Diagnostic issues:
(1) There is no doubt about the diagnosis of rheumatoid arthritis.
(2) The severity of the disease justifies any therapeutic risks to be taken:
(a) The rheumatoid arthritis has been persistently active (for > 6 months).
(b) The patient has developed extra-articular disease (myocarditis, uveitis, pneumonitis, vasculitis, etc.)
(c) The patient has high titers of rheumatoid factor.
(d) There is radiographic evidence of bone and joint deterioration.
Therapeutic issues:
(3) The patient has been adherent yet has had an inadequate response to appropriate doses of salicylates or nonsteroidal anti-inflammatory agents (NSAIDS).
(4) The presence of steroid dependency, with the patient requiring > 7.5 mg of prednisone per day (or its equivalent).
(5) The rheumatoid arthritis is expected to respond to the new regimen.
(6) The patient does not have contraindications to agents in the new regimen.
Patient and physician issues:
(7) The patient is informed, cooperative, and compliant. The patient is willing to tolerate a slow change in the condition.
(8) The physician is experienced in the use of these agents.
Management issues:
(9) The plan, goals and expectations are reasonable.
(10) The patient will be monitored for toxicity.
(a) The patient is able to contact and see the physician.
(b) The physician is accessible to the patient.
