Reevaluating the therapeutic approach to rheumatoid arthritis: the "sawtooth" strategy.

A new therapeutic philosophy for management of rheumatoid arthritis (RA) is required, since the traditional "pyramidal" strategy has failed to measurably improve longterm outcome. This paper attempts a conceptual overview of the problem and suggests an available solution. The increased repertoire of potentially disease-modifying drugs (DMARD) allows a new creativity, and toxicity with these agents has been less than expected. Yet, clinical improvement observed initially with these agents over the first 10 to 20 months of treatment is eventually lost and accelerated increase in disability follows. Given these observations, a "sawtooth" strategy is proposed, with 6 principles: early DMARD use, continual serial DMARD use, regular quantitative monitoring of disability to detect insidious progression, setting a disability ceiling for the individual patient, sequential change in DMARD treatment when the ceiling is reached, and deployment of analgesics and NSAID as adjunctive rather than "first line" therapy. This strategy offers the potential for long-term disease modification with reasonable toxicity levels.