Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease. In the majority of patients the course is progressive and leads to destruction of joints, functional disability, reduced quality of life and increased morbidity and mortality. Advances in treatment for RA have been associated with an improvement in the health status of patients with RA in recent years.1 While the management of RA varies widely across Europe,2 the underlying pathophysiology does not differ between countries. A cross-sectional comparison of patients with RA in 15 different countries (largely European) revealed great variation in the drug management of patients with RA, including the delay in starting a disease-modifying antirheumatic drug (DMARD) ranging from <6 to >12 months, use of methotrexate (<80% of patients in the UK and Serbia had received methotrexate) and use of biological agents (>40% in France and Ireland vs. <10% in Serbia and Poland).3 It is also noteworthy that disease activity scores varied and were highest, on average, in Serbia and Poland.3

Although tumour necrosis factor (TNF) inhibitors have undoubtedly significantly advanced the treatment of RA, they are a higher cost treatment option and may not be suitable for all patients.4 Hence, guidelines have been developed in order to assist the appropriate use of TNF inhibitors within individual countries.

In order to establish the level of access to TNF inhibitors across Europe, European guidelines were translated and reviewed with regard to their similarities and differences in the recommended criteria for the initiation of TNF inhibition. Particular attention was paid to recommended duration of disease and prior treatment with DMARDs, as well as disease activity levels.

The guidelines selected for inclusion were those from Belgium,5 Czech Republic,6 Denmark,7 France,8 9 Germany,10 Italy,11 Romania,12 Spain,13 Sweden14 and the …