Methotrexate (MTX) and biological agents have revolutionized the rheumatoid arthritis (RA) treatment by shifting the focus from alleviating pain to preventing joint degeneration, improving the quality of life and remission of the disease. Many guidelines list MTX as a first line and an anchor drug and recommend use of biologic agents or Janus kinase (JAK) inhibitors when responses to MTX treatment are not adequate. However, in clinical practice we encounter patients for whom this strategy is not feasible for various reasons, and others in whom good outcomes can be achieved with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) other than MTX; thus, csDMARDs continue to be used for RA today. Thorough understanding of the characteristics of other csDMARDs and their appropriate usage are important in RA care, rather than exclusive reliance on MTX and biologic agents.