Combination DMARD therapy for rheumatoid arthritis.

approaches needs to be considered; triple therapy has been reported to be well tolerated at three to five years, while similar data are not available for methotrexate and cyclosporin A. The success of combination DMARD therapy in recent double blind controlled studies is encouraging.2223 As is frequently the case, however, the success of these approaches raises as many questions as it answers. Should all patients with rheumatoid arthritis receive combination DMARD therapy, or should it be reserved for only those with severe disease? Are there ways to predict who will respond best? When in the course of disease should combinations be used? Which combinations are best, or does this vary among patients? After an excellent response occurs, can some or all of these drugs be tapered or discontinued? Where do biological agents fit in, and should they be used in combinations? I do not have the answer to any of these questions. Until these answers are available, we will have to do as we have always done-make the best decisions we can based on the limited data available. As I stated earlier, our goal when treating patients with rheumatoid arthritis should be remission. As we try to achieve this goal, the data available now support the use of certain combinations of DMARD. Whether combinations should be used early in the disease process as suggested by Wilske and Healey'5 or added later is still open to question. As we better understand the mechanisms of actions of drugs and the disease process itself, we will be able to intervene more intelligently at the right time with the right drugs or combinations of drugs to improve the long term outcome for our patients with rheumatoid arthritis.