02-23-2008, 06:41 PM
A 38-year-old man with a long and difficult history of Crohn disease comes to the clinic seeking advice on treatment options. His disease was controlled originally with sulfasalazine, but over the past 3 years has required multiple other agents, including trials of oral steroids, empiric antibiotics, and 6-mercaptopurine. He is currently on 6-mercaptopurine and sulfasalazine, but is still having multiple voluminous bowel movements per day and crampy abdominal pain. He does not wish to restart steroids, because he has required large doses of them in the past and states œthey make him crazy. If necessary, however, he will take steroids. Aside from his Crohn disease, his past medical history is unremarkable, as is the review of systems. Vital signs are: temperature 37.8 C (100.0 F), blood pressure 129/80 mm Hg, pulse 72/min, and respirations 20/min. A small aphthous ulcer is present in the patient™s mouth. Abdominal examination is diffusely tender to palpation, but without rebound or guarding. Rectal examination reveals the presence of old, healed perirectal fistulas. Stool is guaiac positive. After much discussion about the risks and benefits of immunomodulatory therapy, it is decided to start this patient on infliximab. Which of the following is important management when starting a TNF-alpha antagonist in this patient?
A. Begin daily prednisone for long-term control of symptoms
B. Examine a blood smear for evidence of lymphoma
C. Monitor anti-nuclear antibody (ANA) titers
D. Place a positive purified protein derivative (PPD) to screen for latent tuberculosis
E. Start trimethoprim-sulfamethoxazole prophylaxis
A. Begin daily prednisone for long-term control of symptoms
B. Examine a blood smear for evidence of lymphoma
C. Monitor anti-nuclear antibody (ANA) titers
D. Place a positive purified protein derivative (PPD) to screen for latent tuberculosis
E. Start trimethoprim-sulfamethoxazole prophylaxis