He said the major drug companies offer patient assistance programs for those who could not otherwise afford biologic treatments, but getting patients approved for them is a logistical burden for them and for the clinic staff.
But Matteson believes the extra cost is worth it, not just for reduced symptoms, but also in patient-centered outcomes such as ability to work and staying out of the hospital.
Still, Van Feldt said, the cost of biologic drugs is a problem. "Even the very well-heeled cannot afford $1,000 a month for the rest of their lives."
She said the so-called "doughnut hole" in Medicare drug coverage, which leaves some beneficiaries responsible for the full cost of prescriptions, means that some patients have to delay or stop treatment at least temporarily, risking loss of disease control that may be hard to get back.
And the cost issue may get worse, thanks to a growing movement to treat patients with biologics as soon as RA is confirmed.
Some recent studies -- sponsored by the makers of biologic drugs -- have found that starting TNF inhibitors and perhaps rituximab at the same time that methotrexate is begun leads to higher rates of complete remission.
The hope, still unproved, is that these fast, complete remissions can then be maintained with less intensive drug regimens later on.
"Hit them early, hit them hard," as one researcher put it in 2006.
But Hadler said the jury is still out on whether early, aggressive, and expensive treatment for all patients is worthwhile.
"I represent the conservative school arguing that for perhaps a third [of patients] the disease is monophasic and a spontaneous remission is likely, and for another third the course is persistent but mild," he said.
"It's only a third for whom the disease is aggressive, and I reserve more aggressive therapies once the patient has declared himself as in this third."
Regardless of how this debate plays out, clinicians agree that the outlook for patients today is far, far better than it was in 1984.
"RA back then was a terrible disease," said Utz.
"I keep a picture on my desk of ... a 30-year-old woman who died of amyloidosis on her 30th birthday, all from juvenile RA that could have been effectively treated if she had been born now."