Case-Based Approach for the Management of Rheumatic Diseases - Episode 6
Transcript: Madelaine A. Feldman, MD: This patient has a number of hallmarks suggesting that he could have a very advanced and quick progression of his disease activity. A combination of having both a rheumatoid factor and a high CCP [cyclic citrullinated peptide] level is a hallmark of that. In addition, he had what appeared to be rheumatoid nodules on his elbow. So this gentleman does run the risk of not only very quick and advanced disease activity but also perhaps some risk for nonarticular manifestations with his rheumatoid arthritis.
First, he needs to be maximized on methotrexate treatment. We know that GI [gastrointestinal] absorption over 15 mg can be nonspecific, and we are not sure how much the patient is absorbing. With this patient, I would definitely recommend switching to subcutaneous therapy and advancing his methotrexate to 25 mg a week. He’s young, and he’s working. We need to make sure that we can control the inflammation in his joints very quickly. Occasionally, we will use a very low dose of prednisone in someone with this type of a presentation.
I would give him only maybe 8 weeks on the higher methotrexate dose and even the low-dose prednisone. If he is showing any signs or symptoms of continued disease activity, or if the disease activity starts to recur when trying to taper the prednisone, we have to go to the next step.
The next step for this gentleman would be to include a biologic or one of these advanced disease-modifying agents that is nonbiologic. We have a wide array of biologic therapies that we could use in this gentleman. Of course, the ones that have the longest history are the tumor necrosis factor inhibitors. These include certolizumab, adalimumab, etanercept, infliximab, and golimumab. We also have a T-cell costimulator modulator known as abatacept. And then, IL-6 inhibitors are also a possibility for this gentleman. We have sarilumab and tocilizumab. And finally we have JAK inhibitors. They are not biologics, but they are considered to be somewhat advanced in terms of the disease-modifying agents. As of now, we have tofacitinib, baricitinib, and upadacitinib.
Transcript Edited for Clarity