Abstract The management of rheumatoid arthritis (RA) has changed substantially over recent years. The emphases are now on early recognition of persistent synovitis in primary care, rapid referral to specialist services and prompt use of disease-modifying anti-rheumatic drugs (DMARDs). For patients with newly diagnosed active RA, a combination of DMARDs should be offered as first-line treatment as soon as possible. Corticosteroids should be administered in early disease, but are not a good long-term strategy for most patients. A multidisciplinary team is important, and patient education is essential. Tumour necrosis factor-α inhibitors and other cytokine modulators have had a big impact on the management of RA not responding to conventional DMARDs, but in the UK their use has been restricted by cost to patients who have failed on two DMARDs with ongoing active disease. It is sometimes possible to reduce therapy in patients who are doing well, but whether DMARDs can be safely stopped in all patients in remission is highly contentious. In future there may be improvements in early diagnosis and better prognostic markers, and health economic arguments may be able to extend the eligibility for biological drugs so that pharmacological strategies will make remission the rule and not the exception.