determines the next step). If X-Ray does not show bone erosions! this is mild disease.
    If X-ray show bone erosions, this is moderate or severe, depending on slight or extensive process. Moderate and Severe RA get DMARD (methotrexate) – in addition to pain relievers and anti inflammatory drugs.
    If patient improves, DAS-28 (Disease Activity Score 28) will drop below
    3.2 (low disease activity/ moderate disease) If patient deteriorates, it may worsen to greater than 5.1(high disease activity/ severe disease). That’s the point of having moderate and severe disease classification mark. It aids in assessing improvement following treatment.
    If the patient improves, the patient is followed every 3-6 months and X-rays are taken annually (ACR Subcommittee on RA guidelines. Guidelines for the management of RA 2002 update. Arthritis Rheum 2002;46: 328-346)
    If DMARDS fail, I will try immune modulating drugs like Etarnacept, Azathioprine
    See how ‘the next step’ ( X-ray) has made management of RA so easy!
    Next to this is ‘6 Extra Boats and Cars’, absence of this means disease in remission or mild disease while presence of ‘6/Extra /Boats /and Cars’ individually or collectively mean moderate to severe disease.

    ACR 2010 RA criteria score is as followers:
    A- joints – large 1 = 0, 2-10 = 1
    small (with or without large joint involvement)
    1-3 = 2
    4-10= 3
    > 10= 5
    B- serology (let it stand for ‘synovium’ for easy recall, synovium is next to ‘joint’ or A above)
    Negative RF or ACPA *= 0
    Low RF or ACPA = 2
    High RF or ACPA = 3
    Low means 3 times above the upper limit of normal.
    * ACPA stands for Anti-Citrullinated Protein Antibody

    C- aCute phase reactants
    Normal CRP and Normal ESR = 0
    Abnormal CRP or Abnormal ESR = 1

    D- Duration of symptoms
    or = 6 weeks = 1

    • DMARDs include HCQ, LEF, MTX, minocycline, and sulfasalazine
      The goal for managing RA is to treat to low disease activity or remission thus DMARDS are started on the onset of disease activity no how mild

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