How would you manage a patient with arthritis mutilans who has failed TNFi, IL-17i, and JAKi and now on bimekizumab and with worsening joint disease?  

Difficult case of destructive joint disease without a lot of options. If this is truly an "active" disease, and not just pain from prior joint destruction, the addition of cs-DMARDs to current therapy or adding 2 targeted therapies could be tried. TYK-2 (deucravacitinib) could be an option, but may ...

Utilize MRI vs US to evaluate if it is inflammatory in nature and would benefit from a medication change vs chronic deformity/pain with medication continuation and a pain vs ortho hand referral. This is multiple MOA failures in numerous classes: I generally suspect wrong DX or noninflam pain at this...