Developing new therapeutic approaches for rheumatoid arthritis: the continuing challenges of clinical assessments

The management of rheumatoid arthritis has changed dramatically over the last three decades. Improvements in clinical assessment have been a key driver of these changes. However, in the last five years, three areas of unresolved uncertainty have dominated specialist thinking in the field. These challenges comprise identifying the optimal management target, determining how best to reach this target by using intensive treatments, and individualising management because not all patients need or respond to identical treatments. The key problem that links each of these areas is balancing different types of evidence and is most readily appreciated in relation to treatment intensity. Giving more intensive therapy improves outcomes but also increases risks and, with biologic treatments, substantially increases drug costs. Specialists and healthcare funders need to agree on how best to rationalise optimal care for patients with what is most effective and safe and what is affordable.