Global economic slowdown forced a rethink and relook at these agents like old wine in a new bottle. Several studies, especially those using ‘T2T’ have shown that the most important trick PARP inhibitor to achieve remission or low disease activity in RA is early aggressive approach rather than the choice of the medications. Modern management

of RA should, therefore, be directed by this approach. Early and continued suppression of rogue autoimmune cells and their products to delay or abort their attempt to gain autonomy seems to be the key to successful treatment in RA. A number of studies in the recent past have reaffirmed the faith in the conventional DMARDs with favourable efficacy profile such as hydroxychloroquine, sulphasalazine, methotrexate (MTX) and leflunomide, especially when used in a combination regimen. One such combination popularly called ‘triple therapy’ (hydroxychloroquine + sulphasalazine + methotrexate) with or without very low dose steroid has passed the test of time. Much to the disappointment of proponents of biologics as the first line therapy, new studies have found combination of synthetic DMARDs non-inferior to the coveted biologics alongwith

greatest economic advantage to their credit, provided the treatment is started early and intensity of dosage is guided and adjusted by T2T approach. Addition of other inexpensive agents like vitamin D and fish oil can add even further benefit and have been variably reported. However, the strongest point ZIETDFMK that remains in favour of the biologics is the rapid onset of action and radiological healing; these advantages, unfortunately, are enjoyed only by privileged few with funding support from state, insurance or self. Whether to use biologics in early disease or in patients who have persistently active disease despite conventional DMARDs, therefore, is more of a sociopolitical issue than a scientific one. In the following paras, find more we will dissect out these issues with facts.

All biological agents including tumour necrosis factor (TNF) inhibitors namely Infliximab, Etanercept, Adalimumab, Golimumab and Certolizumab, interleukin-6 antagonist Tocilizumab, T cell costimulatory antagonist Abatacept, B cell depleting agent Rituximab and the upcoming JAK signaling inhibitor Tofacitinib have proven their efficacy in active RA patients who failed MTX in clinical trials. In addition to the treatment goal of achieving symptomatic relief, these biologic agents in combination with MTX as an anchor drug have also shown superiority over MTX monotherapy in clinical outcomes including induction of remission, retardation of structural deformity and preservation of physical function in established RA as well as in early RA, with the exception of Tocilizumab which has been shown to be superior to MTX even as monotherapy by itself alone.