Joint Pain and Anti-CCP Antibody

🗒️ Question

A 48 year old woman presents to clinic with a 6 month history of progressive joint pain and stiffness, predominantly affecting her wrists, hands and knees. The symptoms are worse in the morning, lasting more than an hour and improve with activity.

On examination, there is swelling and tenderness in the MCP and PIP joints of both hands, as well as the knees. Blood tests show elevated ESR and CRP and positive rheumatoid factor and anti-CCP antibody.

What is the most appropriate next step of management?

(A) Hydroxychloroquine and continued NSAIDs
(B) Methotrexate and folic acid
(C) Sulfasalazine with regular LFT monitoring
(D) Leflunomide and monthly blood monitoring
(E) TNF inhibitor and follow-up in 3 months