A 55-year-old woman with rheumatoid arthritis on methotrexate 20 mg/week and hydroxychloroquine continues to have active disease (DAS28-CRP 4.2). Anti-CCP antibodies are positive; RF is positive. Per EULAR guidelines, the most appropriate next step in disease management is:

• A Switch methotrexate to leflunomide
• B Add a TNF inhibitor (e.g., etanercept or adalimumab) ✓
• C Triple DMARD therapy (add sulfasalazine)
• D Increase methotrexate to maximum tolerated dose only

Explanation

Per EULAR RA management guidelines, after failure of one conventional DMARD (csDMARD) strategy with poor prognostic factors (positive anti-CCP, positive RF, erosions), the next step is a biological DMARD — typically a TNF inhibitor — or a targeted synthetic DMARD (JAK inhibitor). Switching to leflunomide monotherapy or adding sulfasalazine (triple therapy) are options when biologics are not feasible, but biologics are preferred in this scenario.

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

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Written and medically reviewed by the StethoPrep medical team.