Rheumatoid arthritis (RA) is a long-term problem that causes pain and swelling (inflammation) in the joints. Many patients need treatment with drugs known as biologics, usually starting with a group known as TNFi. If patients do not respond to a TNFi, the National Institute for Health and Care Excellence currently recommends another biologic, rituximab, but again not all will respond.

The aim of the SWITCH trial was to find out whether or not two alternative biologics (alternative TNFi or abatacept) were as good as rituximab at improving disease activity, quality of life, safety and cost-effectiveness in patients who did not respond to their initial TNFi treatment.

Between July 2012 and December 2014, 122 patients from 35 hospitals were recruited into the trial and randomly put into three treatment groups (1) rituximab, (2) alternative TNFi or (3) abatacept. We planned to recruit 477 patients into the SWITCH trial. The trial was stopped early because of slow recruitment (largely attributable to operational challenges throughout the study period), achieving only 122 patients enrolled, and as a result was too small to test if either drug works as well as rituximab in reducing disease activity. A similar general improvement in patients’ physical functioning, quality of life relating to their RA, general health and safety over the 12-month period was apparent for all three treatments.

Switching to alternative TNFi may be cost-effective compared with the current treatment; however, the use of abatacept is unlikely to be cost-effective.

Alternative options to rituximab may work in patients who do not respond to their first biologic therapy, but uncertainty remains about which treatments to choose following an initial TNFi treatment failure.