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Anti-TNF Failure Switch — RACP Adult Medicine MCQ

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ModerateRheumatologyAnti-TNF Failure SwitchRACP Adult Medicine

A 50-year-old man with RA on adalimumab (anti-TNF) for 2 years develops secondary loss of response (rising DAS28 despite good adherence). Anti-drug antibodies to adalimumab are positive with low drug trough levels. What is the most appropriate strategy?

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Correct answer: D — Switch to a non-TNF biologic (tocilizumab or abatacept)

Secondary anti-TNF failure with positive anti-drug antibodies (immunogenicity-mediated) — switching to another anti-TNF may work if immunogenicity was the issue (different antibody target). However, switching to a non-TNF biologic (different mechanism: tocilizumab [IL-6R], abatacept [T-cell costimulation], rituximab [B-cell depletion]) provides a mechanistically distinct approach and is often preferred after anti-TNF failure. JAK inhibitor is another valid option.

Reference: ARA – 2024 – RA; EULAR 2024; PBS 2024