American Board of Internal Medicine (ABIM) Certification Practice Exam

If monotherapy for rheumatoid arthritis is insufficient, which second disease-modifying drug may be initiated?

1. Mycophenolate mofetil

2. Hydroxychloroquine

3. Adalimumab

4. Methylprednisolone

The correct answer is: Hydroxychloroquine

When considering the management of rheumatoid arthritis (RA), if monotherapy with a disease-modifying antirheumatic drug (DMARD) proves to be insufficient, the addition of a second DMARD or biologic therapy may be warranted. Hydroxychloroquine is a DMARD that is often used in the treatment of RA and can serve as an effective second-line agent. Hydroxychloroquine, which is primarily an antimalarial medication, has immunomodulatory effects that can help in controlling symptoms of RA, including joint pain and inflammation. It may be selected in cases where there is mild disease activity or in patients who may have contraindications to more potent agents. Its safety profile is generally favorable, making it a suitable choice for many patients. Other options, while relevant in specific contexts, serve different roles. Mycophenolate mofetil is more commonly used for conditions like lupus or organ transplant immunosuppression and is not a standard second-line treatment for RA. Adalimumab is a biologic agent and while effective, it is not categorized as a second DMARD; it’s typically used as a first-line biologic therapy after traditional DMARDs. Methylprednisolone, a corticosteroid, is not a