Advances and issues in the pharmacotherapy of rheumatoid arthritis

Rheumatoid arthritis (RA) is an unremitting and progressive disease despite the use of second-line drugs in the majority of patients. In addition, a shortened life-span directly attributable to RA is now recognized. The additions of methotrexate and sulfasalazine to the therapeutic armamentarium represent important treatment advances during the past decade. To improve the effectiveness of second-line drug therapy, earlier intervention and use of these newer drugs in combination with older second-line drugs is being advocated. Several proposed strategies for intervening earlier, combining second-line drugs, and/or improving patient selection for second-line drug therapy are reviewed. Systematic evaluation of these strategies is needed. Controlled studies to date have not demonstrated combining second-line drugs is superior to using individual second-line agents. Future advances in optimizing patient outcomes with these drugs will require systematic screening for potentially superior treatment strategies followed by supportive proof of effectiveness in the form of large-scale studies.