Clinical Review

Recent advances in the management of rheumatoid arthritis

BMJ 2010; 341 doi: (Published 21 December 2010) Cite this as: BMJ 2010;341:c6942
  1. Naomi B Klarenbeek, PhD student1,
  2. Pit J S M Kerstens, rheumatologist2,
  3. Tom W J Huizinga, professor of rheumatology1,
  4. Ben A C Dijkmans, professor of rheumatology3,
  5. Cornelia F Allaart, rheumatologist1
  1. 1Department of Rheumatology, Leiden University Medical Centre, Albinusdreef 6, 2333 ZA, Leiden, Netherlands
  2. 2Department of Rheumatology, Jan van Breemen Institute, Amsterdam, Netherlands
  3. 3Department of Rheumatology, VU Medical Centre and Jan van Breemen Institute, Amsterdam, Netherlands
  1. Correspondence to: N B Klarenbeek n.b.klarenbeek{at}
  • Accepted 28 November 2010

Summary points

  • Rheumatoid arthritis is a common autoimmune disease that can lead to serious functional limitations, joint destruction, extra-articular disease, poor quality of life, and premature death

  • Early recognition of arthritis and speedy referral to a rheumatologist are essential

  • Treatment should start early and aggressively to prevent functional limitations and structural damage

  • Innovations in treatment and monitoring have resulted in patients achieving early and sustained clinical and radiographic remission

  • Methotrexate is the first line drug, but in high risk patients early combination of methotrexate with prednisone or a tumour necrosis factor inhibitor improves outcomes

Until the 1990s patients with rheumatoid arthritis were initially treated with aspirin or other non-steroidal anti-inflammatory drugs; disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate, were introduced only as the disease progressed. Combined treatment with more than one DMARD was reserved for patients with the most severe disease. The outcome for most patients was functional deterioration with progressive damage. However, innovations in drugs, better tools for monitoring treatment, and tight control strategies have improved the outlook for patients with rheumatoid arthritis. Remission with limited radiological damage and no functional deterioration is now a realistic treatment goal. Several randomised controlled trials have shown that treatment with DMARDs, corticosteroids, and biological agents early in the course of disease can retard progression of disease, reduce joint destruction, and improve functional ability and health related quality of life. This, along with the introduction of new tools to monitor response to treatment, has led to a new treatment approach and improved outcomes.1 We review evidence from randomised trials, systematic reviews, and recently published guidelines and outline the new approach to treatment, emphasising the importance of early diagnosis, referral, and treatment.

Sources and selection criteria

We used recently published recommendations on the treatment of rheumatoid arthritis. We also searched the Cochrane Database of Systematic Reviews (without time …

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