Which of the following agents would be most appropriate for providing additional chronic antiinflammatory activity?

A 56-year-old woman is to be treated for severe chronic rheumatoid arthritis. She is already receiving maximum doses of naproxen. Which of the following agents would be most appropriate for providing additional chronic antiinflammatory activity?

(A) celecoxib
(B) dexamethasone
© infliximab
(D) methotrexate
(E) tacrolimus

Explanation:

(D) Methotrexate has been shown to be a disease-modifying antirheumatic drug (DMARD) and, therefore, is appropriate therapy for rheumatoid arthritis that is not responding adequately to nonsteroidal anti-inflammatory drugs (NSAIDs). Low doses of methotrexate are adequate to reduce the immunologic process that underlies the disease, so toxicity is low. Celecoxib (choice A) is an NSAID like naproxen and would not have additional effect. Infliximab (choice C) is an expensive parenteral monoclonal antibody with much more severe adverse effects than methotrexate in the doses used. Tacrolimus (choice E) is an inhibitor of calcineurin, an intracellular mediator of T-cell function that is important in transplant rejection reactions.