PURPOSE OF REVIEW: Dramatic improvement seen in the prognosis of rheumatoid 
arthritis has been driven by higher expectations, led by newer drugs and more 
intensive use of the older drugs. Although methotrexate has retained its place 
as the first-line agent, there has been great interest in comparing biologicals 
to conventional Disease Modifying Anti Rheumatic Drugs (DMARDs) over the past 
few years with the updated guidelines from both the American College of 
Rheumatology and European League Against Rheumatism. We have tried to critically 
summarize the findings of some landmark trials that compare these two 
approaches.
RECENT FINDINGS: Treatment of Early Rheumatoid Arthritis, The Swedish 
Pharmacotherapy study and Rheumatoid Arthritis Comparison of Active Therapies 
are landmark trials that were designed to compare strategies using biologicals 
vs. conventional DMARDs. We will review the safety and efficacy data from these 
three trials here and also briefly the important cost differential.
CONCLUSION: Methotrexate should be the first-line therapy for most rheumatoid 
arthritis patients and will produce the desired results in greater than 
one-third of the patients. When methotrexate is not adequate, triple DMARD 
therapy should be added which will result in control of approximately another 
one-third of the patients. Ultimately, and usually before 1 year of disease, the 
remainder of patients will require biological therapies usually added to 
conventional DMARDs. There is no evidence that this step-up approach results in 
any long-term disadvantage and good evidence that it results in substantial cost 
savings.