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DOI 10.1186/s40064-015-0979-6achieve successful remission. Within the last decade the field of therapeutics have witnessed an evolution in the of Saudi Arabia Full list of author information is available at the end of the articleIntroduction Rheumatoid Arthritis is a systemic autoimmune inflam-matory disease of indefinite etiology. The disease specific-ally affects the synovial joints contributing to significant synovial inflammation, progressive joint destruction and deformity of the affected joints. RA affects approximately 1 % of adults all over the world with the diagnosis usually established between the third and fifth decade of life. Women are 2 to 3 times more likely to be diagnosed than men. The disease might additionally contribute to extra-articular multi-organ inflammation with variable outcome. Improperly treated the disease might lead to significant morbidity and incapacitation. For decades the conven-tional synthetic DMARDs (csDMARDs) have been the corner stone for the management of RA with methotrex-ate being the anchor drug in most of the designed regi-mens. Multiple studies and real life reports have documented that even with the highest standards of care with the use of csDMARDs either alone or in combina-tions up to 60 % of the affected cases with RA fail t