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Rheumatoid arthritis (RA) has started to be perceived as a potentially curable condition with early, aggressive use of disease-modifying antirheumatic drugs. We review the pathophysiological concepts of RA development, the technological advances used to estimate the individual risk of progression to RA, and the impact of antirheumatic therapy for patients presenting with early inflammatory arthritis.The finding of a strong gene–environment interaction has modified our concepts of RA pathogenesis and opened new opportunities for disease prevention and therapeutic interventions. Anticyclic citrullinated antibodies and prediction rules have improved our ability to estimate the risk of progression to RA in individual patients presenting with early inflammatory arthritis. In patients at high risk of developing RA, results from trials suggest that treating these patients with potent antirheumatic therapies may slow the progression from early inflammatory arthritis to definite RA and inhibit the progression of joint damage.Early inflammatory arthritis is a critical period of the disease, during which therapy may have a durable effect and change the natural course of the condition. Physicians need to assess the individual risk of progression to RA in patients presenting with early inflammatory arthritis and consider initiating early disease-modifying antirheumatic drug therapy in patients at high risk of developing RA.