I believe the two approaches both practiced in different parts of the UK are the step up and step down methods Nikk. The step up approach involves taking a dmard such as MTX or Sulpha or Hydroxy first off then adding drugs in once they are proven to be tolerated by the patient. The step down (what you seem to have) is when you are started on several DMARDs and then as disease is controlled you slowly step down in dosage.

I'm still fairly new to this RA business but I was started on MTX and have now had Hydroxy/ Plaquenil added in - but only because I'd already tried Sulphasalazine last year and had a bad reaction to it as my rheumy didn't mention Hydroxy/ Plaquenil to me and GP's say it's rarely been prescribed for RA patients where I live. I basically have had to research the drugs and ask to have new medications introduced once the MTX hasn't worked fully - and it's been very slow and frustrating steering my own ship with GPs on board but no rheumy - or only at a distance waving a busy, lofty hand!

I have only been able to discuss this with my GP and have not seen my rheumy since diagnosis in November, nor have I a rheumy nurse to ask. But I read on this NRAS site that it is thought that the step down method is the most favoured approach these days - however like each person's local rheumatology service it's the usual variable post code lottery thing as to how your rheumy approaches the medication of RA patients it seems. Guidleines don't always filter down into good practice and rheumatologists seem to have their own approaches and some don't care for change. TTx

Hi Nikk, it's also that RA is hugely variable between people. A good percent of people have an RA that responds very well to being treated with one DMARD like MTX and they can do very well on that for years and years. At the other end of the scale are people who have an RA that resists lots of drugs, and then the majority of us are somewhere Inbetween. And things change over time, so often people do need to swop meds after several years.

Unfortunately there's no way of telling which drugs will work best for which people (yet - there is research on this going on) so You do have to go through a bit of trial and error to find out what suits you best. Which is horribly frustrating but generally the docs want to get you to the point where you're as stable as you can be on the least amount of drugs. So often in England they use the step up approach that tilda described. Hope that helps. Polly

Thank you both very much for your answers - That has cleared it all up a bit in my head - Polly I'm in Wales which may explain the step down approach I seem to be on! So far I'm tolerating all the drugs pretty well so I'm hoping I'm one of the "lucky" ones who can take whatever helps.

However I don't have any let up at all with the pain yet. I can still do everything I want (except popping pillls out of foil when my fingers are useless!) its just very painful at times. Both treatments take a while to get started as I understand and I didn't start taking them in Feb due to clerical errors(!) so hopefully they will kick in soon.

Very interesting reading the different approaches to treatment thanks again for your answers - Nikk

Hi Nikk,
I was diagnosed in March this year. Started taking Methotrexate on the 17th, slowly increased the dosage from 10mg to 20mg, Folic Acid 5mg once a week,
I also take Naproxen (only one tablet a day at the mo), Lansoprazole 15 mg daily these are gastro-resistant capules.

I am virtually pain free at the present time, no swelling, so I have been very lucky that the MTX worked very quickly.

Before starting on the meds, my fingers were incredibly sore and just about every joint in my body gave me pain at some time.

Hope all goes well for you and you get relief from the pain.

Hi Nikk
im on the same as you MTX and salaz
its done me good so far and been on it about 16 months
debs x

Hi Nikk

Tilda is absolutely right about the step up and step down approaches, and the variance will be partly down to consultant preference and partly taking into acount the severity of the disease, as well as other factrs such as patient choice and other conditions or medications they might be on etc.

Methotrexate is the most commonly prescribed DMARD initially, with sulfasalazine second. There is an article on combination therapy on our website which may be of interest. It explains why the use of drugs in combination were recommended in the NICE guidelines:

www.nras.org.uk/about_rheum...

Kind regards

Victoria
(NRAS Helpline & Information Coordinator)

Hello First poster. At the moment I am on pain patches ( fentanil) and tramadol & hydroxicloroquin and Naproxen I have quite a lot of pain and am not happy with the concoction of meds I have Inflamitory Ra in all joints and synovial osteo-chondromatosis in my knees , I dont get much sleep due to the pain