Severe rheumatoid arthritis with multiple baseline anti-inflammatory drugs intolerance

Abstract

The present study considers a care of a 42-year old female patient with a severe variant of rheumatoid arthritis and extra-articular manifestations. The debut clinical symptoms included polyarthritis, fever, and anemia. On selection of a basic therapy, intolerance (leucopenia, flu-like syndrome) and inefficiency of treatment regimen have been revealed. Administration of a genetically engineered biological drug resulted in the development of tuberculosis and the patient required a long break in the biotherapy for a specific treatment course. The use of anti-TNF agents is associated with an increased risk to tuberculosis and anti-TNF agents are stopped when active tuberculosis develops. However, discontinuation of treatment results in a flare of the underlying disease. The rituximab therapy was initiated because the clinicolaboratory activity was high. Due to the strategy “Treat to Target”, the patient reached improvement by classification criteria and clinical and laboratory remission. The use of high doses of glucocorticoids during the patient’s planning pregnancy led to the development of secondary osteoporosis with spontaneous fractures of pelvic bones and ribs, expressed progression of erosive process, deformations of small and large joints. Specific features of the course of disease with formation of a severe progressing form of rheumatoid arthritis and the conducted treatment were considered from the point of view of difficulty in the selection of therapy when rheumatologists had a limited arsenal of drugs. The risk of re-onset of tuberculosis infection mandates careful follow-up.