Natural history and treatment decisions in rheumatoid arthritis revisited

Compliance with RA therapeutic intervention must be viewed within the context of the natural history of the disease with or without drug treatment. Published studies from the 30s to the 80s provide a grim picture: both premature death and marked functional morbidity occur even in population-based analyses. Intervention with drugs appears to have short-term gains with little impact beyond 2 years. The reasons for this apparent paradox are two-fold. (1) our drugs are not as successful as we would like; and (2) clinical trials and long-term outcome studies exaggerate their differences from each other by selection criteria and other methodologic issues. Nevertheless, the picture that is emerging for the 90s is revolutionary. Patients with the worst prognosis are being treated more aggressively earlier in their course, and those that have a favorable prognosis do well without aggressive management and are treated differently. Traditional outcome measures are giving way to others that are more realistic and patient-oriented. The assumption that more (not less) treatment will remedy the situation is being tested. The impact of the success of Methotrexate on this change in philosophy should not be underestimated.