Management of the patient with rheumatoid arthritis

Until the early eighties, the treatment of rheumatoid arthritis (RA) was based on the principle of responding to the damage caused by disease progression at the time when the damage actually occurred. In this strategy, known as the “pyramid approach”, the physician responded to the patient’s worsening condition by initiating a possibly more effective therapeutic option, always at a late stage in disease progression. As the efficacy and toxicity of the medications available were poorly known, such a strategy generally led to inevitable deterioration of the patient’s autonomy because the decision to treat necessarily lagged behind the progress of the disease in spite of the contributions made by prosthetic surgery (1). In the eighties, three lines of research led to a complete change in planning the management of RA. Methotrexate was rediscovered as a long-acting drug and meticulous comparative studies were carried out on the efficacy and toxicity of all disease-modifying anti-rheumatic drugs (DMARD). They finally concluded on the supremacy of methotrexate both for controlling flares and for the prevention of joint destruction (2). A second line of research confirmed the importance of early diagnosis by demonstrating the rapidity of joint damage at the very onset of the disease (3) and as a corollary the need for effective, appropriate treatment started as soon as possible (4). The relative inefficacy of the basic DMARDS in arresting structural joint destruction finally led to the search for other modes of treatment. The most immediate option consisted in applying the principles of synergistic action of different treatments to fight the same entity; an approach which had yielded encouraging results against cancer or infectious diseases (5).