A 48-year-old female patient diagnosed with RA in 2018 had been managed with methotrexate (MTX) monotherapy, MTX combined with prednisone, leflunomide (LEF), etanercept, or baricitinib. Unfortunately, satisfactory outcomes were not achieved in this patient. At the time of 2018, her IGRAs was negative and DAS28-ESR a high score, indicating that her disease was highly active. The patient presented to our clinic on November 16, 2020. She diagnosed with RA ( Table 2 ). Her IGRAs was tested positive in 2022. Since the chest computed tomography (chest CT) did not suggest tuberculosis, rifampicin was used to prevent her from developing Latent tuberculosis infection (LTBI).
On November 16, 2020, she started on MTX combined with Tofacitinib (Simcere Pharmaceutical Co. Ltd.), prednisone, and rifampin. Two months later, she had not improved. Duloxetine was added to her treatment regime to manage a suspected fibromyalgia syndrome, but the patient was still nonresponsive to it.
She has been using Tofacitinib in combination with MTX for more than 3 months from November 2020 to January 2021. However, the pain and fatigue tortured her. DAS28-ESR on January 14, 2021 (>5.1) showed that she was still in high active condition.
After in-depth communication with the patient, based on economic cost and convenience, we initiated a new treatment strategy on February 23, 2021, as MTX (10mg weekly) combined with Tofacitinib (5mg twice a day, Simcere Pharmaceutical Co. Ltd.), Adalimumab (40mg every two weeks, Simcere Pharmaceutical Co. Ltd.) and prednisone (10mg daily).
The patient had been on long-term irregular glucocorticosteroid therapy between 2018 and 2020. We used 15mg of prednisone at the beginning. The dose of prednisone was tapered from 15mg to 10mg and then 5mg daily. Finally, the prednisone was discontinued.
This patient was followed for more than one year. DAS28-ESR was assessed routinely. We also monitored infection indicators, new-onset cardiovascular events, herpes zoster and other adverse events. Her condition was improved significantly, and she had no noticeable side effects. In the subsequent three months, prednisone was tapered and eventually stopped. In addition, her DAS28-ESR showed complete remission, for more than a year of follow-up. The patient did not develop LTBI, and she was also not diagnosed with herpes and thrombus ( Figure 1 ).