The appearance of measurable structural damage in rheumatoid arthritis (RA) is an indicator of disease severity and future disability. Disease-modifying anti-rheumatic drugs (DMARDs) used in combination appear to be more effective than monotherapies at reducing the rate of progressive joint damage during randomized controlled trials. In clinical practice, however, combination DMARD therapy is still largely reserved for patients who have failed to respond to monotherapy. High dose corticosteroid, when given in early disease with combination DMARD therapy, may continue to ameliorate disease severity and progression for years after discontinuation of the high dose. To date, no DMARD combination has totally arrested joint damage in all patients with early RA. Future randomised controlled trials should always include prospective radiographic data as a primary outcome measure.