Rheumatoid Arthritis
18 cases on conventional and biologic DMARD sequencing, JAK inhibitor risk stratification, and treatment adjustment across pregnancy, surgery, and travel — choose a case below to open its full multi-voice debate.
Denise K., 52, needs her first biologic after methotrexate fails — with a treated breast cancer history complicating the choice. The disagreement is whether a TNF inhibitor's efficacy edge is worth a theoretical recurrence risk rituximab doesn't carry.
Harold T., 63, has failed two TNF inhibitors and carries real cardiovascular risk factors of his own. The disagreement is whether ORAL Surveillance's cardiovascular warning genuinely applies to him, or whether it was built from a different population entirely.
Priya R., 45, can't tolerate methotrexate or leflunomide, closing off the combination-therapy pathway trials actually tested. The disagreement is whether IL-6 inhibitor monotherapy really matches a TNF-inhibitor-plus-methotrexate combination, or whether that's an assumption nobody has proven.
Walter B., 67, is a partial responder to adalimumab, and the trial built to test trough-guided switching, ADDORA-switch, just reported no benefit to doing exactly that. The disagreement is whether a trough level and antibody test still have anything meaningful left to tell his team.
Renata S., 39, has failed one JAK inhibitor, and no randomized trial has ever tested whether a second one from the same class is worth trying. The disagreement is whether receptor selectivity justifies staying in-class, or whether switching mechanism entirely is the only defensible move.
Marcus O., 58, has had a sustained response to his first rituximab course, and the cohort data used to time his retreatment has shifted since the original comparison was made. The disagreement is whether fixed-interval redosing or B-cell-count-guided dosing better reflects what the newer data shows.
Elena V., 71, is in sustained remission with mild methotrexate-related liver and kidney changes already showing. The disagreement is whether her biologic or her methotrexate should come off first — and which choice actually protects her, rather than just following habit.
Samuel P., 66, has a total knee replacement scheduled and a TNF inhibitor that's kept him functional. The disagreement between his surgeon and rheumatologist is whether the 2022 ACR/AAHKS perioperative guidance actually resolves his infection-versus-flare tradeoff, or just names it.
Amara J., 33, is early in a planned pregnancy on an adalimumab regimen that's working well. The disagreement is whether switching to certolizumab pegol's better-studied placental-transfer profile is worth disrupting a treatment that isn't broken.
Frank D., 55, has failed two biologics with genuinely different mechanisms, landing him in EULAR's own difficult-to-treat RA category. The disagreement is whether a fourth mechanism is the right next move, or whether some of his persisting symptoms were never truly inflammatory.
Grace L., 60, isn't reaching remission on oral methotrexate, and a biologic is the obvious next step. The disagreement is whether a route switch to subcutaneous methotrexate deserves a real trial first, or whether that just delays the treatment she actually needs.
Ted M., 74, recently widowed, is still on a bridging steroid well past its planned window. The disagreement between his rheumatologist and geriatrician is whether accelerating methotrexate or simply continuing the low-dose steroid better serves a patient whose life circumstances are part of the calculation.
Nadia F., 48, is mid-course on rituximab with international travel planned that requires a live yellow fever vaccine — a combination current guidance doesn't allow safely. The disagreement is whether delaying rituximab, delaying travel, or seeking a medical waiver is the least bad option.
Victor H., 57, has an excellent response to his TNF inhibitor and a new psoriasiform skin reaction that the same drug caused. The disagreement between his dermatologist and rheumatologist is whether the paradox is worth tolerating or is the drug's own signal to switch mechanism.
Won K., 29, a nurse newly diagnosed with seronegative rheumatoid arthritis, already has early erosive change on imaging. The disagreement is whether her negative serology should soften an otherwise aggressive early treat-to-target plan, or whether the erosions already answered that question.
Louis A., 62, has a labeled VTE risk factor that rules a JAK inhibitor out before the debate even starts. The real disagreement is which of two remaining mechanisms should replace it — a rare case where the voices agree on what to avoid and split on what comes next.
Carmen T., 41, hasn't reached remission on methotrexate alone, and the next step forks between cost and complexity. The disagreement is whether triple conventional DMARD therapy is genuinely competitive with adding a TNF inhibitor, or whether the evidence base only looks that way at first glance.
Robert ‘Bob’ S., 69, has a severe rheumatoid vasculitis flare with mononeuritis multiplex — a genuine medical emergency. The disagreement is whether registry-level evidence for rituximab is strong enough to prefer over cyclophosphamide's longer, better-established track record.