How to Work With Your Doctor to Switch a Biologic

Medically Reviewed by Brunilda Nazario, MD on February 10, 2022
5 min read

What can you do when the biologic you take for your rheumatoid arthritis (RA) doesn’t work or no longer seems effective? First, talk to your rheumatologist to decide if it’s time to switch to a new RA treatment.

Biologics can be effective treatments for some people with RA, but not every biologic works for every person. Sometimes, your biologic can stop doing its job after you’ve taken it for a while.

About 30% to 40% of people with RA who take a biologic stop using it because it doesn’t work or has side effects they can’t live with. Some people with RA may try several biologics in a row without finding one that works for them.

When this happens, it’s common to switch to a different treatment. Your rheumatologist may prescribe:

  • Another biologic in the same class to see if it works for you
  • A biologic that targets a different part of your immune system
  • Combination therapy of your current biologic and a disease-modifying antirheumatic drug (DMARD) like methotrexate or azathioprine to see if this lowers your disease activity

How can you tell if your biologic no longer works? One sign is that RA symptoms like joint pain and stiffness return.

Your biologic may not be working if lab test results show your disease activity is rising, especially if it stays moderate to high over 3 to 6 months. Another sign is radiographic progression, which means X-rays show that your joint damage is getting worse.

There are a few reasons your biologic may not work or might stop working over time:

  • The same antibodies that your immune system makes to fight off germs that cause disease can also mistake your biologic as something harmful.
  • Even biologics in the same class don’t all work exactly the same way. You may try one tumor necrosis factor (TNF) inhibitor, a type of biologic, and not have a good response, but another may work better for you.
  • Your disease activity is driven by a different immune system target. You may need to switch to a biologic that works in a different way.

Tell your rheumatologist if you’re worried that your biologic has stopped working. They can discuss signs of active RA, like swollen and tender joints. They can give you tests like ultrasound to see if you have synovitis, or inflamed tissue lining your joints, another sign of active RA.

Blood tests may show if your disease is mainly driven by a different cytokine, or inflammatory protein, than the one your current biologic treats. That’s a sign that a biologic with a different target may work better for you. 

Talk to your rheumatologist before you assume your biologic has stopped working. Symptoms like tender, swollen, or stiff joints may not always result from RA. They’re also signs of osteoarthritis (OA), which many people develop along with RA, or other types of chronic pain or injury.

If you’ve had RA for a long time, you may also have joint stiffness, pain, or fatigue that just don’t respond as well to treatment. You may think your RA is active again, when it isn’t. If your joints were already damaged when you started your biologic, they may not respond as well as you hoped.

If your biologic isn’t working, you may need to switch drugs. Here are some options:

Cycling -- try another drug in the same class: First, your rheumatologist may switch you to a different drug in the same class. Many people who find that their first TNF inhibitor stops working can switch to another TNF inhibitor that does control their RA. This approach is also called “cycling.”

Some people with RA find that when they switch to a second or third TNF inhibitor, their new drug is less effective. In one study, only 51% of people had a successful response to a second TNF biologic, and 35% responded well to a third TNF biologic.

Swapping -- try another class of biologic: Your other option is swapping biologics. There are several biologics that target different processes in your immune system. If you’ve used a TNF inhibitor and it stops working, your rheumatologist may prescribe a biologic in a different class. In one study of 318 people with RA whose TNF inhibitor stopped working, more people who switched to a biologic targeting a different protein found success than those who switched to another TNF inhibitor.

If you’ve tried several TNF inhibitors that didn’t work, your rheumatologist will recommend that you swap to a non-TNF biologic. It’s more likely to work for you.

Add or change nonbiologic treatment: If your biologic doesn’t work, other options include taking another drug with your biologic, such as a disease-modifying antirheumatic drug (DMARD). You may have taken a DMARD like methotrexate before you started a biologic, so your doctor may suggest you use it again. If you’ve been taking a DMARD along with your biologic, the doctor might change the DMARD dose to get your RA under control.

Give your new biologic a chance to work. After 3 months, the doctor can test you to see if your disease activity is going down. It may take even longer to notice a drop in RA symptoms with a new biologic. One study followed 461 people with RA whose TNF inhibitors stopped working. After 6 months on a different TNF inhibitor, their RA symptoms were reduced.

No matter what drugs you take, there  may just be times when your disease is active and other times when it is calm.  Other factors can lower your response to a biologic or any drug, including smoking and obesity. About 15% of people with RA don’t take their biologic on schedule, so their drug is less effective and their disease activity doesn’t go down.

Don’t put off talking to your rheumatologist if you notice signs that your biologic isn’t working, like sudden joint stiffness or pain. They can make changes to your treatment plan to reduce your symptoms and help prevent joint damage.