In a patient with a 10‑year history of small‑joint polyarthritis, fever, and an elevated rheumatoid factor (100 IU/mL), what is the first‑line disease‑modifying therapy: NSAID, corticosteroid, or methotrexate?

First-Line Disease-Modifying Therapy for Rheumatoid Arthritis

Methotrexate is the first-line disease-modifying therapy for this patient with established rheumatoid arthritis, not NSAIDs or corticosteroids alone. 1, 2, 3

Rationale for Methotrexate as First-Line DMARD

The patient presents with a 10-year history of polyarthritis, elevated rheumatoid factor (100 IU/mL, normal <58), and small joint involvement—all features defining established, seropositive rheumatoid arthritis requiring immediate disease-modifying therapy. 1, 2

• Methotrexate should be initiated at 15-25 mg weekly with folic acid supplementation, escalating rapidly to 25-30 mg weekly within a few weeks to prevent irreversible joint damage. 1, 2
• Delaying DMARD initiation leads to irreversible joint damage and worse long-term outcomes; treatment must begin immediately upon diagnosis. 1, 2
• Methotrexate is the "anchor drug" for rheumatoid arthritis management and demonstrates superior efficacy in placebo-controlled trials, with one-third of patients showing no radiographic progression at 1 year. 1, 4

Why NSAIDs and Corticosteroids Are Inadequate as Monotherapy

NSAIDs provide only symptomatic relief of pain and inflammation but do not modify disease progression or prevent joint destruction. 1, 2, 5

• NSAID monotherapy beyond 1-2 months is inappropriate for patients with active arthritis, as it fails to address the underlying autoimmune process. 1
• Corticosteroids alone are not disease-modifying therapy and do not prevent radiographic progression despite controlling symptoms. 2
• High-dose corticosteroids used as monotherapy fail to halt joint damage and carry significant long-term toxicity risks including osteoporosis, fractures, cataracts, and cardiovascular disease. 1, 2

Appropriate Role of Adjunctive Therapy

Low-dose corticosteroids (≤10 mg/day prednisone equivalent) should be added to methotrexate as a "bridge" for rapid symptom control while methotrexate takes effect, but only for less than 3 months. 1, 2

• NSAIDs may be continued for symptomatic relief alongside methotrexate after evaluating gastrointestinal, renal, and cardiovascular status. 1, 3
• Corticosteroids should be used at the lowest effective dose for the shortest duration, then tapered and discontinued once methotrexate achieves disease control. 2

Treatment Targets and Monitoring

The treatment goal is clinical remission (SDAI ≤3.3 or CDAI ≤2.8) or low disease activity (SDAI ≤11 or CDAI ≤10), assessed every 1-3 months. 1, 2

• A ≥50% improvement in disease activity is expected within 3 months of initiating methotrexate. 2
• The treatment target must be attained within 6 months; if not achieved, therapy must be escalated to combination DMARDs or biologic agents. 1, 2
• If oral methotrexate is not tolerated or ineffective at 20-25 mg weekly, switch to subcutaneous administration before declaring treatment failure. 1, 2

Critical Pitfalls to Avoid

Relying on NSAIDs or corticosteroids as monotherapy in established rheumatoid arthritis allows irreversible joint damage to progress unchecked. 1, 2

• Undertreating with suboptimal methotrexate doses (<25 mg weekly) prevents achieving remission and allows disease progression. 2
• Continuing corticosteroids beyond 1-2 years results in cumulative toxicity (fractures, cataracts, cardiovascular disease) that outweighs any benefit. 1, 2
• Failing to escalate therapy when there is <50% improvement at 3 months or target not reached at 6 months perpetuates active inflammation and joint destruction. 2