Overarching Principles

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Question 1

The most appropriate course of action would be:

Start sulfasalazine increasing to 1g BID and advice to reduce alcohol intake
Start methotrexate 15mg/week along with folic acid 5mg/week
Start sulfasalazine increasing to 1g BID along with methotrexate 15mg/week and folic acid 5mg/week
Avoid using methotrexate until able to reduce alcohol intake but start leflunomide 20mg QOD instead

It would be entirely appropriate to try sulfasalazine initially and to avoid both methotrexate and leflunomide until the patient is able to reduce his alcohol intake

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Question 2

The next step which would NOT be appropriate is:

Ask patient to stop drinking alcohol completely and to avoid the use of NSAIDs like naproxen
Continue with current dose of methotrexate
Withhold methotrexate and restart at 10mg per week when the LFTs return to normal
Request hepatology review if LFT abnormalities persist

It would be inappropriate to continue with the methotrexate at the current dose in this situation. All the other options are entirely reasonable including a hepatology review if the LFT abnormalities persist.

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Question 3

The best next course of action would be:

Switch methotrexate to the subcutaneous route +/- use higher dose of folic acid
Try another csDMARD agent like leflunomide
Start him on a bDMARD (e.g. TNF inhibitor) agent
Avoid using any of the above agents because of the LFT abnormalities

The use of a TNF inhibitor would be justified in many healthcare systems as he has failed treatment with conventional synthetics DMARDs. If there is limited or no access to biologics, then either leflunomide or parenteral methotrexate would be reasonable options.

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Question 4

Under these circumstances, would it be appropriate to:

Manage flare-ups of his arthritis with intra-articular and/or intra-muscular steroid injections
Avoid the use of steroids because of the risk of potential worsening of his skin psoriasis
Restart the adalimumab as his malignancy has been surgically resected
Explain to him that he must use disease modifying therapy

There is very little risk of worsening of skin psoriasis with intra-articular and/or intra-muscular steroids, and this form of treatment would be entirely appropriate if that is what the patient wants to have. There would be concerns with the use of TNF inhibitor therapy because of his recent malignancy, and also he should not be forced to use any disease modifying medication because the patients' wishes are always paramount.

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Question 5

What would be the most appropriate next course of action?

Start a tsDMARD (e.g., apremilast)
Try a non-TNF inhibitor bDMARD (e.g., ustekinumab or secukinumab)
Revert to another csDMARD (e.g., leflunomide or subcutaneous methotrexate)
Continue using intra-articular and/or intra-muscular steroid injections like before instead of trying any of the above agents

The most appropriate next course of action would be to trial apremilast. A non-TNF inhibitor bDMARD could be considered, but at present we do not have enough data regarding their use in patients with previous malignancy. Similarly, leflunomide or sucutaneous methotrexate could also be considered but the apremilast would be a better choice in this situation because of its lack of liver toxicity.

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Clinical Case