Much has been written about the need for early treatment of rheumatoid arthritis. But how early? How aggressively?

New research has demonstrated that rheumatoid arthritis (RA) treatment, if given within 15 days of initial presentation compared with four months after diagnosis can lead to remarkable improvement in outcome measures.

Most studies have demonstrated that a narrow window of opportunity exists between the onset of rheumatoid arthritis and when treatment can make a difference in terms of preventing x-ray damage and disability.

Progressive x-ray damage occurs early and 70 per cent of patients will develop x-ray damage within the first three years of disease. This x-ray damage is closely correlated with subsequent disability. Work disability is strongly associated with general functional decline as well as premature death.

Aggressive treatment after the initial patient visit improves patient outcomes. It also reduces the financial burden of hospitalization which often accompanies poorly treated or untreated rheumatoid arthritis.

In the mid 1990's the goal of management in RA was to control pain, avoid damage, and preserve function. The goals now have changed dramatically. They include: prevent damage; promote healing of existing damage; suppress immune driven inflammation (ie, induce remission); minimize side effects of therapy. Prior to 2000, most treatment costs associated with RA were due to either hospital admissions or drug toxicity (before the advent of biologic therapy!)

So in 2007, the key considerations include: early diagnosis; assessment of risk factors that might point toward greater disease severity; goal of inducing complete remission; avoiding under treatment; effective use of disease modifying anti-rheumatic drugs such as methotrexate early; close measurement of disease activity; early institution of biologic therapy to induce remission as soon as possible; close observation of the patient to ensure a minimal amount of side-effects and toxicity.

The choice of treatment options is dependent on the experience of the rheumatologist. Patient education is important in the decision making. One of the biggest obstacles to aggressive treatment may be the patient who feels that "good enough is good enough." Good enough may not be good enough if inflammation persists. Because... as mentioned earlier, persistent inflammation leads to x-ray damage which is very strongly correlated with functional decline and disability.