W. B. Harrison B. A. C. Dijkmans During the last decade intervention has been instituted for
all kinds of disease- even in a premorbid state as early as possible to control the activity
of the disease to avoid further damage and to maintain quality of life. Apart from the
principle 'Treat now not later emphasis is laid on aggressive initial therapy. These adagia
have influenced in recent times all fields of medicine from oncology to infectious diseases
and also - the topic of the present edition - the autoimmune diseases. As an example of the
latter rheumatoid arthritis (RA) demonstrates how the attitude of physicians has been changed.
From an expectant point of view in the eighties (primum nil nocere) the attitude has been
changed as we approached and entered the new millennium to initial ag gressive therapy
especially in patients with a poor prognosis. Despite the advance of instituting monotherapy
with a single optimised disease-modifying anti-rheumatic drug (DMARD) - with methotrexate as
prototype agent in RA - adequate disease re mission is not often achieved and adverse events
may well prevent the use of higher dosages of the single agent in question. Therefore the next
step was to combine two or more DMARDs. The choice of combining DMARDs can be purely practical
and based upon the anti-rheumatics most used in daily practice for instance methotrexate and
sulphasalazine. The choice of combining drugs can be influenced by different toxicity patterns
to avoid cumulative toxicity.
