Primary hyperparathyroidism in MEN 1 is due to parathyroid hyperplasia and not adenoma?

For management of RA isn’t anti TNF alpha drugs further down in the line of management?

Shouldn’t we start with Methotrexate and steroids ?

The American College of Rheumatology (ACR) guidelines for the management of rheumatoid arthritis (RA) recommend that treatment should start with non-biologic disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate and/or sulfasalazine, and low-dose glucocorticoids if needed to control symptoms.

Anti-TNF alpha drugs such as infliximab, etanercept, and adalimumab are biologic DMARDs that are usually reserved for patients who have failed to respond to traditional DMARDs, or who have more severe or rapidly progressing disease. These drugs can be highly effective in controlling disease activity and preventing joint damage, but they are also associated with higher costs and potential side effects.

Therefore, the ACR guidelines recommend a stepwise approach to the management of RA, with treatment escalation based on disease activity and response to therapy. In general, non-biologic DMARDs such as methotrexate are the first-line therapy for most patients, and biologic DMARDs such as anti-TNF alpha agents are reserved for patients who have failed or cannot tolerate non-biologic DMARDs.