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● An immediate monotherapy with a Disease-Modifying Anti-Rheumatic Drug (DMARD) constitutes the treatment basis. Methotrexate given weekly (not daily!) is the first-line DMARD based on clinical experience and tolerance. Folic acid can be given to reduce its side-effects.
● In patients with poor prognostic factors such as functional limitation, extra-articular disease, positive rheumatoid factor, anti-cyclic citrullinated peptide antibodies, or bony erosion, methotrexate is started in combination with 1 or 2 other DMARDs such as sulfasalazine or hydroxychloroquine, or with an anti-TNF alpha drug.
● Glucocorticoids (preferably prednisolone) are usually given as a step-down therapy to bridge the time until the immunosuppressive effects of DMARDs have set in. Delayed-release prednisone taken in the evening is particularly effective against morning stiffness.
● Use NSAID drugs or opioids against pain as needed.
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