Rheumatoid arthritis affects about 1-2% of adults in the UK. Although the disease is sometimes mild, chronic synovitis, progressive destruction of articular cartilage and bone, and systemic manifestations commonly lead to marked disability and premature death.1,2 Disease-modifying antirheumatic drugs (DMARDs) are given to try to arrest or slow this deterioration. Until quite recently, DMARDs were started only when simpler measures (analgesics, physical treatments and non-steroidal anti-inflammatory drugs) had failed. Used in this way, DMARDs can suppress markers of disease activity and improve function and some have been shown to slow the progress of joint erosions.3 However, their impact on long-term disability has been disappointing. We discuss how these observations, and a fuller understanding of the pathogenesis and natural history of rheumatoid arthritis, have led to changes in the way DMARDs are used.
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