Updating the British Society for Rheumatology guidelines for anti-tumour necrosis factor therapy in adult rheumatoid arthritis (again).

Because of the significant cost implications of biological treatment, most UK rheumatologists are willing to accept limitations in the use of these drugs. They are, however, aware of the increasing literature on biological treatment and are concerned about the rigid nature of the guidelines. Guidelines cannot be static and must be adjusted according to new information so that they can best meet the needs of our patients. No government is likely to allow unlimited access to anti-tumour necrosis factor (anti-TNF) drugs for rheumatoid arthritis (RA) unless these drugs suddenly become inexpensive. We have data in abundance for the efficacy and safety of anti-TNF drugs, but ‘cheap’ is not an adjective we will be able to apply to them for the foreseeable future. In the meantime, UK clinicians see patients with active RA in whom their clinical instinct says that anti-TNF therapy is indicated, yet they fail to fulfil the current British Society for Rheumatology (BSR) and National Institute for Health and Clinical Excellence (NICE) guidelines. Is there a case for modifying the eligibility criteria without breaking the NHS bank? In 2003 the process to update the original 2001 BSR RA anti-TNF guidelines began [1]. Uniquely for NICE, these guidelines were incorporated unchanged into their Health Technology Appraisal [2]. At the time, it was felt that there was little evidence for changing many of the eligibility criteria, and the document concentrated on an update on safety issues. In April 2004 the guidelines were presented in draft form at the BSR Annual General Meeting and feedback was invited. The limited comments from BSR members and from the drug companies suggested slight changes in content, but no disquiet about the eligibility criteria. In 2005 the updated anti-TNF guidelines for adult RA were published in this journal [3]. In the time lag between these events, many more data have emerged on the appropriate use of disease-modifying anti-rheumatic drugs (DMARDs) and anti-TNF drugs. Furthermore, other national societies and representative bodies have published anti-TNF guidelines. Many of these are less restrictive than those produced by the BSR: