BACKGROUND: Therapy of rheumatoid arthritis (RA) is typically characterized by 
the sequential use of disease-modifying anti-rheumatic drugs (DMARDs). This 
study aimed to reveal treatment patterns with traditional DMARDs and their 
changes during the two decades before the recent introduction of new DMARDs.
METHODS: A total of 593 RA patients were followed from their first presentation 
to our clinic throughout the course of their disease; 222 patients received 
their first DMARD therapy while under our care. More than 2,300 patient years of 
therapy were analysed for the efficacy [using C-reactive protein (CRP) and 
erythrocyte sedimentation rate (ESR) as surrogates] and duration of drug therapy 
of consecutive DMARDs.
RESULTS: Before 1985, 65-90% of initial DMARDs were gold compounds, but their 
use decreased continuously thereafter. Antimalarial (AM) drugs were important 
initial DMARDs in new patients at all times, whereas sulphasalazine (SSZ) and 
methotrexate (MTX) gained increasing significance after 1985 (the first DMARD 
was MTX in up to 29% of new patients). Penicillamine (DPA), azathioprine (AZP), 
cyclosporin (CyA) and combination therapies were not usually employed initially, 
but were reserved for the later course of the disease. Gender, age and 
rheumatoid factor were not different between patients receiving different 
DMARDs. The baseline acute-phase response was higher in patients treated with 
MTX (mean CRP 3.5 mg/dl) than in those treated with SSZ (CRP 2.4 mg/dl; P < 
0.05) or AM (CRP 2.1 mg/dl; P < 0.05), suggesting that MTX was used 
preferentially in patients with high disease activity. On the other hand, once 
AM or SSZ had been discontinued, MTX was the most common subsequent DMARD (in 31 
and 56% respectively). Comparison of first DMARDs with subsequent ones revealed 
that first DMARDs were more effective: the acute-phase response decreased most 
prominently during first therapies (CRP reduction was 1.28 mg/dl during first 
courses and 0.35 mg/dl during fourth or later courses; P < 0.01); and retention 
rates were significantly longer for first compared with subsequent therapies 
(median of 24.5 months for first and 18.6 months for fourth or subsequent 
therapies; P < 0.001).
CONCLUSION: MTX was the most commonly employed DMARD therapy for RA and was used 
increasingly as first therapy in newly diagnosed RA. Patients with high disease 
activity were given MTX therapy more often than other DMARDs, while those with 
low activity were more likely to receive SSZ or AM, and MTX on failure of these 
drugs. First DMARDs in new patients were retained longer than subsequent DMARDs, 
apparently because they are more effective.