Management decisions in the rheumatic diseases require an understanding of the natural history of the disorder as well as the expectation of rational therapy. However, many of the diseases treated by rheumatologists display widely variable clinical expression. Diagnostic and therapeutic conundrums are encountered frequently by practitioners and no single disease can be expected to respond predictably to prescription therapy. Because of this, “one-size-fits-all” practice guidelines do not always achieve improvement in clinical outcomes. In this issue of Best Practice & Research , we attempt to frame this discussion in the context of individual disorders that frequently pose difficult management decisions for the rheumatologic practitioner. Effective management strategies demand an understanding of what can realistically be expected when treatment options are discussed with the patients. In this issue, we consider common as well as less common rheumatic syndromes. Also discussed are issues specific to particular age groups or clinical situations. In some cases, we have tried to be provocative in answering the question: Can we alter or reverse the natural history of the disease? Each of the articles attempts to address real-life practice-based issues and provide evidence- based direction for their consideration.

In the articles by Dr. Machold and by Drs. Schett and Rudwaleit, the authors directly address the issue of whether or not disease progression can be altered in rheumatoid arthritis and ankylosing spondylitis respectively. In the case of rheumatoid arthritis, Dr. Machold further addresses the contentious issue of whether RA can actually be cured.

Common rheumatic diseases are discussed from both a classification and management standpoint. Dr. Punzi and colleagues elaborate on the common classification of osteoarthritis including inflammatory and non-inflammatory subgroups. This stratification has potential therapeutic implications. Drs. Paiva and Dupree-Jones discuss the management of fibromyalgia in a busy solo practice and identify useful pharmacologic and non-pharmacologic strategies. Two of the more difficult management issues that arise in rheumatology are the treatment of rapidly progressive systemic sclerosis and the management of treatment resistant inflammatory myopathy. The former topic is addressed by Drs. Khanna and Denton who provide a rational approach to such patients. In the case of treatment resistant myopathy, Drs. Mann, Vencovsky and Lundberg outline a stepwise approach for such patients and describe recent clinical trials in this field.

A less common, yet potentially devastating, disorder is that of central nervous system angitis. Dr. Hajj-Ali discusses a differential diagnosis for this disorder and contrasts it a close mimic, reversible cerebral vaso constriction syndrome. Important clinical, laboratory and imaging modalities are outlined and an approach suggested for stratifying these patients.

An emerging disorder that has been found to be more frequent than previously suspected is that of auto-inflammatory syndromes. The classification and evaluation of patients suspected of these syndromes is discussed by Drs. Grateau and Tuncay Duruoz. These conditions are being recognized more frequently in rheumatology.

Finally, three common clinic scenarios are discussed. Dr. Bhalia provides evaluation and management suggestions for pre-menopausal women with osteoporosis. Another important area, discussed by Drs. Schwab, Lipton and Kerr, is that of rheumatologic sequelae that occur in individuals with organ transplantation. Dr. Clowse then provides a comprehensive review of contraception and pregnancy in the rheumatic diseases.

Taken together, these articles provide an overview of common and uncommon rheumatologic disorders and address areas that provide clinical difficulties in terms of contemporary management. Evidence-based discussion of these issues is the predominant theme of the current issue.