Four patients who fulfilled criteria for adult onset Still's disease were treated sequentially with increasing doses of acetylsalicylic acid, nonsteroidal antiinflammatory drugs (NSAID) and prednisone to control their fever and systemic manifestations. Persistence of the fever led us to treat them with small doses of methotrexate (MTX) with excellent response. Low dose MTX should be considered in patients unresponsive to antiinflammatory drugs before using high doses of prednisone.