A 46-year-old woman presents to her family physician with 10 weeks of bilateral hand and wrist pain and swelling. She has morning stiffness lasting about 90 minutes and difficulty making a fist. She takes no regular medications and has no known drug allergies. A urine pregnancy test today is negative and she uses condoms for contraception. On examination, the metacarpophalangeal joints, proximal interphalangeal joints and both wrists are warm, swollen and tender. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies are positive at high titre. ESR is 52 mm/h (0-20) and CRP is 38 mg/L (less than 5). Hemoglobin is 118 g/L (120-160), WBC is 7.2 x 10^9/L (4.0-11.0), platelets are 410 x 10^9/L (150-400), ALT is 24 U/L (less than 35) and creatinine is 68 umol/L (45-90). Hepatitis B and C serology are negative. Hand X-rays show periarticular osteopenia without erosions. The earliest rheumatology appointment is in 3 weeks.
| Heart rate | 78/min |
| Respiratory rate | 14/min |
| Temperature | 36.9 °C |
| O2 saturation | 98%, room air |
| Blood pressure | 126/78 mm Hg |
Question 1 of 28
Which of the following are the most appropriate medication options to start at this visit?
Select 2. (0 / 2 selected)
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