Case Study About Rheumatoid Arthritis

Posted on 11/01/13

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?


According to Centers for Disease Control and Prevention (CDC) statistics, approximately 1.5 million US adults have RA, a chronic, autoimmune inflammatory disorder.1 The disease is characterized by synovial inflammation that causes stiffness and tenderness and can eventually lead to cartilage damage, bone erosions, and joint destruction. When inadequately treated, RA is associated with significant activity limitations and disability.2

In recent years, the primary therapeutic goals for patients with RA have shifted from relieving symptoms to reducing disease activity and progression.3 Many rheumatologists view remission as an attainable goal for their patients with RA. Regarding management strategies, research evidence and clinical experience support 2 key themes:

  • Treating early and aggressively with disease-modifying antirheumatic drug (DMARD) monotherapy or combination therapy
  • <span style="Times New Roman" "="">Tight control, or treating to the targets of low disease activity or remission

According to the updated 2012 guidelines of the American College of Rheumatology (ACR), patients recently diagnosed with RA (disease duration of less than 6 months) characterized by low disease activity should be treated with synthetic (nonbiologic) DMARD monotherapy.4 The standard first-line therapy is MTX (10-25 mg weekly), administered orally or subcutaneously. MTX acts by inhibiting the proinflammatory activity of autoreactive T cells, which play a key role in RA immunopathogenesis. Among other proposed mechanisms of action, methotrexate stimulates T-cell apoptosis.5 For patients with moderate disease activity and features of poor prognosis, methotrexate may be prescribed with other synthetic DMARDs, including sulfasalazine, leflunomide, or hydroxychloroquine.4

For patients recently diagnosed with moderately to severely active RA, or for patients with established RA (disease duration over 6 months) who do not respond to a synthetic DMARD, ACR guidelines recommend a tumor necrosis factor alpha (TNF-α) inhibitor, either alone or added to methotrexate.4 TNF-α inhibitors are biologic agents that bind soluble and membrane-bound TNF-α, a cytokine that causes joint inflammation and degeneration through various mechanisms. To date, 5 TNF-α inhibitors are approved by the FDA for treating moderate to severe RA: etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab. Clinical trials have consistently demonstrated that, compared with methotrexate alone, the addition of a TNF-α inhibitor is associated with significantly better clinical, radiologic, and functional outcomes.6 Adverse events associated with TNF-α inhibitors include injection- or infusion-site infections, tuberculosis, and opportunistic infections. Severe adverse events include malignancies, hepatitis B and C reactivation, hematologic abnormalities, and exacerbation of congestive heart failure.7

For patients with moderate to severe disease activity who do not respond to a TNF-α inhibitor, the ACR guidelines recommend the combination of methotrexate and a biologic agent that acts through mechanisms other than blocking the effects of TNF-α.8 These biologics include:

  • Rituximab, which depletes B cells and thereby inhibits their pro-inflammatory effects in RA
  • Abatacept, which inhibits the activation and harmful effects of autoreactive T cells
  • Tocilizumab, which blocks interleukin-6 (IL-6) signal transduction and thereby reduces the pro-inflammatory and degenerative effects of IL-6 on joint tissue

In clinical trials, patients treated with a biologic agent plus methotrexate have experienced significantly better clinical and radiologic outcomes compared with patients treated with methotrexate alone.6 Like TNF-α inhibitors, the addition of these biologics poses risks of injection- or infusion-site reactions, and patients are more susceptible to infections, especially opportunistic infections. In addition, these agents have been associated with exacerbations of chronic obstructive pulmonary disease (abatacept); rare cases of progressive multifocal leukoencephalopathy (rituximab); and elevated liver enzymes and lipids, neutropenia, and GI perforations (tocilizumab).8

As revealed through head-to-head comparison studies and meta-analyses, efficacy outcomes are generally similar for RA patients treated with different synthetic DMARDS and biologic agents, respectively.9 The Agency for Healthcare Research and Quality (AHRQ) commissioned a comprehensive analysis of new research findings, and in April 2012, published a systematic review, “Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis in Adults - Update.” The review was conducted by investigators at the RTI International University of North Carolina Evidence-Based Practice Center. The comparative effectiveness review is available at no charge on AHRQ's Effective Health Care Program website (

In conclusion, experts in rheumatology emphasize that optimal patient outcomes depend on compliance with the evidence-based and consensus therapeutic strategies of early, aggressive treatment and tight control. The ultimate patient-centered goals of therapy are to inhibit progressive structural damage, reduce comorbidity and mortality risks, restore function and quality of life, and achieve remission.4


1. Arthritis-Related Statistics. Center for Disease Control and Prevention. August 2011. 

2. Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001;358(9285):903-911

3. Mease PJ. Improving the routine management of rheumatoid arthritis: the value of tight control. J Rheumatol. 2010;37(8)1570-1578.

4. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res. 2012;64(5):625-639.

5. Segal R, Yaron M, Tartakovsky B. Methotrexate: mechanism of action in rheumatoid arthritis. Semin Arthritis Rheum. 1990;20(3):190-200.

6. McIness IB, O’Dell JR. State of the art: rheumatoid arthritis. Ann Rheum Dis. 2010;69:1898-1906.

7. Thalayasingam N, Issacs JD. Anti-TNF therapy. Best Pract Res Clin Rheumatol. 2011;25(4):549-567.

8. Agarwal SK. Biologic agents in rheumatoid arthritis: an update for managed care professionals. J Manag Care Pharm. 2011;17(9 Suppl.B):S14-18.

9. Donahue KE, Jonas DE, Hansen RA, et al. Comparative effectiveness of drug therapy for rheumatoid arthritis in adults – update. Comparative effectiveness review No. 55. Agency for Healthcare Research and Quality. AHRQ publication no.12-EHC025-EF. April 2012. 

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Life with Rheumatic Disease

The Simple Tasks campaign aims to educate rheumatology patients about policy issues impacting their care and encourage patients to advocate for healthcare policies that promote safe, effective, affordable, and accessible rheumatology care.

If you’re wondering what it’s like to live with a rheumatic disease, we invite you to explore these rheumatoid arthritis case studies and other case studies focusing on what it’s like to live with rheumatic diseases.


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Christine Schwab

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Shanelle Gabriel

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Leslie M.

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