Rheumatology Q37

A 49-year-old woman is evaluated for recently worsening joint symptoms. She has a 13-year history of Crohn disease characterized by four to six stools daily and mild crampy abdominal pain. She also has a 1-year history of arthritis. She currently has pain in the left knee, right ankle, and two joints of the right foot; diffuse swelling involving the left third toe; and 30 minutes of morning stiffness. She has been treated with various NSAIDs, which seem to worsen her bowel disease. She has tried, in succession, azathioprine, mesalamine, and methotrexate, without notable improvement in her symptoms. She currently is taking methotrexate.

On physical examination, vital signs are normal. The left knee has a small effusion. Dactylitis of the left third toe is present. The right ankle and the right second and third metatarsophalangeal joints are tender to palpation.

Which of the following is the most appropriate long-term treatment?

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