A woman presented with active bilateral synovitis

A 36-year-old woman initially presented to her rheumatologist with active bilateral synovitis in her hands, wrists, and ankles, and nodules on her left elbow. Her laboratory results were as follows:

  • C-reactive protein (CRP) = 5.7 mg/dL (normal: 0.1–0.9 mg/dL)
  • Erythrocyte sedimentation rate (ESR) = 38 mm/h (normal: 0–15 mm/h)
  • Rheumatoid factor (RF) = 344 (normal: 0–29 IU/mL)
  • Cyclic citrullinated peptide (CCP) = 90 (normal: 0–20)
  • Other parameters within normal limits

A radiography revealed small erosions in both feet. She was subsequently diagnosed with moderate rheumatoid arthritis (RA) and started on methotrexate (MTX) at 10 mg/week, which was then increased to 15 mg/week. At her next visit, she reported some symptomatic relief after a few weeks of treatment. After 3 months, however, she visited her rheumatologist, presenting with stiffness, pain, and swelling in her wrists. Her sedimentation rate was elevated, and she complained that she could not be fully productive at work because of joint pain.

Questions to consider:

  • Can this patient be considered refractory to MTX?
  • How should this patient’s treatment regimen be modified?
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