To switch or not to switch after a poor response to a TNFα blocker? It is not only a matter of ACR20 OR ACR50

Autoimmun Rev. 2012 Jun;11(8):558-62. doi: 10.1016/j.autrev.2011.10.012. Epub 2011 Oct 22.


The introduction in the therapeutic armamentarium of TNF inhibitors (TNFi) has greatly advanced the chance of obtaining a control of clinical manifestations and of structural damage progression in an important proportion of patients with rheumatoid arthritis (RA) Methotrexate (MTX)-poor responders. However not more than 50% of TNFi treated patients can reach relevant clinical benefits. Therefore the unmet medical question is: should we continue the therapeutic approach with a second or a third TNFi, or should we use other drugs, and change the mode of action of the second drug? These are practical issues that still do not have a definite answer. The real problem is that up to this moment no real biomarker is available to make the appropriate choice. The only clear-cut biomarker is represented by the positivity of rheumatoid factor (RF) or anti citrullinated peptide autoantibodies (ACPA). Seropositive patients seem to respond better than seronegative ones to B cell depletion therapy (Rituximab). This paper discusses the pros and cons of switching or swapping in RA patients poorly responder to the first TNFi.

Publication types

  • Review

MeSH terms

  • Animals
  • Antirheumatic Agents / pharmacology
  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Rheumatoid / drug therapy*
  • Arthritis, Rheumatoid / immunology
  • Drug Discovery
  • Drug Substitution*
  • Humans
  • Immunotherapy* / trends
  • Methotrexate / therapeutic use*
  • Treatment Failure
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors*


  • Antirheumatic Agents
  • Tumor Necrosis Factor-alpha
  • Methotrexate