A 52-year-old woman with rheumatoid arthritis treated with adalimumab for two years develops new scaly plaques and palmoplantar pustules, biopsy-consistent with psoriasis, with no personal or family history of the disease. Her arthritis is well controlled. The most appropriate next biologic strategy is:
- A Increase the adalimumab dose to suppress inflammation further
- B Discontinue the anti-TNF agent and switch to a different drug class such as an IL-17 inhibitor ✓
- C Switch to a second anti-TNF agent such as etanercept
- D Add oral cyclosporine while continuing adalimumab unchanged
Correct answer: B. Discontinue the anti-TNF agent and switch to a different drug class such as an IL-17 inhibitor
Explanation
This is paradoxical psoriasis, a known class effect of anti-TNF therapy arising from type I interferon-driven inflammation. Because the reaction is class-related, switching to another anti-TNF agent frequently reproduces it, so management requires stopping the anti-TNF drug and moving to a different mechanism of action, typically an IL-17 or IL-23 inhibitor. Escalating the offending agent or adding immunosuppressants without changing class does not address the underlying paradoxical pathway.
Reference: Rook's Textbook of Dermatology, 9th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.