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Cardiovascular risk assessment in patients with rheumatoid arthritis (RA) is challenging. Not all risk calculators adjust for RA status, yielding discording results. A 56-year-old woman with RA presented for bilateral pain and swelling in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. She was diagnosed with RA 10 years ago, currently treated with methotrexate (MTX), sulfasalazine, and hydroxychloroquine. She has a history of type 2 diabetes mellitus, a total abdominal hysterectomy with bilateral salpingo-oophorectomy for an epidermoid carcinoma of the cervix, and surgical excision of a pulmonary rheumatoid nodule. Multiple subcutaneous nodules are seen bilaterally on the MCP and PIP joints. MTX may be associated with nodulosis in RA patients, which in turn is related to a further increase in cardiovascular risk compared to RA alone. MTX was discontinued. Abatacept was the biologic of choice, due to recent evidence suggesting superior efficacy in decreasing cardiovascular risk compared to anti-TNF therapies, especially in patients with diabetes and with positive rheumatoid factor. Initiating high-dose statin and abatacept may be a useful primary prevention strategy in complex RA patients that require biologic therapy.. [ABSTRACT FROM AUTHOR]

Tumor necrosis factor inhibitors are the first biological agents used in the treatment of rheumatoid arthritis (RA) to have yielded satisfactory results in terms of clinical improvement and radiologic progression, but they are also associated with the possibility of occurrence of a number of autoimmune systemic events [drug-induced lupus (DIL), vasculitis, sarcoidosis] and localized adverse events [uveitis, psoriasis, interstitial lung disease, erythema multiforme including the major form Stevens-Johnson syndrome (SJS)]. During treatment with TNF inhibitors, many patients develop positivity for antinuclear, antihistone and anti-double stranded DNA antibodies, though only a minority of patients will develop clinical manifestations and approximately less than 1% will fulfill the classification criteria for systemic lupus erythematosus. Mucocutaneous manifestations are the most frequent manifestations of DIL following treatment with TNF inhibitors, and can be severe and occasionally difficult to differentiate from erythema multiforme/SJS. Stopping the causative drug (the TNF inhibitor) and general supportive measures are usually sufficient in mild forms, but in moderate to severe forms, systemic glucocorticoids and sometimes immunosuppressive drugs are required. The present report presents the case of a patient with rheumatoid arthritis who developed severe recurrent cutaneous reactions and positive autoantibodies during TNF inhibitor treatment, with difficulties in differential diagnosis and treatment. A review of the literature is also presented. [ABSTRACT FROM AUTHOR]