Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept, all in combination with methotrexate, are recommended as options for treating rheumatoid arthritis, only if:

• disease is severe, that is, a disease activity score (DAS28) greater than 5.1 and

• disease has not responded to intensive therapy with a combination of conventional disease‑modifying antirheumatic drugs (DMARDs) and

• the companies provide certolizumab pegol, golimumab, abatacept and tocilizumab as agreed in their patient access schemes.

Adalimumab, etanercept, certolizumab pegol or tocilizumab can be used as monotherapy for people who cannot take methotrexate because it is contraindicated or because of intolerance, when the criteria in section 1.1 are met.

Continue treatment only if there is a moderate response measured using European League Against Rheumatism (EULAR) criteria at 6 months after starting therapy.

After initial response within 6 months, withdraw treatment if a moderate EULAR response is not maintained.

Start treatment with the least expensive drug (taking into account administration costs, dose needed and product price per dose). This may need to be varied for some people because of differences in the mode of administration and treatment schedules.

Take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the DAS28 and make any appropriate adjustments.

People whose treatment with adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab or abatacept is not recommended in this NICE guidance, but was started within the NHS before this guidance was published, should be able to continue treatment until they and their NHS clinician consider it appropriate to stop.