ABSTRACT

Rheumatoid arthritis (RA) is an autoimmune disease of unknown aetiology which primarily targets the synovial tissue, cartilage and bone. In the last two decades, it is well established that structural cartilage damage also may occur before it is visible on radiograph, so new terms, “early arthritis” in 1990s and “very early synovitis or arthritis” in 2000s, were defined. However, patients presenting with early arthritis evoke new problems in predicting progression to RA in the long-term. Definable risk factors, such high titers of anti-CCP and/or RF (rheumatoid factor) at presentation, history of smoking may assist in classification. The goal in RA is based on early and agressive therapeutic management to prevent functional disablity over long-term, even in patients presenting with undifferentiated arthritis or highly suspected RA. Methotrexate (MTX) is the anchor drug in RA due to its long-term safety use, low toxicity profile and ability of combining with biologics. In addition to MTX, prednisone, at high or low doses, is also recommended to control the symptoms in short-term as well as in long term. In case of inadequate response despite primary therapy (MTX+prednisone) within the first 3 to 6 months, combination particularly with one of biologics or DMARD’s (leflunomide, sulfasalazine, hydroxycloroquine) other than MTX should be considered as the second phase to achieve the target (remission or low disease activity). In the cases of low clinical response to the second phase of therapeutic regimen (biologics+MTX), patients should be switched to another biologic until the time to an optimal outcome.