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Inequities in access to biologic and synthetic DMARDs across 46 European countries
  1. Polina Putrik1,
  2. Sofia Ramiro2,
  3. Tore K Kvien3,
  4. Tuulikki Sokka4,
  5. Milena Pavlova5,
  6. Till Uhlig6,
  7. Annelies Boonen7,
  8. Working Group ‘Equity in access to treatment of rheumatoid arthritis in Europe’
  1. 1Department of Health Promotion and Education, Maastricht University, School for Public Health and Primary Care (CAPHRI), Maastricht, The Netherlands
  2. 2Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal; Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  3. 3Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  4. 4Department of Medicine, Jyväskylä Central Hospital, Jyvaskyla, Finland
  5. 5Department Health Services Research, CAPHRI, MUMC, Maastricht University, Maastricht, The Netherlands
  6. 6National Research Center for Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  7. 7Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center and School for Public Health & Primary Care (CAPHRI), University Maastricht, Maastricht, The Netherlands
  1. Correspondence to Polina Putrik, Department of Health Promotion and Education, Maastricht University, Peter Debyeplein 1, Maastricht 6229HA, The Netherlands; polina.putrik{at}


Objectives We investigated access to biologic and synthetic disease modifying drugs (bDMARDs and sDMARDs) in patients with rheumatoid arthritis (RA) across Europe.

Methods A cross-sectional study at national level was performed in 49 European countries. A questionnaire was sent to one expert, addressing the number of approved and reimbursed bDMARDs and sDMARDs, prices and co-payments, as well as acceptability of bDMARDs (barriers). Data on socio-economic welfare (gross domestic product per capita (GDP), health expenditure, income) were retrieved from web-based sources. Data on health status of RA patients were retrieved from an observational study. Dimensions of access (availability, affordability and acceptability) were correlated with the country's welfare and RA health status.

Results In total, 46 countries (94%) participated. Six countries did not reimburse any of the five sDMARDs surveyed, and in ten countries no bDMARDs were reimbursed. While the price of annual treatment with an average sDMARD was never higher than GPD, the price of one year treatment with a bDMARD exceeded GPD in 26 countries. Perceived barriers for access to bDMARDs were mainly found among financial and administrative restrictions. All dimensions of access were positively correlated with the country's economic welfare (coefficients 0.69 to 0.86 for overall access scores).

Conclusions Patients with RA in lower income European countries have less access to bDMARDs and sDMARDs, with particularly striking unaffordability of bDMARDs in some of these countries. When accepting that sDMARDs and bDMARDs are equally needed across countries to treat RA, our data point to inequities in access to pharmacological treatment for RA in Europe.

  • DMARDs (biologic)
  • DMARDs (synthetic)
  • Health services research
  • Rheumatoid Arthritis

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