skip to main content

Switching Biologic Mechanism — SCE Rheumatology MCQ

Instant feedback + full explanation. One question, done properly.

ModerateRheumatoid ArthritisSwitching Biologic MechanismSCE Rheumatology

A 42-year-old woman has severe active rheumatoid arthritis (DAS28 6.0) despite optimised methotrexate and adequate sequential trials of two TNF inhibitors. Neither TNF inhibitor produced a clinically meaningful response. She has no contraindication to rituximab and can continue methotrexate. According to NICE technology appraisal guidance, what is the most appropriate next biologic strategy?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Switch to rituximab in combination with methotrexate

The correct answer is D. NICE TA195 recommends rituximab in combination with methotrexate for severe active rheumatoid arthritis that has responded inadequately to other DMARDs, including at least one TNF inhibitor. This patient has objective severe disease and primary non-response to two sequential TNF inhibitors, can continue methotrexate and has no contraindication to rituximab. A third TNF inhibitor is therefore not the preferred NICE sequence. Rituximab must replace, not be combined with, the TNF inhibitor, so B is incorrect. Returning to conventional synthetic DMARDs alone would inadequately treat severe refractory disease, and continuing an ineffective TNF inhibitor would contravene treat-to-target practice. Other non-TNF agents may be appropriate in different circumstances, particularly when rituximab cannot be used.

Reference: National Institute for Health and Care Excellence. TA195, Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor, recommendations 1.1–1.3, 2010. https://www.nice.org.uk/guidance/ta195/chapter/1-Recommendations