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Although disease-modifying antirheumatic drugs (DMARDs) have become the mainstay of drug therapy for rheumatoid arthritis (RA), the choice of which DMARD to select for treatment depends on numerous factors including the severity of the disease, the patient's overall health, and the doctor's preference based on past experience.

Specific recommendations for treatment can only be made by your doctor, however, it is useful to review some general principles of drug therapy that apply to the management of rheumatoid arthritis (RA). These general principles include:

• To halt progression of the disease and prevent loss of function and disability, treatment with DMARDs should be initiated within 3 months after the onset of symptoms of RA.

• As a general "rule of thumb", methotrexate is usually the DMARD of choice for the initial treatment of RA based on its long track record of proven clinical efficacy. Methotrexate, however, cannot be used in patients with serious underlying medical conditions (e.g., liver or kidney disease) or women of childbearing age who are trying to conceive.

• Patients with RA who are being treated with methotrexate or another DMARD should be monitored every 4-8 weeks by blood tests to check for signs of liver and/or kidney damage.

• Methotrexate may be used alone as initial treatment for RA or, at the discretion of the physician, it may be combined with a corticosteroid (e.g., low-dose cortisone) for a short period of time. The prednisone dose is then gradually decreased and then stopped altogether while the patient continues on methotrexate for long-term therapy.

• Methotrexate may be taken by mouth as a pill or, if symptoms persist, it may be administered by injection either into a muscle or under the skin. To reduce the side-effects of methotrexate, it is usually given together with folic acid.

• Patients whose disease continues to progress after a 2-3 month course of methotrexate therapy (with or without a corticosteroid) may be considered for combination DMARD therapy - a treatment which involves the use of several DMARDs simultaneously. Treatment options for combination DMARD therapy include:

  • methotrexate plus sulfasalazine (Azulfidine) and/or hydroxychloroquinine (Plaquenil)
  • methotrexate plus leflunomide (Arava)- neither of these DMARDs should be used in women of childbearing age who are trying to conceive.
  • methotrexate plus a biological response modifier such as infliximab (Remicade) or etanercept (Enbrel)

• Patients with RA who have failed to respond to treatment with one or more DMARDs may be considered for treatment with a selective costimulation modulator (abatacept; Orencia).