A 55-year-old woman with long-standing seropositive RA on methotrexate for 3 years has progressive joint erosions and DAS28-CRP of 5.8 (high disease activity). She is started on a biologic. She is a non-smoker with no prior TB, no hepatitis B, and a normal chest X-ray. Which biologic is FIRST-LINE as add-on to methotrexate per ACR/EULAR guidelines?

• A Tofacitinib (JAK inhibitor)
• B Abatacept (CTLA4-Ig)
• C Rituximab (anti-CD20)
• D TNF inhibitor (e.g., adalimumab, etanercept) ✓

Explanation

Current ACR and EULAR guidelines recommend TNF inhibitors (adalimumab, etanercept, certolizumab, golimumab, infliximab) as the preferred first-line biologic add-on to methotrexate in patients with moderate-to-high disease activity who have failed csDMARD therapy. JAK inhibitors (tofacitinib, baricitinib) are alternatives but are generally used after biologic failure due to emerging safety signals (thromboembolism, cardiovascular events noted in the ORAL Surveillance trial). Rituximab is preferred in anti-CCP positive patients with RF+ who have failed TNF inhibitors.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.