The early stage of rheumatoid arthritis (RA) is a unique and critical phase of disease which is often characterized by profound inflammation, severe symptomatology and a high likelihood of radiological progression. Decisions on treatment strategies need to be taken before irreversible damage and functional deterioration occur. There is evidence that early intervention with disease-modifying drugs may reduce functional deterioration and improve long-term outcome. Stable genetic markers and rheumatoid factor are useful in predicting disease severity and thus in identifying those patients who require early aggressive therapy. The acute phase response (APR) is a valuable marker of disease activity and catabolism in RA, and suppression of the APR improves outcome. The use of early aggressive therapy to suppress disease efficiently in patients with a poor prognosis should improve the long-term morbidity and mortality associated with RA.