Combination therapy for rheumatoid arthritis

Traditionally, NSAIDs have been used in the initial treatment of patients with rheumatoid arthritis (RA). If the patient's disease progressed, then therapy was "stepped up" to use disease-modifying antirheumatic drugs (DMARDs). However, NSAIDs rarely provide appropriate monotherapy in established RA. Corticosteroids provide relief of symptoms, but they have several adverse effects. Initiation ofDMARD therapy early in the disease course has gained acceptance. Because the RA disease process has many inflammatory and proliferative pathways, multiple agents targeted at specific aspects of the immune response may provide effective therapy without increasing toxicity. Methotrexate is included in most regimens. Hydroxychloroquine and sulfasalazine are commonly used. Newer drugs that may be used in combination therapy include biologic response modifiers that target specific cytokines.