The past decade has greatly enhanced our understanding of rheumatoid arthritis (RA). Not only have new drug therapies become available, but this period has witnessed dramatic changes in treatment strategies as well. Since 1989, when the proposal on reversing the pyramid approach (the stepdown bridge concept) was published, the concept of early and aggressive treatment of RA has become the leading paradigm. The theory underlying this approach is based on a better understanding of the devastating long term consequences of RA in most patients, and the logical tenet that irreversible damage must be prevented before it occurs. Evidence has shown the irreversible joint damage in RA occurs early in the disease, making a "wait and see" approach unacceptable. Thus, it appears logical to begin treatment as soon as a diagnosis of RA is confirmed, to slow disease progression by treatment with disease modifying antirheumatic drugs. This review will address the evidence supporting the benefit and the principles of early treatment, as well as the current update on pharmacological management in early RA.