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List of abbreviations

All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices, in which case the abbreviation is defined in the figure legend or in the notes at the end of the table.

NIHR Health Technology Assessment programme

The Health Technology Assessment (HTA) programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. ‘Health technologies’ are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.

Assessment of factors relevant to the NHS and other parties

Wide use of biologic agents, NICE guidance on RA and the recent NAO report on services for patients with RA have profound implications for specialist rheumatology services. The NAO report suggests that acute trusts and primary care trusts (PCTs) have not yet met all the challenges they face. For example, monthly review in patients with active disease, as recommended in NICE guidance, is achieved by only 15% of acute trusts surveyed by the NAO. The main barriers reported by trusts were staffing, limited outpatient capacity and pressures to improve the ratio of follow-up to new patients. A majority of the acute trusts reported that they were unable to provide adequate follow-up for RA patients. Models of shared care between primary care and secondary care exist, but only around half of the GPs in the NAO survey said that they had a shared care agreement with their local acute trust. Good shared-care schemes with appropriate patient selection, could reduce the burden on specialists and meet some of the objectives set out in Lord Darzi's review.

Definition of the decision problem

Decision problem 1: whether there are significant differences in clinical effectiveness and cost-effectiveness between ADA, ETN, IFX, RTX and ABT (referred to as ‘the interventions’ hereafter), when used within their licensed indications in adults with active RA who have had an inadequate response to a first TNF inhibitor prescribed according to current NICE guidance.


We thank Karen Biddle for providing administrative support.


This monograph is based on the Technology Assessment Report produced for NICE. The full report contained a considerable number of data that were deemed commercial-in-confidence. The full report was used by the Appraisal Committee at NICE in their deliberations. The full report with each piece of commercial-in-confidence data removed and replaced by the statement ‘commercial-in-confidence information (or data) removed’ is available on the NICE website: www.nice.org.uk.


There is a lack of good-quality evidence directly comparing the effectiveness of the five technologies against each other. This imposes significant uncertainties with regard to any assessment of their relative cost-effectiveness. Adjusted IC suggests that there is no significant difference in the effectiveness between RTX and ABT, both of which are supported by good-quality RCT evidence. Existing data do not allow reliable quantification of the effectiveness of TNF inhibitors compared with RTX and ABT. Independent modelling comparing each of the other four technologies with RTX (recommended in current NICE guidance) suggests RTX dominating ADA, ETN and infliximab, and an estimated ICER of £131,000 (per QALY) for ABT compared with RTX.

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