Early aggressive treatment with DMARDs vs. step-up therapy in rheumatoid arthritis: a traditional review of joint damage and functional outcomes

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.