Case 1: rheumatoid arthritis

A 45-year-old woman is being treated by her rheumatologist for seropositive rheumatoid arthritis of 5 years’ duration. She is at a critical point in her care because her rheumatologist believes her current regimen of low-dose prednisone, full-dose subcutaneous methotrexate, and meloxicam has not halted the inflammation or disease progression. Her rheumatologist feels that, on the basis of her clinical assessment, the persistently elevated erythrocyte sedimentation rate, C-reactive protein (CRP), and the presence of anemia and thrombocytosis, high CDAI score, and low MDHAQ, her disease is active and uncontrolled and an anti-tumor necrosis factor (TNF) should be added to her current regimen. However, she is afraid to move on to even more powerful drugs because of their potential side effects, and the devil she is comfortable with and has already learned to live with is better than the devil she doesn’t know. Recent plain radiographs of the hands show no erosions or joint space narrowing, a fact that gives her comfort and supports remaining on her current regimen.

Old paradigm: The rheumatologist would base his/her recommendation on clinical grounds and plain radiographs, and the likelihood that, without a change in treatment, damage will likely ensue.

New paradigm: Given the fact that ultrasound and magnetic resonance imaging (MRI) can detect erosions 2 years before a plain radiograph shows them, an ultrasound of the dominant right hand was performed and the patient was able to actually see the presence of erosions, the power Doppler demonstration of active inflammation on power Doppler (“imaging sedimentation rate”), and synovial hypertrophy and tenosynovial thickening. Based on this, she agrees to starting an anti-TNF and obtaining follow-up ultrasounds at least every year to be sure that her inflammation remains tightly controlled and can be correlated with clinical parameters.