Bones, Joint, Rheumatology

Question 1

Self-Assessment Questions
Answers and explanations to these questions can be found
at the end of the chapter.
1. J.T. is a 68-year-old woman returning to her primary
care practitioner’s office to review the results
of her most recent dual-energy x-ray absorptiometry
(DEXA) scan. Her physician reports that her lumbar
spine T-score is -2.1 standard deviations (SDs)
(Z-score -1.1). The physician also reports that J.T. has
a World Health Organization (WHO) Fracture Risk
Assessment Tool (FRAX) score of 12% for major
osteoporotic fracture and 4% for hip fracture. Which
is best for J.T.’s physician to consider to preserve her
bone density?

A. Initiate high-dose vitamin D (50,000 international
units) weekly for 8 weeks and then 2000 units
daily thereafter.
B. Initiate calcium carbonate plus vitamin D (600
mg elemental plus 400 international units) twice
daily.
C. Initiate alendronate 35 mg weekly plus calcium/
vitamin D supplementation.
D. Initiate alendronate 70 mg weekly plus calcium/
vitamin D supplementation.

Answer 1

1. Answer: D
   According to her DEXA scan results, the patient would
   traditionally be classified as having osteopenia in her
   lumbar spine. In many cases, this would require her to be
   treated only with calcium and vitamin D supplementation.
   However, because her 10-year risk of a hip fracture is
   greater than 3% with the FRAX tool, the NOF would consider
   this patient to have osteoporosis and recommend that
   she receive antiresorptive therapy. Of the choices, alendronate
   is the only agent to have antiresorptive properties,
   and of the two doses, 70 mg once weekly is recommended
   (Answer D is correct; Answers A–C are incorrect).
   Alendronate 35 mg once weekly is considered a prevention
   dose for bisphosphonates.

Question 2

2. D.M. is a 72-year-old woman presenting to her primary
   care provider for a routine follow-up. At the
   visit, her provider discusses with her that she has been
   taking alendronate 70 mg once weekly for the past 5
   years for osteoporosis (L2/L3 compression fracture
   post-fall). The physician would like to discontinue
   the medication and choose a different medication to
   maintain her bone mineral density (BMD). At her last
   dual-energy x-ray absorptiometry (DEXA) scan, the
   patient’s T-scores were -2.6 and -1.8 at the lumbar
   spine and hip, respectively. These values are relatively
   unchanged from her baseline. She has no renal
   or hepatic complications, and her metabolic profile is
   within normal limits. Which is best for the patient to
   replace alendronate?
   A. Risedronate 150 mg by mouth once per month.
   B. Raloxifene 60 mg by mouth once per day.
   C. Teriparatide 20 mcg subcutaneous injection once
   per day.
   D. Denosumab 60 mg subcutaneous injection once
   every 6 months.

Answer 2

2. Answer: D
   The patient should restart therapy but change to a nonbisphosphonate
   antiresorptive agent. Using an agent
   for osteoporosis for this patient is important because of
   her history of osteoporosis with fracture. Continuing a
   bisphosphonate is an option, but the likelihood of a serious
   adverse event (MRONJ [medication-related osteonecrosis
   of the jaw], atypical femur fracture) increases with duration
   of bisphosphonate use. Reducing the dose would not be
   appropriate for secondary fracture prevention. Although
   raloxifene is efficacious for secondary fracture prevention,
   its usefulness is more for preventing breast cancer in
   women at high risk, and it is not cost-effective to use routinely
   for fracture prevention. Denosumab is the best option
   for this patient because it will maintain the same efficacy
   as a bisphosphonate for fracture prevention (Answer D is
   correct; Answers A–C are incorrect). Unfortunately, we do
   not yet know whether the risk of serious adverse events
   is increased with the duration of sequenced medication
   use (i.e., bisphosphonate to RANKL inhibitor). An anabolic
   agent should be reserved for future use, more severe
   disease, lack of response, and/or contraindication to antiresorptive
   therapies.

Question 3

3. C.A. is a 69-year-old woman with rheumatoid arthritis
   (RA). She is treated with oral methotrexate 15
   mg once weekly, prednisone 10 mg once daily, and
   naproxen 500 mg twice daily as needed. On returning
   for a follow-up with her rheumatologist, she is
   instructed to decrease prednisone to 7.5 mg once daily
   for another 6 months. A recent DEXA scan reveals an
   11% decrease in her lumbar spine since her DEXA
   about 1 year ago. According to the American College
   of Rheumatology (ACR), which approach is best to
   prevent osteoporosis?
   A. No intervention is required because the patient is
   premenopausal.
   B. Administer calcium carbonate 500 mg plus cholecalciferol
   400 units twice daily.
   C. Administer risedronate 150 mg monthly plus calcium
   and cholecalciferol supplementation.
   D. Administer raloxifene 60 mg once daily plus calcium
   and cholecalciferol supplementation.

Answer 3

3. Answer: C
   According to the latest edition of the ACR’s guidelines for
   managing glucocorticoid-induced osteoporosis, bisphosphonates
   should be used for patients older than 40 with
   moderate fracture risk (according to Z-score) if they are
   using 7.5 mg or more of prednisone daily for more than
   6 months. Because the patient meets these criteria, risedronate
   150 mg monthly plus calcium and vitamin D supplementation is warranted (Answer C is correct;
   Answers A, B and D are incorrect).

Question 4

4. F.R. is a 62-year-old woman with RA. She currently
   uses etanercept 50 mg subcutaneously once weekly
   and ibuprofen 600 mg every 6 hours as needed for
   pain. At her latest visit to her primary care physician’s
   office, she states that she will be traveling abroad later
   this year and needs typhoid vaccination. Which is
   most appropriate for her at this time?
   A. Hold etanercept for 1 month; then vaccinate with
   intramuscular Typhim Vi.
   B. Start vaccination today with oral typhoid vaccine
   (Vivotif).
   C. Vaccinate today with intramuscular typhoid vaccine
   Typhim Vi.
   D. She is not a candidate for typhoid vaccination.

Answer 4

4. Answer: D
   Patients with RA receiving bDMARDs should not be
   administered live vaccines such as oral typhoid. The intramuscular
   typhoid vaccination is an inactivated vaccine
   and is therefore safe to administer in patients receiving
   bDMARDs. It is unnecessary to hold biologics before vaccination
   with an inactivated vaccine (Answer D is correct;
   Answers A–C are incorrect).

Question 5

5. A.T. is a 26-year-old woman who presents to a rheumatologist
   after being given a diagnosis of RA. She
   has symptoms in her elbows, knees, and hips and
   easily becomes fatigued throughout the day. She has
   difficulty dressing in the morning and has missed 10
   days of work in the past 90 days because of her symptoms.
   Her laboratory results suggest RA, and she has
   no evidence of blood, liver, or kidney disease. She
   is married but does not plan to have children in the
   foreseeable future. Her medical history is significant
   for menorrhagia, for which she has been using a lowdose
   ethinyl estradiol/norgestimate monophasic pill
   for the past 3 years. Which medication would be best
   for the patient, according to the 2015 ACR treatment
   recommendations?
   A. Methotrexate 10 mg by mouth once weekly plus
   folic acid 1 mg once daily.
   B. Leflunomide 10 mg by mouth daily.
   C. Adalimumab 40 mg subcutaneously every other
   week.
   D. Tofacitinib 5 mg by mouth twice daily.

Answer 5

5. Answer: A
   For this patient, the ACR 2015 treatment recommendations
   encourage providers to use methotrexate as a first-line
   agent for patients presenting within the first 3 months of
   diagnosis. Although leflunomide may be an option, it is
   recommended as an add-on to methotrexate if monotherapy
   insufficiently controls the patient’s symptoms. A TNF
   inhibitor such as adalimumab could also be an option and
   would have been an option for this patient using the 2012
   guideline update, but it has been moved to second line,
   after failure of methotrexate, for the 2015 iteration (Answer
   A is correct; Answers B-D are incorrect). The JAK inhibitor
   tofacitinib is recommended for disease-naive patients
   (less than 6 months) whose second-line measures fail or
   for disease-experienced patients (more than 6 months) in
   whom at least a TNF inhibitor fails.

Question 6

6. J.P. is a 34-year-old man with a medical history significant
   for psoriasis. For the past 15 years, he has
   been treated successfully with hydrocortisone cream
   and moisturizers, rarely requiring oral systemic corticosteroids.
   Today, he presents to his primary care
   physician’s office with a worsening joint pain in his
   hands and elbows. He says the pain is minimal (2/10),
   but annoying. He has been receiving sufficient pain
   relief from naproxen 500 mg twice daily as needed
   but wonders if he could be doing more. On physical
   examination, he has actively inflamed joints in his left
   hand. His physician performs some radiographic evaluations,
   which reveal signs of axial disease, and the
   physician determines that J.P.’s symptoms are likely
   caused by psoriatic arthritis (PsA). Given the patient’s
   presentation, which is the best regimen for treating his
   arthritic symptoms?
   A. Continue naproxen 500 mg twice daily as needed.
   B. Initiate sulfasalazine 500 mg twice daily.
   C. Initiate etanercept 50 mcg twice weekly.
   D. Initiate etanercept 50 mcg twice weekly plus sulfasalazine
   1000 mg three times daily.

Answer 6

6. Answer: A
   According to the ACR and GRAPPA, patients with minimal
   to no functional limitations from PsA should be treated
   only with NSAIDs or other analgesics. When the symptoms
   progress to moderate severity and affect the patient’s
   activities of daily living, or when the symptoms do not
   respond to simple analgesics, providers should consider
   adding either a DMARD (e.g., sulfasalazine) or a biologic
   agent (e.g., etanercept). Combination DMARD and biologic
   agent should be reserved for patients with severe disease or
   for those whose condition does not respond to either agent
   alone (Answer A is correct; Answers B-D are incorrect).

Question 7

7. J.O. is a 76-year-old woman with a history of type 2
   diabetes and chronic stable angina (medically managed).
   She has bilateral knee osteoarthritis (OA) pain
   that has not been sufficiently controlled with physical
   therapy or acetaminophen 1000 mg every 6 hours. She
   cannot perform many activities of daily living because
   she requires a walker, which considerably impairs her
   mobility. Which regimen is best to help alleviate the
   patient’s chronic pain?
   A. Meloxicam 7.5 mg once daily.
   B. Topical diclofenac 1% gel.
   C. Ketorolac 10 mg every 6 hours.
   D. Morphine sulfate extended release 15 mg twice
   daily.

Answer 7

7. Answer: B
   For this patient, the next best choice for pain relief is topical
   diclofenac 1% gel. The ACR 2012 guidelines do not recommend
   the routine use of opiate analgesia for OA pain. In
   addition, given her history of ischemic heart disease, she should avoid using meloxicam or oral diclofenac because
   of an FDA report regarding NSAID use and risk of CV
   events. Although diclofenac gel is an NSAID, its topical
   application limits the amount of systemic absorption and
   possibly systemic adverse events (Answer B is correct;
   Answers A, C and D are incorrect). Patients who use topical
   NSAIDs are at a higher risk of dermatologic reactions
   than those who use systemic NSAIDs.

Question 8

8. T.Q. is a 29-year-old woman without obesity who has
   been treated with hydroxychloroquine for systemic
   lupus erythematosus (SLE) for the past 3 years. Her
   current dose is 400 mg once daily (about 5.4 mg/kg).
   She speaks with her pharmacist, who asks whether she
   has been receiving regular ophthalmologic screenings
   for patients chronically treated with hydroxychloroquine.
   The patient has never had her eyes checked.
   Which would be the best recommendation for this
   patient’s current and future ophthalmologic screening?

A. Initial screening now and then every 5 years.
B. Initial screening now and then annually thereafter.
C. Initial screening now and then annually starting
at year 5.
D. Initial screening now and then every 6 months
starting at year 5.

Answer 8

8. Answer: B
   Even though the patient has used hydroxychloroquine for
   less than 5 years, her current daily dose is greater than
   5 mg/kg/day, placing her in a higher-risk category for
   hydroxychloroquine-related ocular complications. People
   in the major risk category should have a baseline, followed
   by annual, funduscopic examination. (Answer B is correct;
   Answers A, C and D are incorrect)

Question 9

9. R.V. is a 42-year-old woman with a significant history
   of depression and schizophrenia. Her current drug regimen
   is ziprasidone 40 mg twice daily and selegiline
   transdermal 6 mg/24 hours. Her symptoms are consistent
   with fibromyalgia syndrome, but she has been
   reluctant to start treatment until now because she was
   afraid it would interfere with her other mental health
   medications. However, the symptoms have worsened
   during the past 6 months, and she now asks to begin
   therapy. Which medication would be the best for R.V.
   to begin taking?
   A. Nortriptyline 25 mg once daily in the evening.
   B. Gabapentin 100 mg twice daily.
   C. Pregabalin 75 mg twice daily.
   D. Duloxetine 60 mg once daily.

Answer 9

9. Answer: C
   The patient would best begin treatment with pregabalin
   75 mg twice daily. Although all the medications listed are
   appropriate for treating fibromyalgia syndrome, several
   issues need to be considered. Nortriptyline and duloxetine
   would create a significant drug-drug interaction with
   transdermal selegiline because it inhibits both monoamine
   oxidase A and monoamine oxidase B (nonselective), most
   likely resulting in hypertensive crisis and/or serotonin syndrome.
   However, this is not true for oral selegiline. Oral
   selegiline at a dose of 5 mg twice daily maintains specificity
   to inhibit monoamine oxidase B, which is primarily
   responsible for monoamine oxidase activity in platelets
   and the brain. Because of this selectivity, when used at
   approved doses, oral selegiline and other serotonergics
   pose no increased risk of serotonin syndrome. The gabapentin
   dose is too low for the patient and would most likely
   not have a clinically significant change in her symptoms.
   The target dose for gabapentin for fibromyalgia is 1800–
   2400 mg daily (divided three times). (Answer C is correct;
   Answers A, B and D are incorrect)

Question 10

10. L.L. is a 58-year-old man with chronic tophaceous
    gout and stage 4 chronic kidney disease (CKD). He
    reports only taking over-the-counter (OTC) ibuprofen
    for gout in the past but states he was told to stop
    because it “hurt his kidneys.” He states that the tophi
    sometimes bother him and that he has two or three
    attacks per year. The patient has 10–12 alcoholic
    drinks a day and regularly consumes a lot of meat proteins.
    In addition to dietary counseling, which therapy
    is best to decrease tophi and prevent gouty attacks in
    this patient?
    A. No therapy is required until he has two or more
    gouty attacks in a 12-month period.
    B. Administer allopurinol 50 mg once daily, slowly
    titrated over the next few months.
    C. Administer allopurinol 300 mg once daily, slowly
    titrated over the next few months.
    D. Administer colchicine 0.6 mg three times weekly.

Answer 10

10. Answer: B
    The patient has CKD, thereby limiting the choice of medications
    and doses that can be used to prevent recurrent
    gouty attacks. The patient is a candidate for gout prevention
    and treatment of hyperuricemia. The number of attacks per
    year does not factor in when initiating therapy. Colchicine
    does not affect tophi formation. Xanthine oxidase inhibitors
    (allopurinol first line) are the drug of choice for patients
    with tophi. The ACR guidelines state that in patients with stage 4 CKD or worse, allopurinol therapy can be initiated
    at 50 mg/day, increasing the dose every 2–5 weeks to
    achieve the desired uric acid concentrations; doses greater
    than 300 mg/day are allowed but with appropriate patient
    education and monitoring for toxicity (Answer B is correct;
    Answers A, C and D are incorrect)

Question 11

Patient cases

1. F.R. is a 74-year-old woman with a history of a right hip replacement after a fall and fracture. In addition to her
   hip fracture, she has a history of type 2 diabetes (most recent hemoglobin A1C 7.3%) and hypothyroidism (current
   thyroid-stimulating hormone concentration [TSH] 0.1 mIU/L), for which she receives treatment. A dual-energy
   x-ray absorptiometry (DEXA) revealed F.R.’s T-score at her femoral neck as -2.7. The Z-score associated with her
   femoral neck T-score was -2.1. Her physician believes this was a fracture secondary to drug-induced bone density
   loss. Which medication most likely contributed to her bone mineral density (BMD) loss and fracture?
   A. Metformin.
   B. Glipizide.
   C. Levothyroxine.
   D. Lovastatin.

Answer 11

1. Answer: C
   Many medications contribute to BMD loss by either accelerating
   bone resorption or inhibiting osteogenesis. For this
   patient, levothyroxine most significantly affected her BMD
   by speeding up the bone resorption process (Answer C is
   correct; Answers A, B, and D are incorrect). Excessive
   thyroid hormone supplementation or drug-induced hyperthyroidism
   places patients at risk of OA and fracture.
   Practitioners should be cognizant of TSH and free thyroid
   hormone concentrations, treating patients to a euthyroid
   state and a TSH concentration of around 2.0–3.0 mIU/L.
   This suggestion does not apply to patients who require
   maximal thyroid hormone suppression (i.e., have a history
   of thyroid cancer).

Question 12

2. M.J. is a 61-year-old white woman (height 65 inches, weight 68 kg) who consults with her pharmacist about how best
   to preserve her bone density and prevent a fracture. The patient’s medical history is significant for a maternal hip
   fracture (mother was age 71). Her 10-year risk of a major osteoporotic fracture (FRAX score) is estimated at 19%
   and, for the hip, 6.3%. From these results, which is the best course of action for the pharmacist to take?
   A. Recommend that the patient contact her primary care provider to request a DEXA scan.
   B. Recommend that the patient contact her primary care provider to request a DEXA scan and start calcium
   plus vitamin D supplementation.
   C. Recommend that the patient contact her primary care provider to request a DEXA scan, start calcium plus
   vitamin D supplementation, and start taking a bisphosphonate.
   D. Recommend that the patient NOT have a DEXA scan and that she begin calcium plus vitamin D supplementation
   and start taking a bisphosphonate.

Answer 12

2. Answer: B
   The patient in question has not yet had a DEXA scan or
   received a T-score for her lumbar spine or femoral neck.
   Therefore, antiresorptive therapy is unwarranted until
   the results are available. She should begin treatment with
   calcium and vitamin D to preserve BMD. If the DEXA
   scan reveals osteopenia (T-score between -1.0 and -2.5),
   bisphosphonate therapy should be initiated because the
   patient’s risk of hip fracture in the next 10 years is greater
   than 3% (Answer B is correct; Answers A, C and D are
   incorrect)

Question 13

3. O.T. is a 65-year-old woman given a diagnosis of osteopenia after a scheduled DEXA scan. Her other medical conditions
   include type 2 diabetes, irritable bowel syndrome, gastroesophageal reflux disease, and migraine headaches.
   Her medications include metformin, pantoprazole, amitriptyline, and sumatriptan. She regularly participates in
   aqua aerobics and walking and uses laundry detergent bottles to strengthen her upper body. Her dietary calcium
   intake is limited to 1 glass of milk (8 oz each) per day. She has not yet started calcium, but she would like to add it
   to her medications and daily supplements. Which OTC calcium regimen is best to recommend for her?
   A. Calcium carbonate 600 mg/vitamin D 500 international units 1 tablet twice daily with food.
   B. Calcium carbonate 600 mg/vitamin D 500 international units 2 tablets twice daily with food.
   C. Calcium citrate 315 mg/vitamin D 500 international units 1 tablet twice daily.
   D. Calcium citrate 315 mg/vitamin D 250 international units 2 tablets twice daily.

Answer 13

3. Answer: D
   Because the patient has an extensive history of GI disease
   and receives chronic therapy with a PPI, she will most
   likely benefit from treatment with a calcium citrate supplement.
   Calcium carbonate salts, when administered with an
   acid-suppressing agent, yield less calcium availability than
   a calcium citrate formulation. However, when converting
   from a calcium carbonate tablet to a calcium citrate tablet,
   the “serving size” is usually doubled, and the patient
   requires 2 tablets of calcium citrate to equal the elemental
   calcium in 1 calcium carbonate tablet (Answer D is correct;
   Answers A–C are incorrect) The maintenance therapy of
   vitamin D3 is 1000-2000 IU daily.

Question 14

4. E.U. is a 58-year-old woman with a medical history significant for primary progressive multiple sclerosis with
   severe limitation, for which she spends most of her time in bed or lying on a couch. She tries to ambulate but cannot
   do so without a walker and/or assistance. Her DEXA scan reveals osteoporosis of the lumbar spine, and she
   now requires treatment. She has no history of fracture. Her provider deems her disease in the “high-risk” category.
   She already takes 1200 mg of calcium carbonate daily (600 mg twice daily) and 800 units of vitamin D (400 units
   twice daily). Which is best for E.U. to prevent vertebral fracture?
   A. Zoledronic acid 5-mg infusion once yearly.
   B. Risedronate 150-mg tablet once monthly.
   C. Raloxifene 60-mg tablet once daily.
   D. Romosozumab 210 mg once monthly.

Answer 14

4. Answer: A
   This patient’s inability to be mobile (and possibly upright)
   drastically limits her medication choices for the primary
   prevention of an osteoporotic fracture. Zoledronic acid
   seems to be the most appropriate agent because data analyses
   support its ability to maintain vertebral bone density, and patients do not have to adhere to strict post-dosing
   restrictions when using it. Risedronate is appropriate if the
   patient can remain upright for 30–60 minutes, but this may
   be too physically demanding for the patient. Romosozumab
   is reserved for patients as a later line option would be a
   poor choice for the patient. Raloxifene has a high incidence
   of venous thromboembolism and, in conjunction with the
   patient’s limited mobility, might increase her risk of a
   venous thromboembolism (Answer A is correct; Answers
   B-D are incorrect)

Question 15

5. K.W. is a 37-year-old female executive (height 64 inches, weight 70 kg [155 lb]) with RA (diagnosed 3 months ago),
   type 2 diabetes, and hypertension who smokes cigarettes. Her basic metabolic profile and complete blood cell
   count (CBC) are all within normal limits. Her RF is about 4 times the upper limit of normal; she has elevated anticyclic
   citrullinated peptide antibody values and ESR (high disease activity). Her radiographs reveal evidence of
   bony erosions. During the 2 months before her diagnosis, she had severe functional limitation, sometimes missing
   work because she could not prepare herself in a timely fashion. She is married and has two children with no plans
   for additional children. According to the ACR recommendations, which medication regimen is best for K.W.?
   A. Hydroxychloroquine 400 mg once daily and folic acid 1 mg daily.
   B. Methotrexate 10 mg once weekly titrated to a target dose of 20–25 mg once weekly and folic acid 1 mg daily.
   C. Methotrexate 10 mg once weekly, folic acid 1 mg daily, and infliximab 3 mg/kg every 8 weeks.
   D. Methotrexate 10 mg once weekly, folic acid 1 mg daily, and anakinra 100 mg daily.

Answer 15

5. Answer: B
   The 2015 update to the ACR recommendations for managing
   RA advocate DMARD monotherapy, particularly
   methotrexate, for all patients regardless of their disease
   severity and time since symptom onset. For this patient,
   Answer B is correct. She may combine TNF inhibitors
   with methotrexate, but this would be only after she cannot
   achieve disease remission with methotrexate alone.
   Hydroxychloroquine alone is not a preferred DMARD
   monotherapy, and combining anakinra with methotrexate
   would be inappropriate; anakinra is not included in the
   guidelines as an appropriate biologic option because of its
   lack of efficacy in patients with RA (Answer B is correct;
   Answers A, C and D are incorrect).

Question 16

6. T.D. is a 28-year-old female graduate student meeting with a rheumatologist regarding worsening RA symptoms.
   She currently takes methotrexate 20 mg by mouth weekly, folic acid 1 mg by mouth daily, and naproxen 500 mg by
   mouth twice daily as needed for pain. Her symptoms have been worse during the past 3 months, and she has been
   using naproxen around-the-clock for the past 30 days. Which is best to help T.D. control her symptoms?
   A. Recommend that she change methotrexate to hydroxychloroquine 200 mg once daily.
   B. Increase methotrexate to 30 mg weekly.
   C. Continue methotrexate and add adalimumab 40 mg subcutaneously every other week.
   D. Replace methotrexate with infliximab 3 mg/kg intravenously every 8 weeks.

Answer 16

6. Answer: C
   Although the maximal studied dose of methotrexate for
   patients with RA can be up to 30 mg weekly, the maximal
   recommended dose is 25 mg weekly. If a patient reaches
   the 25-mg dose by mouth without sufficient clinical effect,
   a prescriber should reconsider the effectiveness of the
   current therapeutic approach. Hydroxychloroquine is not
   recommended as monotherapy in a patient who has not
   responded adequately to methotrexate. Both adalimumab
   and infliximab are TNF inhibitors, but only adalimumab
   can be used as monotherapy (between the two agents).
   Infliximab should always be given in combination with
   methotrexate (Answer C is correct; Answers A, B and D
   are incorrect).

Question 17

7. D.K. is a 37-year-old woman with RA for the past 8 years. She is currently treated with methotrexate 25 mg orally
   once weekly and etanercept 50 mg subcutaneously once weekly, but she returns to the rheumatology office today
   with worsening RA symptoms (classified as moderate to severe disease). She previously tried infliximab; however,
   she developed an infusion-related reaction to treatment and was subsequently changed to etanercept. Her concerns
   were the same 6 months ago, but she was given a course of oral corticosteroids in the hope that they would cause
   her symptoms to remit. However, her symptoms are still present and worsening. Which is the best next step to help
   control the patient’s RA and symptoms?
   A. Initiate another course of prednisone, but increase the dose to 20 mg daily and continue indefinitely.
   B. Add another anti-TNF agent to the patient’s regimen, such as adalimumab.
   C. Discontinue etanercept, and initiate abatacept therapy for the patient.
   D. Continue etanercept, and initiate abatacept therapy for the patient.

Answer 17

7. Answer: C
   The patient should discontinue etanercept and begin
   therapy with abatacept. The ACR recommends abatacept
   for patients without an adequate rheumatologic response
   to methotrexate and an anti-TNF agent, which would be
   appropriate for this patient, especially given that she has tried two anti-TNF agents. Increasing and continuing
   prednisone may help alleviate pain, but long-term treatment
   with corticosteroids is not warranted for everyone,
   and efforts should focus on the best way to maximally suppress
   bone deformation. Adding another anti-TNF agent or
   combining abatacept with an anti-TNF agent is also not
   recommended due to additive risk of infection (Answer C
   is correct; Answers A, B and D are incorrect).

Question 18

8. T.M. is a 42-year-old man with a medical history significant for psoriasis and PsA. His current medications include
   topical betamethasone/calcipotriene and diclofenac extended release 150 mg daily. His psoriatic arthritis symptoms,
   including peripheral joint swelling and pain in his right hand and both feet with new-onset axial symptoms,
   have worsened during the past 12 months, but he has been reluctant to use anything more than an NSAID. A recent
   imaging study reveals sacroiliitis. He has extreme debilitation more days than not and sometimes requires assistance
   with tasks such as dressing and simple cleaning. If he chooses to intensify his therapy, which is the best approach?
   A. Prednisone 10 mg once daily for 6 weeks.
   B. Methotrexate 10 mg once weekly.
   C. Golimumab 50 mg once monthly.
   D. Methotrexate 10 mg once weekly plus golimumab 50 mg once monthly.

Answer 18

8. Answer: D
   The patient presents with severe PsA with axial symptoms
   and requires treatment with a combination biologic and
   synthetic DMARD – in this case, golimumab and methotrexate.
   Although using either agent alone may help alleviate
   the symptoms, the extreme severity of the patient’s symptoms
   requires an aggressive treatment approach that can
   eventually be decreased once his symptoms are lessened
   with combination therapy. Systemic corticosteroids are not
   recommended in patients with PsA. This is an insufficient
   dose of burst therapy, and systemic corticosteroids should
   not be used as chronic maintenance therapy for controlling
   PsA symptoms (Answer D is correct; Answers A–C are
   incorrect).

Question 19

9. T.W. is a 67-year-old man with severe degenerative joint disease of his right knee. His medical history is significant
   for coronary artery disease (myocardial infarction 6 years earlier), heart failure (ejection fraction 30%), hypertension,
   erectile dysfunction, and gastroesophageal reflux disease. He takes lovastatin 40 mg daily, fosinopril 20 mg
   daily, carvedilol 12.5 mg twice daily, aspirin 81 mg daily, calcium carbonate chewable tablets as needed (about
   three times weekly), and sildenafil 25 mg as needed. His knee pain causes significant physical limitations, and he
   is embarrassed to use an electronic cart when he shops at grocery and department stores. He would like to be more
   active but has difficulty even with the activities of daily living. Given this information, which is the best initial
   choice for this patient’s knee OA?
   A. Take acetaminophen 650 mg two tablets every 6 hours as needed for pain.
   B. Take ibuprofen 400 mg one tablet every 6 hours as needed for pain.
   C. Take naproxen 500 mg one tablet every 12 hours as needed for pain.
   D. Apply diclofenac 1% gel to affected knee up to four times daily.

Answer 19

9. Answer: D
   The man in this case has moderate to severe OA of the
   knee that causes considerable limitations in the activities
   of daily living. Given his history of a myocardial infarction,
   ibuprofen is discouraged by the ACR for pain control
   because of its potential interaction to decrease the cardioprotective
   efficacy of aspirin. Although naproxen is
   recommended over ibuprofen, the patient’s heart failure
   could be made worse with scheduled use. The acetaminophen
   dose exceeds 4 g daily. The topical NSAID is
   appropriate for this person because of its low likelihood of
   adverse events and interactions with other medications and
   diseases (Answer D is correct; Answers A–C are incorrect).

Question 20

10. M.F. is a 32-year-old woman presenting to her primary care physician’s office with fatigue, “pain all over,” and
    headaches for the past 4 weeks. She has a history of major depression but has successfully been treated with regular
    counseling. She has a dull, aching pain most days in her shoulders and upper arms (bilateral), hips (bilateral),
    neck, and lower back. She says that she has fatigue daily (cannot play with children), difficulty sleeping 2 or 3
    nights per week, and chronic headaches. She heard from a friend that she has all the symptoms of fibromyalgia,
    and she would like to be treated for it. Which is the best response for the physician to provide to the patient?
    A. Her symptoms do not meet the fibromyalgia diagnosis criteria.
    B. Her fibromyalgia would benefit most from tai chi.
    C. Her fibromyalgia requires drug therapy.
    D. Her fibromyalgia will require treatment with a two-drug regimen.

Answer 20

10. Answer: A
    Although the patient’s physical symptoms meet the criteria
    for diagnosing fibromyalgia (WPI score 8 and SSS
    estimated to be greater than 5), she has had these symptoms
    for only the past 4 weeks. According to the ACR, the
    patient must have had symptoms for at least 3 months and
    elevated WPI and SSS scores. If these symptoms continue,
    the patient will qualify for a diagnosis of fibromyalgia,
    and she should be treated with a tricyclic antidepressant
    such as amitriptyline. If she does not have sufficient pain
    relief or if she has adverse events, she may try one of the alternative agents such as duloxetine, fluoxetine, or gabapentin
    (Answer A is correct; Answers B-D are incorrect).

Question 21

11. S.E. is a 39-year-old woman with a medical history significant for minor depressive disorder. She presents to a
    medication management clinic after starting amitriptyline therapy for fibromyalgia. She increased the dose to 50
    mg during the past 4 weeks but with no significant change in her symptoms. However, she does report that her
    negative feelings have lessened and her sleep is much improved, but the pain and discomfort associated with her
    fibromyalgia remain. She asks for a new medication to help control her symptoms. Which medication would be
    best to replace amitriptyline?
    A. Gabapentin titrated to 800 mg three times daily.
    B. Pregabalin 75 mg twice daily.
    C. Duloxetine 30 mg once daily titrated to 60 mg once daily.
    D. Tramadol 50 mg every 6 hours as needed for pain.

Answer 21

11. Answer: C
    This patient may benefit most from a trial of duloxetine 60
    mg once daily. She has minor depressive disorder and states
    that some of her symptoms (sad feelings and sleep issues)
    have improved with the tricyclic antidepressant but that the
    main reason for the medication (her pain) was unaffected.
    When patients do not respond to first-line treatment, alternative
    agents should be used. The α2δ ligands (gabapentin
    and pregabalin) are acceptable, but her beneficial response
    for non-pain symptoms with the antidepressant would warrant
    a trial of another agent with antidepressant properties.
    In addition, tramadol is recommended only for patients
    with fibromyalgia when all other alternative agents have
    been tried and have failed (Answer C is correct; Answers
    A, B and D are incorrect).

Question 22

12. D.B. is a 29-year-old woman with a medical history significant for SLE and lupus nephritis. Her current treatment
    is hydroxychloroquine 200 mg once daily, but she continues to have complications because of the disease, including
    persistent proteinuria and serositis. To control her symptoms, which intervention would be best?
    A. Increase the hydroxychloroquine dose to achieve a serum concentration greater than 1000 ng/mL.
    B. Add prednisone 40 mg daily for the next 6 months.
    C. Add omega-3 fatty acids (eicosapentaenoic acid 1.8 g and docosahexaenoic acid 1.2 g) per day.
    D. Add azathioprine 2 mg/kg/day.

Answer 22

12. Answer: D
    In this patient’s situation, adding azathioprine will offer
    more benefit than the other listed options. In patients with
    SLE and evidence of lupus-related organ damage, adding
    an immunologic agent is warranted when the patient
    lacks a sufficient response to an antimalarial agent such
    as hydroxychloroquine. The practice of treating patients to
    a serum hydroxychloroquine concentration of greater than
    1000 mg/mL has not proven beneficial. In addition, using
    systemic corticosteroid doses greater than 10 mg daily
    for extended periods is not recommended. Introducing
    an immunologic agent is meant to control symptoms and
    limit the amount of systemic corticosteroid use in a patient.
    Although fish oil reduces disease severity scores for those
    with SLE, the presence of target-organ damage requires
    more aggressive treatment (Answer D is correct; Answers
    A–C are incorrect).

Question 23

13. M.K. is a 46-year-old man with a medical history significant for chest pain with exertion, dyslipidemia, impaired
    fasting glucose, hypertension, obesity, and gout (one episode, 5 months ago). His current medications include simvastatin
    40 mg daily, nicotinic acid (extended release) 1000 mg at bedtime, lisinopril 40 mg daily, amlodipine 5 mg
    daily, and aspirin 81 mg daily. He presents to his primary care practitioner’s office with symptoms consistent with
    gout in his left first metatarsophalangeal joint and left ankle, starting this morning. The metatarsophalangeal joint
    is swollen, inflamed, erythematous, and sensitive to light touch. Which is the best approach for M.K.’s therapy?
    A. Colchicine 1.2 mg for first dose and then 0.6 mg 1 hour after and daily until symptoms resolve.
    B. Colchicine 1.2 mg for first dose and then 0.6 mg 1 hour after; also, initiate allopurinol 300 mg once daily.
    C. Colchicine 1.2 mg for first dose and then 0.6 mg every hour thereafter as tolerated.
    D. Colchicine 1.2 mg for first dose and then 0.6 mg every hour thereafter as tolerated; also, initiate allopurinol
    300 mg once daily.

Answer 23

13. Answer: A
    Because this patient is having an acute gouty attack, allopurinol
    is inappropriate. Allopurinol should be initiated at
    a starting dose (100 mg), but the time separating the acute
    attack and the prophylaxis remains unanswered (immediate
    vs. 1–2 weeks later). Older data analyses suggest that
    starting ULT during an acute attack will prolong the attack
    because uric acid is mobilized out of the joint space too
    quickly; however, newer evidence suggests this is not true,
    but the evidence is very limited. Therefore, many clinicians
    still choose to wait until the acute attack is resolved before
    initiating ULT. For colchicine, the maximum daily dose is 1.8 mg because of safety concerns and lack of efficacy with
    higher doses. The “as-tolerated” instructions for Answers
    C and D would place the patient at risk of overdosing and
    could cause the patient to have GI adverse effects and even
    life-threatening hematologic effects (Answer D is correct;
    Answers A–C are incorrect).

Question 24

14. Y.W. is a 58-year-old man with a medical history significant for hypertension, type 2 diabetes, dyslipidemia, and
    obesity. His medications include glimepiride 2 mg daily, hydrochlorothiazide 12.5 mg daily, bisoprolol 5 mg daily,
    and simvastatin/ezetimibe 20/10 mg at night. During a routine laboratory evaluation, his primary care provider
    finds his serum uric acid concentration to be 7.3 mg/dL. Which is the most appropriate strategy to decrease the
    patient’s serum uric acid concentration?
    A. Therapy is not indicated because the patient has not yet had a gouty attack.
    B. Initiate allopurinol 100 mg daily and titrate to achieve a serum uric acid concentration less than 6 mg/dL.
    C. Initiate febuxostat 40 mg daily and titrate to achieve a serum uric acid concentration less than 6 mg/dL.
    D. Initiate probenecid 500 mg twice daily and titrate to achieve a serum uric acid concentration less than 6 mg/dL.

Answer 24

14. Answer: A
    The patient should not be treated for hyperuricemia.
    Patients are candidates for ULT if they have two or more
    attacks per year, presence of tophi, stage 2 CKD or worse,
    or a history of urolithiasis. One to 2 weeks after the first
    attack, patients may begin uric acid–lowering therapy, and
    they should be treated until a serum uric acid concentration
    of less than 6 mg/dL is attained. Until their first attack,
    treatment with a xanthine oxidase inhibitor or uricosuric
    agent is not indicated (Answer A is correct; Answers B-D
    are incorrect).