A 42-year-old woman with RA on methotrexate 20 mg/week and hydroxychloroquine develops worsening synovitis and DAS28-CRP of 4.8. Which biologic should be AVOIDED if she has a history of prior lymphoma 8 years ago (now in remission)?
- A Abatacept
- B Rituximab
- C Adalimumab ✓
- D Tocilizumab
Correct answer: C. Adalimumab
Explanation
TNF inhibitors (like adalimumab) are relatively contraindicated in patients with a history of lymphoma due to potential risk of lymphoma recurrence or development, particularly given that RA itself already increases lymphoma risk. Rituximab (anti-CD20) is actually considered relatively preferred in RA patients with prior lymphoma since it has anti-tumour activity. Abatacept and tocilizumab have more favourable profiles in the context of prior malignancy. Current ACR and EULAR guidelines recommend avoiding TNF-i when prior lymphoma history exists.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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