Choosing a Management Strategy in RA

Stephen Paget, MD: My name is Dr Stephen Paget. I'm the physician-in-chief emeritus at the Hospital for Special Surgery in New York City. This is Conversations With Experts.

Vivian Bykerk, MD: I'm Dr Vivian Bykerk, head of the Inflammatory Arthritis Center of Excellence here at the Hospital for Special Surgery.

Dr Paget: I wanted to give a little bit of background on the treatment of rheumatoid arthritis (RA) before we talk about the role of anti-tumor necrosis factor (TNF) agents plus methotrexate vs triple therapy, an important topic for today.

In the early 1950s, nonsteroidal anti-inflammatories were available, and a Nobel Prize was won for the use of steroids in the treatment of RA as well as rheumatic fever. They knew very quickly that steroids were a double-edged sword and kind of a "deal with the devil," because they were effective but had a lot of side effects. Then we used gold, penicillamine, and eventually methotrexate, which has really had a profound effect upon RA outcomes. Subsequently, anti-TNF medications were developed and are now in our armamentarium. They have given an extra boost in the treatment of this inflammatory systemic disease.

Defining Disease Modification

Dr Paget:Today, I'm going to talk with Vivian specifically about the near battle between the use of the anti-TNF and methotrexate combination versus triple therapy, which includes sulfasalazine, hydroxychloroquine, and methotrexate.