Combination therapy in rheumatoid arthritis

Increasing evidence is emerging of the advantages of combination therapy in RA. However, not all combinations of disease-modifying agents are effective or tolerated by the patient (Table 10). Improved understanding of the mechanism of action of disease-modifying agents and the role of multiple-drug resistance genes may allow the logical development of effective combinations. Combination therapy can be used in a variety of ways, including step-up or step-down approaches. As joint damage occurs early in disease it is logical to commence therapy as soon as the diagnosis is confirmed. Combination therapy can be used in early disease if those patients with persistent aggressive disease can be identified. The use of intensive therapy may increase the rate of remission if used in appropriate patients early enough. Targeting aggressive therapy to patients with poor prognosis disease minimises the cost/benefit ratio, and strategies for predicting poor prognosis are now becoming available. New biological therapies with well-defined mechanisms of action are also just becoming available and combining these to produce a multi-hit approach is likely to be beneficial in the future.