1 Recommendations

1.1 Adalimumab, etanercept and infliximab, all with methotrexate, are recommended as options for treating active rheumatoid arthritis in adults, only if:

  • intensive therapy with 2 or more conventional disease-modifying antirheumatic drugs (DMARDs) has not controlled the disease well enough and

  • disease is moderate (a disease activity score [DAS28] of 3.2 to 5.1) and

  • the companies provide adalimumab, etanercept and infliximab at the same or lower prices than those agreed with the Commercial Medicines Unit.

1.2 Adalimumab and etanercept can be used as monotherapy when methotrexate is contraindicated or not tolerated, when the criteria in 1.1 are met.

1.3 Continue treatment only if there is a moderate response measured using European League Against Rheumatism (EULAR) criteria at 6 months after starting therapy. If this initial response is not maintained, stop treatment.

1.4 If more than one treatment is suitable, start treatment with the least expensive drug (taking into account administration costs, dose needed and product price per dose). This may vary because of differences in how the drugs are used and treatment schedules.

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

1.6 Abatacept with methotrexate is not recommended, within its marketing authorisation, for treating moderate active rheumatoid arthritis in adults when 1 or more DMARDs has not controlled the disease well enough.

Why the committee made these recommendations

This appraisal reviews some of the treatments (adalimumab, etanercept, infliximab and abatacept) recommended for severe rheumatoid arthritis in NICE technology appraisal guidance 375 and considers them for moderate rheumatoid arthritis. The clinical evidence suggests that these treatments are likely to be similarly effective in both moderate and severe disease.

The most likely estimates suggest that adalimumab, etanercept and infliximab after 2 or more conventional DMARDs are a cost-effective use of NHS resources. So, they are recommended for treating moderate rheumatoid arthritis. The most likely cost-effectiveness estimates for abatacept are higher than what NICE normally considers cost effective, so it is not recommended for moderate disease.

  • National Institute for Health and Care Excellence (NICE)