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The combination treatment with COBRA therapy works very rapidly, and will be continued for at least 6 months. Then, we will try to taper and stop one or more drugs. You should take into account that you will have to continue using at least one drug, because of the possibility that disease activity returns. You will also notice that other anti inflammatory drugs or painkillers will no longer be necessary, which means that you can decrease the number of other tablets you have to take. In the figure below, you can see a visual representation of the therapy. As you can see, COBRA therapy starts strongly to quickly suppress the disease, but high-dose prednisolone is rapidly tapered so that after 6 weeks you are on low-dose maintenance therapy. After 6 months we try to tapering one, and later on two drugs. Every three months, you and your rheumatologist look whether adjustments are needed.

Apart from taking these drugs, it is advised that you exercise as much as possible; for example by swimming, walking or cycling.

Visual representation of the COBRA therapy.

Starting and tapering

The dosage of sulphasalazine is built up in the first week, to a fixed dose of 2 grams a day, in tablets of 500 mg each. You take methotrexate once a week, for example, every week on Monday mornings. You take all three tablets of each 2.5 mg at the same time. This way, you use 7.5 mg a week. The dosage of prednisolone is tapered during the first 7 weeks. We use tablets of 20 mg and 5 mg for this. This means that during the first week, you take 3 tablets of 20 mg, in the second week 2 tablets of 20 mg, in the third week 1½ tablets of 20 mg and in the fourth week 1 tablet of 20 mg. Then, you switch to the smaller tablets of  each. In the fifth week you take 3 tablets of 5 mg, in the sixth week 2 tablets of 5 mg and in the seventh week 1½ tablet of 5 mg. When you have to take half a tablet, you can break the tablet in two and swallow it without chewing. If things go well your rheumatologist will advise you to start tapering prednisolone after 28 weeks/6 months and continue with tapering either sulphasalazine or methotrexate after 40 weeks/9 months. Normally, you continue to use either sulphasalazine or methotrexate for a longer period of time.


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