Treatment with methotrexate is indicated for this patient with rheumatoid arthritis (RA). She has a polyarticular inflammatory arthritis involving the small joints of the hands as well as a wrist and an ankle, with radiographically demonstrated marginal erosions and periarticular osteopenia and positive anti–cyclic citrullinated peptide antibodies and rheumatoid factor, all of which support a diagnosis of RA. Methotrexate with or without the addition of another disease-modifying antirheumatic drug (DMARD) should be instituted immediately in patients with erosive disease documented at disease onset. Methotrexate is the gold standard therapy because it is usually better tolerated than other DMARDs and has good efficacy, long-term compliance rates, and relatively low cost.

Hydroxychloroquine is indicated to treat early, mild, and nonerosive disease. Hydroxychloroquine therapy alone has not been shown to retard radiographic progression of RA and therefore should be used only in patients whose disease has remained nonerosive for several years. This patient has erosive disease, and hydroxychloroquine as a single agent is not appropriate.

Rituximab, the anti-CD20 B-cell depleting monoclonal antibody, is FDA approved for the treatment of moderately to severely active RA in combination with methotrexate in patients who have had an inadequate response to tumor necrosis factor α inhibitor therapy. Rituximab may also be considered for patients with high disease activity and poor prognostic features despite sequential nonbiologic DMARDs or methotrexate in combination with other DMARDs. It is not appropriate initial treatment for RA in a patient who has not been given a trial of methotrexate.

Tofacitinib is also indicated for use in the management of RA but only in patients who have already not responded to methotrexate alone. This relatively recent addition to the treatment armamentarium for RA is the first oral agent to be introduced in decades but is indicated for use in patients who are intolerant to or have had an inadequate response to methotrexate.