Rheumatoid arthritis (RA) is common and debilitating. It affects approximately 1% of adults in the UK, with a prevalence which increases with age; over the age of 60 years roughly 2% of men and 5% of women are affected.1 Early in the disease most patients will receive analgesics and NSAIDs, which relieve symptoms but do not affect the underlying disease process.2 Slow-acting antirheumatic drugs (SAARDs) – gold, penicillamine, hydroxychloroquine/chloroquine or sulphasalazine – have conventionally been used later.3 These drugs act slowly, improve symptoms and suppress clinical and serological markers of RA activity. Moreover they appear to slow progression of the disease, although whether they modify disease outcome in the long term is not clear. Many rheumatologists now advocate their earlier use in some patients. We review the place of SAARDs, including methotrexate and immunosuppressants, in the treatment of RA.