One of the most talked about sessions in our Go With Us coverage at the 2025
European Alliance of Associations for Rheumatology (EULAR) congress was a lively debate on early treatment for people at high risk of rheumatoid arthritis (RA). Tiffany and Deb attended together, and it sparked important questions that many patients are already asking in real life. If you are at high risk for RA, should treatment start before full disease develops? And what does early treatment actually accomplish?
Here is a clear, patient centered breakdown of what was discussed and why it matters.
The big question: Can early treatment prevent RA?
The session was framed around a bold question: should DMARDs be given to people at high risk for RA to prevent the disease?
DMARDs, or disease modifying antirheumatic drugs, include medications like methotrexate, leflunomide, sulfasalazine, and more advanced options like biologics and JAK inhibitors. These medications are already the backbone of RA treatment once the disease is diagnosed.
What quickly became clear during the debate is that prevention and delay are not the same thing.
This distinction shaped the entire discussion.
The case for early treatment
The physician arguing in favor of early treatment started with history. For centuries, medicine has recognized that untreated disease leads to worse outcomes. In RA, we already moved away from a wait and see approach decades ago and toward what is known as treat to target, meaning treatment is adjusted aggressively and intentionally to control disease activity.
The argument focused on people who are most likely to develop aggressive or difficult to treat RA. These are not all at risk individuals, but a smaller subgroup with known risk factors, including:
- Being ACPA positive, which is a biomarker strongly associated with more severe RA
- Smoking
- Obesity
- Other environmental and immune related risk factors
Difficult to treat RA is defined as disease that does not respond after failing two biologics with the same mechanism of action, such as two TNF inhibitors. These patients often have more aggressive disease from the very beginning.
The
pro early treatment argument emphasized that early intervention
can:
- Delay the onset of RA by up to five years in high risk individuals
- Reduce joint damage and disease burden
- Improve long term quality of life
- Potentially lower overall healthcare costs if remission is achieved early
Several studies were discussed. Methotrexate trials showed limited benefit, especially in ACPA positive patients. However, studies using biologics like abatacept showed something more meaningful. While RA was not prevented, onset was delayed, in some cases by as much as five years. That time matters to patients.
The case against early treatment
The opposing physician focused on one core issue: there is currently no evidence that RA can be prevented. From this perspective, treating people early without being able to fully stop disease raises concerns.
Key points from this side included:
- About half of people considered high risk may never develop RA
- Treating everyone early could mean unnecessary medication exposure for many
- Long term costs could increase if people stay on therapy for years without progressing
- Methotrexate did not significantly help those who later became difficul t to treat
This side argued that delaying disease is not the same as preventing it, and questioned whether treatment is justified when prevention is not yet possible.
Where the debate really landed
Both Tiffany and Deb, along with many audience members, felt the debate question itself was flawed. The data presented did not support prevention, but it clearly supported delay and improved outcomes for certain high risk patients.
A key moment came when it was clarified that early treatment is not meant for everyone. It is aimed at a small group of patients who show strong indicators of future aggressive disease.
Another important takeaway was about treatment choice. Methotrexate helps control inflammation and prevent further damage, but it does not repair existing bone damage. Biologics, on the other hand, have shown potential to reverse bone loss and improve bone density. Only about 30 percent of patients respond well to methotrexate alone, which raises questions about starting with less effective therapy in patients already likely to struggle.
There was also discussion about tapering and micro dosing. Research shows that when patients taper off biologics, many flare again. A more realistic strategy may be early biologic treatment, disease control, and then careful dose reduction to maintain remission.
What this means for patients
The most important message from this debate is that early treatment should be a shared decision, not a one size fits all rule. If you have biomarkers, risk factors, and clinical signs that suggest a high chance of aggressive RA, early biologic treatment may offer meaningful benefits, even if prevention is not yet possible.
This debate reinforced several patient centered truths:
- Delaying disease can still be life changing
- Quality of life matters just as much as disease labels
- Biomarkers and risk profiles should guide decisions
- Patients deserve to be part of these conversations
The real question may not be “Can we prevent RA?” but rather “If we know someone is likely to have severe disease, should we act sooner to reduce harm?” That is a conversation worth having with your rheumatology team.
