What is your approach to a patient with RF+/CCP+ rheumatoid arthritis that was previously on TNFi now with high-titer ANA and dsDNA (crithida 1:2560), +chromatin, +histone?

This scenario reads like TNF inhibitor drug-induced serological lupus. The first clinical issue is: are there accompanying symptoms or signs of systemic lupus erythematosus (SLE) beyond the underlying inflammatory arthritis, which would be better attributed to the seropositive rheumatoid arthritis (...

A key part of this question is "previously on TNFi." Anti-TNF-induced lupus (ATIL) usually resolves within 2-8 weeks after stopping the TNFi. This includes anti-dsDNA, which is usually at low to moderate titers when seen in ATIL, rather than the high-titer Crithidia dsDNA as is seen here.

High positi...