Doncaster NICE plus pathway (April 2021) Use standard DMARD treatment(s) for biologic treatment of rheumatoid arthritis (RA) for rheumatoid arthritis (CG79)
No This algorithm is a tool to aid the implementation of NICE guidance on biologic drugs for the treatment of RA with DAS28 score > 5.1? modification as per local agreement with commissioners. (≥ 3.2 for filgotinib (676)/Amgevita (LA))
Commissioners and clinicians should refer to the relevant Yes technology appraisal for each biologic drug for further information about their eligibility and prescription. Is the patient responding to Yes DMARD treatment? Key to terms: DAS28: disease activity score No DMARD: disease modifying anti-rheumatic drug MTX: methotrexate Has the patient undergone 2 x (NUM): NICE technology appraisal number 6-month DMARD trials including No TNF: tumour necrosis factor MTX? LA: local agreement DAS28 response: score ≤ 2.6 or score improve by ≥ 1.2 Yes
Is the patient intolerant to MTX, or Yes is treatment with MTX considered to be inappropriate?
No
Monotherapy: use most cost effective option With MTX: use most cost effective option Adalimumab/Etanercept (375) Adalimumab/Etanercept/Golimumab/Infliximab (375) Certolizumab (415) Certolizumab (415) Tocilizumab (375) Abatacept (375) Baricitinib (466)/Tofacitinib (480)/Upadacitinib (665) Tocilizumab (375) Filgotinib (676) Baricitinib (466)/Tofacitinib (480)/Upadacitinib (665) Filgotinib (676)
Yes – consider Yes – consider alternative alternative Has the biologic been withdrawn Has the biologic been withdrawn because of adverse event within first 6 because of adverse event within first 6 months of treatment? months of treatment?
No No
Adequate DAS28 response to treatment Adequate DAS28 response to treatment Yes – maintain Yes – maintain at 6 months & monitor at 6 months & monitor
No
Does the patient have a No contraindication to rituximab?
Yes No
Yes – maintain Rituximab + MTX (195) & monitor
Adequate DAS28 response Has rituximab been withdrawn No because of an adverse event? to treatment Monotherapy: use most cost effective option at 6 months Yes Adalimumab/Etanercept (195) Certolizumab (415) Tocilizumab (LA)/Sarilumab (485) With MTX: use most cost effective option No Baricitinib (466)/Tofacitinib (480)/Upadacitinib (665) Adalimumab/Etanercept/Infliximab (195 and LA) Filgotinib (676) Golimumab (225 and LA)/Certolizumab (415 and LA) Abatacept (195 and LA) Tocilizumab (247)/Sarilumab (485) Yes - Consider Baricitinib (466)/Tofacitinib (480)/Upadacitinib (665) Alternative Filgotinib (676) Consider Alternative Has the biologic been withdrawn because of Has the biologic been withdrawn because of Yes adverse event? Yes – maintain adverse event? & monitor No No
Adequate DAS28 response to treatment at 6 Adequate DAS28 response to treatment at 6 No months? months?