The prognosis for patients with
rheumatoid arthritis or spondyloarthritides has improved dramatically due to earlier diagnosis, recognition of the need to treat early with conventional synthetic
disease-modifying antirheumatic drugs (csDMARDs), alone or in combinations, the establishment of treatment targets, and the development of
biological DMARDs (bDMARDs). Many patients are now able to achieve clinical remission or low disease activity with
therapy, and reduce or eliminate systemic
corticosteroid use. Guidelines recommend
methotrexate as a first-line agent for the initial treatment of
rheumatoid arthritis; however, a majority of patients will require a change of csDMARD or step up to combination
therapy with the addition of another csDMARD or a bDMARD. However, treatment failure is common and switching to a different
therapy may be required. The large number of available treatment options, combined with a lack of comparative data, makes the choice of a new
therapy complex and often not evidence based. We summarize and discuss evidence to inform treatment decisions in patients who require a change in
therapy, including baseline factors that may predict response to
therapy.