The first approved biological agents for the treatment of rheumatoid arthritis (RA) were tumour necrosis factor (TNF) antagonists, all of which improve disease signs and symptoms, and slow or prevent structural damage; however, they are not equally effective in all patients. About 30% of patients treated with a TNF agent fail to achieve an improvement of 20% in the American College of Rheumatology (ACR) criteria, and even more patients lose efficacy during therapy or experience adverse events. Switching to a second TNF inhibitor has become an established approach to patients who fail or are intolerant of treatment with the first. However, there is only one published large randomised clinical trial evaluating the benefits of switching TNF antagonists, and data from observational studies and clinical practice are conflicting. Many parameters influence switching TNF agents, including the type of failure or TNF antagonist. However, many RA patients can be successfully treated with a second TNF antagonist, especially those discontinuing the first because of secondary failure or adverse events.
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