American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the initial treatment of choice for new-onset, rapidly progressive, or erosive rheumatoid arthritis?

1. Corticosteroids

2. Methotrexate

3. Hydroxychloroquine

4. Biologic agents

The correct answer is: Methotrexate

The initial treatment of choice for new-onset, rapidly progressive, or erosive rheumatoid arthritis is methotrexate. Methotrexate is considered the cornerstone of therapy due to its ability to halt disease progression, manage symptoms effectively, and prevent joint damage, which is particularly important in cases of rapidly progressing disease. This medication is a disease-modifying antirheumatic drug (DMARD) that works by inhibiting the proliferation of immune cells and reducing inflammation. In the context of rheumatoid arthritis, a prompt and aggressive therapeutic approach is essential to minimize joint erosion and disability. While corticosteroids may provide quick symptomatic relief, they do not modify the disease course and long-term use can lead to significant side effects. Hydroxychloroquine is often used as an adjunctive therapy for mild cases but is less effective for rapidly progressive disease. Biologic agents, while effective, are generally considered after the failure of DMARD therapy or for specific cases and are not typically the first-line treatment due to their cost and the potential for adverse effects. Thus, methotrexate stands out as the first-line choice in this clinical scenario.