A 58-year-old man with established RA on methotrexate 20 mg/week has inadequate response (DAS28 score 5.4) after 6 months. He has no prior infections or heart failure. According to ACR 2021 guidelines, the preferred next therapeutic addition is:
- A Add hydroxychloroquine to methotrexate
- B Add a TNF inhibitor (e.g., adalimumab) to methotrexate ✓
- C Switch to sulfasalazine monotherapy
- D Switch to leflunomide monotherapy
Explanation
In RA with moderate-to-high disease activity despite csDMARD therapy (methotrexate), ACR 2021 guidelines conditionally recommend adding a biologic DMARD or targeted synthetic DMARD to methotrexate rather than switching to another csDMARD. TNF inhibitors (adalimumab, etanercept, certolizumab) are first-line biologics; combination with methotrexate is superior to monotherapy. Adding hydroxychloroquine (triple therapy) is an option but is inferior to biologic combination for moderate-high disease activity. Switching to leflunomide loses the synergy of combination therapy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.