Rheumatoid arthritis (RA) is a very heterogeneous disease, the outcome of which is difficult to predict. The vast majority of the patients will have disease progression with bone erosions and cartilage breakdown resulting in joint destruction, functional impairment, and increased mortality. The management of RA to prevent and control disease progression has changed considerably in the past few years. The treatment goal should now be to achieve clinical remission in order to prevent structural damage and long-term disability. A very early use of effective disease-modifying anti-rheumatic drugs (DMARDs) is a key point in patients at risk of developing persistent and erosive arthritis. Intensive treatment such as combination DMARDs plus steroids or mainly biological therapies can induce high rates of remission and control of radiological progression, and can provide better outcomes than DMARD monotherapy in early RA, and should be considered very early in at-risk patients. In addition, close monitoring of disease activity and radiographic progression is mandatory in order to adapt DMARD therapy and strategy if necessary.