Rheumatology (autoimmune diseases, arthritis) — MCQs

Question 1: A 26-year-old woman presents with 8 weeks of symmetric polyarthritis affecting hands, wrists, and feet with 90 minutes of morning stiffness. RF negative, anti-CCP negative, ANA 1:160 (homogeneous), ESR 45 mm/hr. She has no rash, oral ulcers, or systemic symptoms. Radiographs show soft tissue swelling without erosions. She desires pregnancy within the year. Apply the most appropriate initial management considering her reproductive plans.

• A. Defer DMARD therapy until after pregnancy to avoid any fetal risk
• B. Initiate sulfasalazine given safety profile in pregnancy
• C. Start combination hydroxychloroquine and sulfasalazine for adequate disease control (Correct Answer)
• D. Begin hydroxychloroquine as pregnancy-compatible DMARD
• E. Start methotrexate with strict contraception counseling; switch when ready to conceive

Explanation: ***Start combination hydroxychloroquine and sulfasalazine for adequate disease control*** - This patient presents with **symmetric polyarthritis** and an elevated **ANA**, suggesting an early connective tissue disease or seronegative RA; the combination of **hydroxychloroquine and sulfasalazine** is the best choice for achieving remission while ensuring safety for **future pregnancy**. - Both medications are considered **Category B/C** but are standard of care in pregnancy-compatible DMARD regimens to prevent joint damage and systemic flares. *Start methotrexate with strict contraception counseling; switch when ready to conceive* - **Methotrexate** is absolutely **teratogenic** and must be discontinued at least 3 months prior to conception, making it suboptimal for someone wanting to conceive within the year. - Starting a known teratogen when a patient has active pregnancy plans within a short window increases the risk of **accidental fetal exposure**. *Begin hydroxychloroquine as pregnancy-compatible DMARD* - While **hydroxychloroquine** is safe in pregnancy, monotherapy may be insufficient to control **symmetric polyarthritis** with significant inflammatory markers (**ESR 45**). - A more robust initial approach with **combination therapy** is often preferred to quickly suppress inflammation before the patient conceives. *Initiate sulfasalazine given safety profile in pregnancy* - **Sulfasalazine** is safe in pregnancy (with folic acid supplementation), but as monotherapy, it may not provide adequate control for **ANA-positive** inflammatory arthritis. - Utilizing a single agent risks **persistent disease activity**, which itself is associated with poorer pregnancy outcomes compared to well-controlled disease. *Defer DMARD therapy until after pregnancy to avoid any fetal risk* - Deferring treatment is inappropriate as active **maternal inflammation** increases the risk of **preterm birth** and low birth weight. - Non-erosive arthritis can progress to **irreversible joint damage** if left untreated for the duration of a pregnancy and postpartum period.