A 41-year-old woman with RA maintained on methotrexate 20 mg/week develops rising DAS28 score (4.8) despite adequate MTX dosage for 6 months. She has no contraindications to biologics. According to ACR 2021 guidelines, which add-on treatment is recommended as first-line biologic?
- A TNF inhibitor (e.g., adalimumab or etanercept) ✓
- B Abatacept monotherapy without MTX
- C Hydroxychloroquine addition
- D Rituximab as first-line biologic
Explanation
ACR 2021 RA guidelines recommend addition of a TNF inhibitor (adalimumab, etanercept, certolizumab, golimumab, infliximab) as the first biologic after inadequate response to methotrexate monotherapy, based on the most robust efficacy and long-term safety data. JAK inhibitors are an alternative first biologic for patients with contraindications to TNF inhibitors. Abatacept is effective but is not considered first-line biologic in MTX-insufficient patients unless there are specific clinical indications. Rituximab is preferred for RF/anti-CCP seropositive patients who have failed TNF inhibitors. Hydroxychloroquine addition represents triple DMARD therapy, a valid alternative but less so than a biologic at this stage.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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