Rheumatoid Arthritis: Treat Now, Not Later!

Over the past several years, a new approach to the treatment of rheumatoid arthritis has evolved. Rheumatologists now advocate earlier initiation of therapy with a group of heterogeneous drugs termed either “DMARDs” (disease-modifying antirheumatic drugs), “SAARDs” (slow-acting antirheumatic drugs), or “second-line therapies.” These drugs include hydroxychloroquine, sulfasalazine, methotrexate, gold salts, D-penicillamine, azathioprine, and cyclosporine.

The old paradigm of therapy was called the “pyramid approach.” The bottom of the pyramid included anti-inflammatory drugs, such as aspirin and nonsteroidal anti-inflammatory drugs, that were prescribed along with a basic program of exercise, rest, and education. Second-line therapy was initiated only after several years of treatment with antiinflammatory drugs and generally after radiographic evidence of joint damage. In fact, many rheumatologists waited for such evidence, considering it to be the reason to start second-line therapy. Part of the justification for delaying the initiation of second-line therapy was the perceptions that rheumatoid arthritis was a benign disease and that second-line therapies were very toxic. Over the past decade, we have come to realize that rheumatoid arthritis is not benign, that second-line therapies are not as toxic as initially thought, that first-line therapies have substantial toxicities of their own, and that the pyramid approach does not affect functional, clinical, or radiographic progression. This has generated an important dialogue among rheumatologists about modifying that traditional treatment approach [1-4].

Patients with rheumatoid arthritis have increased mortality …