With the advent of biologic therapies, specifically tumor necrosis inhibitors (anti-TNF drugs), it is now possible to get the disease into complete remission. And, it is not out of the realm of possibility that if treated early enough and aggressively enough, some patients with RA can actually be cured.

We know from multiple studies that early aggressive treatment of rheumatoid arthritis is associated with improved disease control, slower x-ray progression and improved functional outcomes.

Tumor necrosis factor blocking therapy is effective but there remain concerns in some circles about long-term risks.

Combining disease-modifying antirheumatic drugs (DMARDs) is a widely used therapeutic alternative; however, there is uncertainty surrounding the most effective regimen. Advocates claim a fairly impressive response rate.

I confess I am not a fan of combination DMARD therapy because I feel that the risks of doing this are greater than the risks of anti-TNF drugs. Also, my experiences using combinations has not been as positive as the results touted in the literature; however, there are still many rheumatologists who use this approach so I will try to explain it.

A popular combination is methotrexate plus sulfasalazine (Azulfidine), but each of these DMARDs can also be used in combination with other DMARDs and in triple drug therapy programs as well. However, due to a number of factors, it is difficult to come to firm conclusions regarding what is the best approach.

Rheumatologists who use combination DMARD therapy claim it is well tolerated and associated with no significant increase in the rate of sides effects compared with monotherapy (using one drug alone). Combinations that have been used include: methotrexate-sulfasalazine, methotrexate-hydroxychloroquine (Plaquenil), methotrexate- cyclosporine (Sandimmune), methotrexate-leflunomide (Arava), methotrexate-intramuscular-gold and methotrexate-doxycycline.

It is felt by some practitioners that triple DMARD therapy is better than DMARD monotherapy or using two DMARDS. Some advocates say that the combination of methotrexate with hydroxychloroquine has synergistic anti-inflammatory properties.

Among rheumatologists who tout the use of combination DMARDS, various approaches are used. These include: a step-up (addition of new DMARDs to an existing treatment), a step-down (initial use of multiple DMARDs with subsequent withdrawal once remission is achieved) or a parallel approach (simultaneous use of two or more DMARDs).

To date though, there is no consensus regarding either the most effective strategy, or the combination of DMARDs for the treatment of RA. Most rheumatologists who do use combinations though feel that any combination should use methotrexate and that combinations not using methotrexate are not as effective.

So... what's a mother to do?

There still is uncertainty regarding the long term use of anti-TNF drugs. No question about it. However, there is some new interesting information that supports their use in regards to lessening of both lymphoma risk as well as cardiovascular risk is patients with RA.

Stay tuned!