In recent years the expectation of benefit of treatment of rheumatoid arthritis (RA) has evolved. Remission, as defined by the disease activity score (table 1), is now a goal for many clinicians. To achieve this it is standard practice to institute disease modifying antirheumatic drug (DMARD) treatment early in the disease course and to use combination DMARD treatment when single drugs prove ineffective. In addition, anti-tumour necrosis factor α (TNFα) treatment has an established role in severe RA. However, despite these advances remission is achieved in only a minority of patients. Few randomised controlled trials (RCTs) in RA report remission data, which in itself is testament to the infrequency of remission. Why are expectations of greater benefit not realised?

In RCTs of the commonly used DMARDs methotrexate (MTX), sulfasalazine (SSZ), and leflunomide (LEF) as monotherapy, remission rates of 12.7–25% have been reported, depending on the population studied.^1–3 Although individual clinical responses to anti-TNFα monotherapy can be dramatic, remission rates in patients treated with anti-TNFα agents alone in RCTs have been disappointing, with 22.4% of patients with established disease achieving remission at 2 years.¹

However, the combination of MTX and anti-TNFα treatment has provided more encouraging clinical results. At 2 years’ follow up in the TEMPO study the combination of etanercept and MTX resulted in remission in 42.4% of patients with established RA compared with 25% remission with MTX or etanercept monotherapy.¹ Similar rates of remission were also seen in the combination arm (MTX, SSZ, hydroxychloroquine (HCQ), and low dose prednisolone) of the FIN-RACo early RA study at 2 years.²

Although there are no published data on remission rates with triple treatment (MTX, SSZ, and …