Over the past decade, remarkable advances have been made in the therapeutic options for rheumatoid arthritis (RA), especially in the realm of biologic therapy. In particular, the tumor necrosis factor (TNF) inhibitors have been demonstrated to decrease inflammation leading to improved symptoms and slowing or halting joint destruction.[1-4]

However, despite these advances, not all patients respond adequately to the currently available anti-TNF alpha agents, either as monotherapy or in combination therapy with methotrexate. Additionally, while some patients may respond initially, they may subsequently lose response to a particular anti-TNF agent over time.

The question of how to manage patients with RA that failed to respond adequately to initial anti-TNF therapy is a difficult one. However, while the available anti-TNF agents are similar to each other in some respects, important differences exist between them in terms of clinical response and pharmacokinetics. As such, switching from one anti-TNF agent to another in patients who failed to respond to initial therapy or those that have had side effects to an initial anti-TNF agent can be a valuable approach in the management of RA.[5]

This interactive case study exemplifies the individualized approach to managing RA in a patient who shows signs of disease progression despite treatment with an anti-TNF agent. With the use of self-test questions, the case discussion provides essential step-by-step decision-making strategies for treatment choices, including the need to switch biologic treatment to improve clinical outcomes for this patient.

Case Presentation

Approximately 3 months before presentation, a 42-year-old woman noted pain and stiffness in her hands and feet. These symptoms were initially intermittent and the patient attributed them to working longer hours. However, over the next few weeks, the symptoms became more consistent. She noted that the pain and stiffness were worse in...

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