Management of inadequate response to TNF-α antagonist therapy in rheumatoid arthritis: what are the options?

The advent of tumor necrosis factor (TNF)-α antagonists for the treatment of rheumatoid arthritis (RA) has led to considerable improvements in effective disease management in patients with an inadequate response to traditional disease-modifying antirheumatic drugs. However, the available TNF-α antagonists have yet to meet the needs of all patients with RA; some patients may have an inadequate clinical response, lose their responsiveness over time, experience unacceptable side effects or have medical issues precluding the use of these medications. An inadequate response is generally determined in the context of a deteriorating clinical state, although there is no standardized definition. This review evaluates the role of two newly available biologic therapies rituximab and abatacept within the challenging treatment context of patients who fail to have an adequate response to TNF-α antagonists. Both medications downregulate the immune inflammatory reaction, albeit via different mechanisms, and have been shown to impede the progression of joint deterioration, providing potential options for these difficult-to-treat patients. Editorial support for this manuscript was funded by BristolMyers Squibb