In a 39‑year‑old woman with deforming rheumatoid arthritis on tofacitinib 5 mg twice daily, methotrexate 15 mg weekly, and hydroxychloroquine 400 mg daily who still has heel pain, what is the appropriate next step in management?

Management of Persistent Heel Pain in a Patient with Deforming Rheumatoid Arthritis on Triple Therapy

This patient requires immediate optimization of her inadequately controlled rheumatoid arthritis through dose escalation of methotrexate to 20-25 mg weekly and addition of a biologic DMARD, while simultaneously addressing the heel pain as a manifestation of active inflammatory disease rather than an isolated mechanical problem. 1, 2

Primary Issue: Inadequately Controlled Rheumatoid Arthritis

Current Regimen Assessment

• The patient is on tofacitinib 5 mg twice daily, methotrexate 15 mg weekly, and hydroxychloroquine 400 mg daily, yet continues to have pain—indicating failure to achieve the treatment target of remission or low disease activity 1, 2
• Methotrexate 15 mg weekly is suboptimal; the 2021 American College of Rheumatology guideline strongly recommends titration to at least 20-25 mg weekly within 4-6 weeks of initiation 1
• The presence of "deforming" arthritis with ongoing symptoms signals high disease activity and poor prognostic factors requiring aggressive treatment escalation 1, 2

Immediate Treatment Optimization Steps

Step 1: Optimize Methotrexate Dose

• Increase methotrexate from 15 mg to 20-25 mg weekly immediately, as starting with 15 mg/week and escalating with 5 mg/month to 25-30 mg/week is the evidence-based recommendation 1
• If oral methotrexate at 20-25 mg weekly is not tolerated or ineffective after 3 months, switch to subcutaneous administration for superior bioavailability 1, 2
• Ensure folic acid supplementation is adequate 1

Step 2: Assess Disease Activity Objectively

• Perform a formal 28-joint count examination to calculate current SDAI (Simplified Disease Activity Index) or CDAI (Clinical Disease Activity Index) score 2
• The treatment target is remission (SDAI ≤3.3 or CDAI ≤2.8) or low disease activity (SDAI ≤11 or CDAI ≤10) 1, 2
• Disease activity should be assessed every 1-3 months during active treatment 1, 2

Step 3: Consider Tofacitinib Dose Escalation

• Current dose of tofacitinib 5 mg twice daily may be insufficient; the ORAL Scan trial demonstrated that both 5 mg and 10 mg twice daily doses are effective, with some patients requiring the higher dose 3, 4
• Real-world evidence shows tofacitinib effectiveness is maintained across different methotrexate dose ranges, but optimal methotrexate dosing (≥17.5 mg/week) enhances efficacy 4, 5
• Consider increasing to tofacitinib 10 mg twice daily if disease activity remains moderate-to-high after methotrexate optimization 3, 6

Step 4: Add Short-Term Glucocorticoid Bridge

• Initiate low-dose prednisone ≤10 mg/day (or equivalent) for rapid symptom control while optimizing the DMARD regimen 1, 2
• Use the lowest effective dose for the shortest duration (less than 3 months) 1, 2
• Taper and discontinue once disease control is achieved, as long-term use beyond 1-2 years carries unacceptable toxicity 2, 7

Addressing the Heel Pain Specifically

Differential Diagnosis of Heel Pain in RA

• Inflammatory arthritis involvement: Heel pain in RA can represent active synovitis of the subtalar or ankle joints, enthesitis at the Achilles insertion, or inflammatory bursitis 1
• Plantar fasciitis: Common in the general population but may coexist with RA 1
• Insertional Achilles tendonitis: Presents with posterior heel pain and swelling, aggravated by activity and shoe pressure 1
• Haglund's deformity with bursitis: Lateral heel prominence with tenderness, more common in women 1

Clinical Evaluation Required

• Examine for tenderness at the plantar fascia insertion (inferior heel), Achilles tendon insertion (posterior heel), or retrocalcaneal bursa (lateral to Achilles) 1
• Assess whether pain is relieved by walking barefoot (suggests posterior heel pathology) or worsened by barefoot walking (suggests plantar fasciitis) 1
• Obtain heel radiographs to evaluate for erosive changes, calcaneal spurs, or Haglund's deformity 1

Local Treatment Measures

• Conservative management: Heel cushions, arch supports, open-backed shoes (if posterior heel involvement), stretching exercises, and activity modification 1
• NSAIDs: Can be used for additional symptomatic relief, though they do not modify disease 1
• Corticosteroid injection: May be considered for refractory plantar fasciitis or retrocalcaneal bursitis, but avoid injection into or near the Achilles tendon due to rupture risk 1
• Physical therapy: Structured calf-muscle stretching and strengthening exercises 1

Treatment Timeline and Monitoring

Expected Response Timeline

• Aim for ≥50% improvement in disease activity within 3 months of treatment optimization 1, 2
• The treatment target must be attained within 6 months 1, 2
• If no ≥50% improvement by 3 months or target not reached by 6 months, further escalation is mandatory 1, 2

If Inadequate Response After Optimization

• For patients with poor prognostic factors (deforming arthritis): Add or switch to a biologic DMARD if tofacitinib optimization fails 1, 2
• TNF inhibitors (infliximab, etanercept, adalimumab) are typically first-line biologic agents and can be combined with methotrexate 1, 2
• Alternative biologics: IL-6 receptor antagonists (tocilizumab), T-cell costimulation modulators (abatacept), or rituximab may be considered 1, 2
• Allow 3-6 months to fully assess efficacy of any newly introduced therapy before making further changes 2

Critical Pitfalls to Avoid

• Do not treat heel pain as an isolated mechanical problem when the patient has active, deforming RA—the heel pain is likely a manifestation of inadequately controlled systemic disease 1, 2
• Do not continue suboptimal methotrexate dosing (15 mg weekly)—this is the most common reason for apparent DMARD failure 1
• Do not delay treatment escalation beyond 3 months if there is no significant improvement—irreversible joint damage continues to accrue 1, 2
• Do not use long-term glucocorticoids (>3 months) as a substitute for proper DMARD optimization 1, 2
• Do not inject corticosteroids into or near the Achilles tendon—this can cause tendon rupture 1
• Do not add multiple new therapies simultaneously—optimize methotrexate first, then reassess before adding biologics 1, 2