Table 1 Summary of the recommendations from the guidance for the use of tumour necrosis factor (TNF) inhibitors in rheumatoid arthritis (RA) in selected European countries
Disease activity level required for initiationTrial of DMARDChoice of agentSwitch between agentsTreatment response measuresTime to see responseAlter frequency/doseRadiographic monitoringMTX combination recommended
Belgium5 Sociéte Royale Belge de RhumatologieNot specifiedTwo (one = MTX) for 6 months totalAnyYesSJC, HAQ3–6 monthsNot specifiedNot mentionedFor IFX: yes
Not specified for Ada or Et
Czech Republic6 Czech Society for Rheumatology, 2007DAS28>5.1Two (one = MTX) for 6 months eachAnyYesDAS2812 weeksYesx Ray every 6–12 monthsYes
Denmark7 Dansk Reumatologisk Selskab, 2000Persistent synovitis ⩾6 jointsTwo (one = MTX) for 4 months eachNot specified (Ada not included)Not specifiedSJC, TJC, pain scale, patient and physician global assessments, HAQ4 monthsNot specifiedx Ray every 6 months for at least first 2 years, then every 2 yearsFor IFX: yes
Not specified for Et
France8 9 Société Française de Rhumatologie, 2007DAS28>5.1 or DAS28>3.2 in presence of corticosteroidOne for 3 monthsAnyYesEULAR (DAS28)12 weeksYesx Rays annually (or more if RA present for long time)Yes
Haute Autorité de Santé, 2007Radiographic progressionAnti-TNF+MTX in severe early RA (such as early joint damage)
Germany10 Deutschen Gesellschaft für Rheumatologie, 2006Not specifiedTwo (one = MTX) for 6 months total (less if marked disease progression)Not specifiedNot specifiedNot specified3 monthsNot specifiedx Rays at least annuallyNot specified
Italy11 Società Italiana di Reumatologia, 2006DAS>3.7 or DAS28>5.1One for 3 monthsNot specifiedYesEULAR (DAS)12 weeksNot specifiedNot mentionedYes
Romania12 Ministry for Health, 2007DAS28>5.1Two (one = MTX) for 12 weeks eachNot specifiedYesSJC, TJC, morning stiffness, ESR, CRP, DAS283 monthsYes for IFXNot mentionedNot specified
Spain13 Sociedad Española de Reumatología, 2006DAS28>3.2 (or lower in some circumstances)Usually one for 3 months but none in aggressive diseaseAnyYesDAS28, ESR, global evaluation of the disease by the patient4 monthsYesAnnual x ray (plus quantitative analysis)Yes
Sweden14 Svensk Reumatologisk Förening, 2004DAS28>3.2Two for 2–3 months each or one (MTX) if rapid progressionNot specifiedNot specifiedDefined on individual basis?2–3 monthsNot specifiedx Ray frequency not specifiedYes
UK15 British Society for Rheumatology, 2004DAS28>5.1Two (one = MTX) for 6 months eachAnyBSR yes, NICE no (not permitted for failure to response but permitted for toxicity)DAS283 monthsPossible, but not generally recommendedNot mentionedYes
  • Ada, adalimumab; BSR, British Society for Rheumatology; CRP, C-reactive protein; DAS(28), (28-joint) Disease Activity Score; DMARD, disease-modifying antirheumatic drug; ESR, erythrocyte sedimentation rate; Et, etanercept; EULAR, European League Against Rheumatism; HAQ, Health assessment questionnaire; IFX, infliximab; MTX, methotrexate; NICE, National Institute for Clinical Excellence; SJC, swollen joint count; TJC, tender joint count.