Current recommendations suggest using biologics as a second-line treatment strategy, with exceptions only in extraordinary circumstances. Patients should first be treated with methotrexate, reaching the maximum possible dose. In developing countries, where patients bear the cost of medications, a trial with combinations of DMARDs is necessary. According to the NICE RA guideline, patients with RA must have moderate levels of persistent disease activity to be eligible for biologic drugs. Specifically, the Disease Activity Score in 28 joints (DAS28) must be 3.2 or higher. Additionally, patients must have failed on two DMARDs, one of which must be methotrexate taken for at least six months, unless contraindicated (Taylor et al. 2023).

The rationale behind this approach is driven by both safety and cost considerations. Clinical response to csDMARDs is observed in more than 50-70% of patients, depending on the severity and duration of the disease. However, there are currently no tests or biomarkers available to identify patients who will not respond to csDMARDs.

REFERENCE

1. Taylor PC, Askari A, Choy E, Ehrenstein MR, Else S, Nisar MK. Approaches to optimising access to NICE-approved biologic anti-TNFs for patients with rheumatoid arthritis with moderately active BMC Med. 2023 Feb 14; 21:55.