Objective. To determine disease progression in patients with rheumatoid arthritis (RA) using methotrexate (MTX) as the first disease modifying antirheumatic drug (DMARD). Methods. Patients with RA treated with MTX as their first DMARD and in whom hand/wrist radiographs prior to MTX administration had been obtained and who had received MTX for at least 10 months were evaluated radiographically for disease progression. Coded radiographs were read for erosions by 2 experienced readers using the modified method of Sharp. Erosion scores and rate of progression (per month) were calculated. Results. Of 24 patients studied, baseline radiographs showed erosions (one or more) in 11 and none in 13. Patients with and without erosions at baseline had comparable demographic and clinical features, although patients with erosions had longer disease duration and higher rheumatoid factor positivity than those without erosions (statistically nonsignificant, however). Half of all patients showed no progression; 73% of those patients with erosions at baseline but only 31% of those without erosions at baseline progressed (p = 0.049); progression rates were 0.017 (± 0.033) and 0.049 (± 0.078) for the 2 groups (p = 0.040). Conclusion. Patients with RA starling MTX before erosions have occurred are less likely to develop them; these patients also experienced a lesser degree of disease progression than patients who started MTX with erosions already present.