The National Institute for Health and Clinical Excellence has issued guidance which again recommends against allowing patients to use a second anti-tumour necrosis factor alpha treatment for rheumatoid arthritis if the first does not prove to be effective.

NICE has issued a Final Appraisal Determination (FAD) guidance, saying that Abbott Laboratories’ Humira (adalimumab), Wyeth's Enbrel (etanercept) and Johnson & Johnson's Remicade (infliximab) should not be available on the National Health Service for the treatment of RA after the failure of a previous anti-TNF inhibitor. At the moment, patients can be prescribed the drugs but NICE has concluded there was insufficient evidence that after a patient failed on one anti-TNF therapy, a second would be clinically effective.

The agency stated that doctors should consider using Roche's MabThera (rituximab), which costs about £3,000 less per year than the anti-TNF drugs, the prices of which can reach £10,000 annually. NICE added that consultees now have the opportunity to appeal, and subject to an appeal being received, final guidance is expected in September.

An appeal is a distinct possibility from patient groups and drugmakers who had initially been cheered by the news when NICE agreed last year to reconsider its earlier draft guidance preventing sequential anti-TNF use.

The charity Arthritis Care described the decision as “rationing without rationality”, saying forces people with severe RA “to become dependent, on the state, the NHS and on their loved ones”. It is “certainly not supporting the independence espoused in wider government policy nor does it reflect the ‘patient choice’ mantra that emerges so often from the lips of health ministers’, the charity claimed.

Arthritis Care went on to say that “it is hardly surprising that NICE reaches the wrong answers when it cannot ask the right questions. It is short-sighted and pernicious that NICE can look only at cost to the NHS, not at total cost to the taxpayer in terms of benefits and social care”.

The charity concluded by asking: “When will the government do the maths and see that treating someone is often far cheaper than not treating them? Denying people effective medication forces them out of work and on to disability benefits at a huge cost to them and to the economy at large”.

Responding to the FAD, Roche noted that MabThera has proven to be clinically effective for patients who cannot tolerate or do not respond to an anti-TNF inhibitor and it “provides such patients with a vital and cost effective treatment option”. The Swiss major added the money that will be released by not cycling to a second anti-TNF “would be available to be used to give new hope to thousands of patients” but added that “it is the fundamental belief of Roche that every eligible patient should benefit from the best available treatment for their disease and wholly support patient choice”.