• rheumatoid arthritis
• DMARDs (synthetic)
• treatment

We appreciate the comments provided by Misra et al 1 on the 2016 update of the European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA).2 They raise a very good point by stating that the use of biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARDs) in countries like India and many others, is limited by unjustifiable drug prices that are the consequence of various policies by drug manufacturers. Therefore, highly effective drugs are not widely accessible to patients in many countries. While EULAR is highly concerned by this reality, the recommendations are not primarily meant to improve accessibility of drugs worldwide. The EULAR recommendations provide what is regarded to be the optimal therapeutic approach according to the evidence derived from systematic literature reviews (SLRs)3–5 and expert opinion. If the best therapeutic approach may not be feasible in some countries, alternatives have to be sought. Of course such alternatives would be to switch to another conventional synthetic DMARD (csDMARD) or to add a csDMARD, rather than to add a bDMARD or tsDMARD. Misra et al try to imply, though, that such an alternative is as efficacious as adding a bDMARD, and this is a comment that the task force did not agree with.

Misra et al refer to the tumour necrosis factor inhibitors …