Early aggressive treatment with DMARDs vs. step-up therapy in rheumatoid arthritis: a traditional review of joint damage and functional outcomes
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Amruth Akhil Alluri
,
Aditya Rajesh Pawar
,
Shruti Suresh Suvarna
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by progressive joint inflammation and structural damage. Two primary treatment strategies – step-up therapy and early aggressive DMARD therapy have been widely debated in clinical practice. The step-up approach begins with NSAIDs or corticosteroids, progressing to DMARDs based on disease severity, whereas early aggressive therapy prioritizes immediate DMARD initiation to prevent irreversible joint damage. This comprehensive review evaluates the effectiveness of these strategies by analyzing randomized controlled trials (RCTs), meta-analyses, and cohort studies assessing treatment outcomes, remission rates, and radiographic progression. A literature search was conducted across PubMed, Scopus, and Web of Science, including studies published between 2010 and 2024. Key clinical trials, including TICORA, COBRA, BeSt, and CAMERA, were critically analyzed to assess the comparative benefits and limitations of both treatment approaches. Evidence suggests that early aggressive therapy is associated with higher remission rates, reduced radiographic progression, and improved long-term physical function, whereas the step-up approach often leads to delayed disease control and cumulative joint damage. However, concerns related to treatment adherence, cost-effectiveness, and safety profiles necessitate further investigation. Future research should focus on biomarker-driven personalized treatment strategies, optimizing drug sequencing, and long-term comparative effectiveness studies to refine RA management.
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Research ethics: This is a review article that does not involve human participants or animal studies. Therefore, ethical approval was not required.
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Informed consent: As this article is based on previously published studies and does not include new patient data, informed consent is not applicable.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: The authors acknowledge the use of ChatGPT exclusively for grammar correction and proofreading assistance. The intellectual content, analysis, and conclusions presented in this work are entirely original and have been independently developed.
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Conflict of interest: The authors declare no conflicts of interest related to this work.
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Research funding: This study received no specific funding from public, commercial, or not-for-profit sectors.
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Data availability: No new data were generated or analyzed for this study. All data used in this review are available in the original published sources, which are cited accordingly.
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