Rheumatology Question 46

A 52-year-old man is evaluated during a follow-up visit for a 2-year history of progressively symptomatic rheumatoid arthritis. He reports increased difficulty with his job due to persistent pain and swelling in the first proximal interphalangeal joints, second and third metacarpophalangeal joints, and bilateral wrists. He also has increased difficulty climbing stairs due to persistent pain and swelling in the right knee. Medications are methotrexate, 25 mg weekly; prednisone, 10 mg/d; naproxen; and folic acid.

On physical examination, vital signs are normal. There is 1+ tenderness to palpation and 1+ swelling of the affected joints.

Plain radiographs of the hands and wrists show periarticular osteopenia, multiple erosions, and carpal joint-space narrowing. Plain radiographs of the knees show medial and lateral joint-space narrowing.

Which of the following is the most appropriate next step in management?

A Add etanercept

B Add rituximab

C Increase methotrexate 

D Increase prednisone

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