Currently

available data Forskolin clinical trial suggest that methotrexate dosage reduction may deserve consideration in patients in remission for at least 6 months under methotrexate therapy [111] and [112]. Again, dosage reduction seems preferable over the abrupt discontinuation of methotrexate or any other synthetic DMARD. Abrupt discontinuation is associated with a high relapse rate of about 70%, i.e., 2-fold that seen with continued treatment [113], [114] and [115], and the reintroduction of the synthetic DMARD only inconsistently restores the previous status [116]. It would seem important to define a sustained remission using a strict composite criterion including the absence of synovitis, systemic inflammation, and structural disease progression [38], [108], [109] and [110]. Before making treatment decisions, the results of disease activity indices should be interpreted based not only on an analysis of the individual index components, but also on the patient’s characteristics, most notably the comorbidity profile. It should be borne in mind, however, that high RA activity is often associated with a heavier comorbidity burden ATM/ATR cancer [117] and [118] and that effective RA treatment may prevent certain comorbidities [119] and [120]. Other important considerations are the tolerance of the drugs by the patient and

the patient’s wishes, which are strongly relevant to shared decision-making and good treatment adherence. Finally, some patients have low disease activity yet continue to experience structural disease progression, as discussed in recommendation 12 (Section 3.2.4.1). The management approach should be global: pharmacotherapy, physical therapy, psychotherapy and, if needed, surgery act complementarily and are inseparable from appropriate assistance

with social and occupational issues. Non-pharmacological interventions should be many considered and may include [6] physical treatments (physiotherapy, occupational therapy, and pedicures or podiatric care); rehabilitation and changes to the environment; therapeutic patient education, psychological support, and dietary therapy. In addition, the high prevalence of cardiovascular morbidity in RA patients mandates routine and regular evaluations of other cardiovascular risk factors, which should be corrected whenever possible (smoking cessation and treatments for dyslipidemia, hypertension, diabetes, and obesity). Given the reported associations between RA and periodontal disease, attention to dental hygiene is recommended [121] and [122]. Referral for advice from a surgeon may be order, most notably in patients at risk for tendinopathy and in those with severe joint destruction.