04-07-2008, 12:44 AM
A 28-year-old woman is evaluated for pain in her arms and legs of 7 years' duration that has recently worsened. She has a 7-year history of rheumatoid arthritis well controlled with methotrexate and etanercept. She has pain in her shoulders, back, elbows, wrists, hips, and knees. She does not have fever, rash, or weight loss. She has increased fatigue, particularly the day after any increased activity, such as grocery shopping.
On physical examination, there is mild interosseous muscle wasting but no synovitis, swelling, or warmth. On musculoskeletal examination, range of motion of the joints is full. Her pain is reproducible on palpation of the trapezius muscles, coracoid processes, bicipital tendons, lateral epicondyles, trochanteric bursae, and gluteal muscles.
On laboratory studies, complete blood count, erythrocyte sedimentation rate, creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone are normal.
Which of the following is the most appropriate initial management for this patient?
A Increase the methotrexate dose
B Add low-dose amitriptyline
C Add prednisone
D Change to another tumor necrosis factor antagonist
On physical examination, there is mild interosseous muscle wasting but no synovitis, swelling, or warmth. On musculoskeletal examination, range of motion of the joints is full. Her pain is reproducible on palpation of the trapezius muscles, coracoid processes, bicipital tendons, lateral epicondyles, trochanteric bursae, and gluteal muscles.
On laboratory studies, complete blood count, erythrocyte sedimentation rate, creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone are normal.
Which of the following is the most appropriate initial management for this patient?
A Increase the methotrexate dose
B Add low-dose amitriptyline
C Add prednisone
D Change to another tumor necrosis factor antagonist