Pharmacology · patient case question
What is the most significant perioperative risk created by her rheumatoid arthritis therapy?
Patient case: Rheumatoid Arthritis and a Needed Extraction
Patient: 56-year-old female
Chief Complaint: “My back bottom left tooth has been aching for two weeks.”
Background: Rheumatoid arthritis for 12 years, currently in partial remission. Reports hives after amoxicillin as a teenager. No other systemic disease.
Medications: Methotrexate 15 mg weekly · Adalimumab (Humira) 40 mg subcutaneous every 2 weeks · Folic acid 1 mg daily
Vital Signs: BP 124/76 mmHg · HR 78 bpm · RR 16 · T 98.6°F
Findings: Maximum interincisal opening 32 mm with bilateral TMJ crepitus. Ulnar deviation of the fingers with metacarpophalangeal swelling. Tooth #18 with a grossly carious crown, non-restorable; extraction planned.
Show answer and explanation
Correct answer: A. Increased susceptibility to infection and impaired wound healing
- A. Correct. Both methotrexate and TNF-α blockade suppress immune function. The combination raises the risk of postoperative infection, delays healing, and can reactivate latent tuberculosis or fungal infection. Coordinate timing with her rheumatologist and consider perioperative antimicrobial coverage.
- B. Incorrect. Gingival hyperplasia is associated with phenytoin, cyclosporine, and calcium channel blockers — none of which she takes.
- C. Incorrect. Neither methotrexate nor adalimumab causes hypertensive crisis. Her blood pressure is normal.
- D. Incorrect. Neither drug produces osteosclerosis. Osteoporosis from chronic corticosteroid use would be a more plausible skeletal concern in rheumatoid arthritis.