Overview of biological and targeted-synthetic disease modifying antirheumatic drugs for rheumatoid arthritis

Note: Biological and targeted-synthetic DMARDs are prescribed by specialists for treatment-resistant RA.
Disease-modifying antirheumatic drugs (DMARDs) are used to reduce or eradicate synovitis, improve pain and prevent joint damage in RA. Biological and targeted-synthetic DMARDs (b/tsDMARDs) can only be prescribed (on authority) by a rheumatologist or immunologist and are subject to strict Pharmaceutical Benefits Scheme (PBS) guidelines. They may be used for the treatment of RA when:
  • clinical remission cannot be achieved with one or more csDMARDs
  • significant disease activity persists after trialling at least 2 csDMARDs.

The b/tsDMARDs are usually prescribed in combination with csDMARDs (most frequently methotrexate). Combination therapy is usually more effective than monotherapy; however, b/tsDMARDs can be used as monotherapy. It is a PBS requirement in Australia that methotrexate must be coprescribed when abatacept or golimumab or infliximab are prescribed.

Several bDMARDs with different mechanisms of action, and 3 tsDMARDs (tofacitinib, baricitinib and upadacitinib), are available in Australia and approved for use in the treatment of moderate to severe, active RA with an insufficient response, or intolerance, to other csDMARDs.

For advice about dose reduction or discontinuation of b/tsDMARDs, see Dose reduction and discontinuation of b/tsDMARDs and for advice about pausing b/tsDMARDs for surgery, see Perioperative use of b/tsDMARDs.