At this year’s European League Against Rheumatism (EULAR) oral presentation session about anti-tumor necrosis factor (anti-TNF) treatments in rheumatoid arthritis (RA), rheumatologists discussed the optimal treatment after RA patients fail to respond to their first anti-TNF therapy, but ultimately failed to agree on a recommended treatment strategy for these patients. Current EULAR guidelines have no clear recommendation on which anti-TNF to select over a non-anti-TNF biologic therapy when patients fail a single anti-TNF. In the absence of a clear consensus, physicians adopt individualised approaches where the patient’s clinical, immunological, and personal preferences (oral over intravenous route of administration, cost of therapy) are considered in making the appropriate choice of therapy.

RA therapy has seen considerable improvements over the past decade; in particular, the treat-to-target approach has resulted in a shift from RA being disabling to manageable. A milestone in the physicians’ treatment armamentarium for RA was the introduction of anti-TNF inhibitors in the early 2000s, which has allowed for the effective management of the signs and symptoms of RA. However, patients regularly experience loss of response to treatment with anti-TNF inhibitors, such as Johnson & Johnson’s (J&J’s) Remicade (infliximab). This marked the beginning of the anti-TNF switching cycle, where patients were switched between different anti-TNF therapies, specifically first generation anti-TNF inhibitors such as Amgen/Pfizer’s Enbrel (etanercept) and AbbVie’s Humira (adalimumab). However, the treatment landscape in RA expanded in the mid- to late 2000s, providing rheumatologists with a choice of switching patients who experience treatment failure with one anti-TNF to another anti-TNF inhibitor, such as UCB’s Cimzia (certolizumab pegol) and J&J’s Simponi (golimumab); to non-anti-TNF biologics, such as Orencia (abatacept), Rituxan (rituximab), or Actemra (tocilizumab); or to the Janus kinase (JAK) inhibitors (the most recent additions to the treatment landscape), such as Pfizer’s Xeljanz (tofacitinib) and Eli Lilly/Incyte’s Olumiant (baricitinib).

Despite considerable progress in the treatment of RA, clinical remission in RA patients is only achieved in approximately 25% of patients. Current guidelines have no clear recommendation on the preferred treatment after patients fail to respond to a single anti-TNF inhibitor. In the absence of clear guidelines, physicians recommend consulting patients on their preferences in terms of route of administration and cost of therapy. During the symposia, some experts recommended limiting the practice of switching patients to a second anti-TNF inhibitor when factors other than immunogenicity were the driver for losing response to treatment, thereby introducing a rational clinical approach on future treatment recommendations.