MKSAP: 49-year-old woman with worsening joint symptoms

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 49-year-old woman is evaluated for recently worsening joint symptoms. She has a 13-year history of Crohn disease characterized by four to six stools daily and mild crampy abdominal pain. She also has a 1-year history of arthritis. She currently has pain in the left knee, right ankle, and two joints of the right foot; diffuse swelling involving the left third toe; and 30 minutes of morning stiffness. She has been treated with various NSAIDs, which seem to worsen her bowel disease. She has tried, in succession, azathioprine, mesalamine, and methotrexate, without notable improvement in her symptoms. She currently is taking methotrexate.

On physical examination, vital signs are normal. The left knee has a small effusion. Dactylitis of the left third toe is present. The right ankle and the right second and third metatarsophalangeal joints are tender to palpation.

Which of the following is the most appropriate long-term treatment?

A. Adalimumab
B. Intra-articular glucocorticoid injections
C. Prednisone
D. Rituximab

MKSAP Answer and Critique

The correct answer is A. Adalimumab.

Adalimumab is the most appropriate treatment for this patient with inflammatory bowel disease–associated arthritis. Various pharmacologic agents may be useful in the treatment of both intestinal manifestations and peripheral arthritis related to Crohn disease and ulcerative colitis, including sulfasalazine, azathioprine, 6-mercaptopurine, methotrexate, glucocorticoids, and certain tumor necrosis factor (TNF)-α inhibitors. Adalimumab, certolizumab pegol, golimumab, and infliximab are more effective than other TNF-α inhibitors in treating the combination of bowel and joint manifestations. This patient with Crohn disease has developed peripheral oligoarthritis and dactylitis (“sausage digit”). She also has symptomatic bowel disease. She is most likely to improve her bowel and joint disease by the addition of a TNF-α inhibitor.

Intra-articular glucocorticoid injections can be used to treat inflammatory arthritis. However, the duration of symptom relief can be short term, practical use is limited by the size and number of joints involved, and this therapy will have no effect on the patient’s dactylitis or inflammatory bowel disease.

Glucocorticoids are effective for inducing but not maintaining remission in Crohn disease. Although prednisone could be used to improve the patient’s joint and bowel symptoms on a short-term basis, it is unlikely to control her bowel and joint symptoms in the long term and is increasingly likely to be associated with significant side effects the longer it is used.

Rituximab depletes B cells and is used in combination with methotrexate to treat rheumatoid arthritis in patients who have not adequately responded to a TNF-α inhibitor. Rituximab is not indicated for this patient’s arthritis or bowel disease and is not recommended.

Key Point

  • Long-term treatment options for bowel and joint symptoms associated with inflammatory bowel disease include sulfasalazine, azathioprine, 6-mercaptopurine, methotrexate, and the tumor necrosis factor α inhibitors adalimumab, certolizumab pegol, golimumab, and infliximab.

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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