A 65-year-old man with rheumatoid arthritis has been on methotrexate 20 mg/week for 3 years with good disease control but now has DAS28 of 4.2. Anti-CCP is strongly positive. Per EULAR 2022 guidelines, which is the recommended next step?
- A Add a biologic (TNF inhibitor or non-TNF biologic) or JAK inhibitor ✓
- B Switch to leflunomide monotherapy
- C Add hydroxychloroquine to methotrexate
- D Increase methotrexate to 25 mg/week
Correct answer: A. Add a biologic (TNF inhibitor or non-TNF biologic) or JAK inhibitor
Explanation
EULAR 2022 RA management recommendations state that if the treatment target (remission or low disease activity) is not achieved after adequate trial of first csDMARD (methotrexate), a bDMARD (biologic — TNF inhibitor, abatacept, rituximab, or IL-6 inhibitor) or a tsDMARD (JAK inhibitor) should be added, stratified by comorbidities and risk factors. DAS28 >3.2 indicates non-remission, justifying escalation. Simply adding hydroxychloroquine or switching to leflunomide without biologic therapy represents insufficient escalation at this disease activity level.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.