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Subsequent therapeutic choices remain poorly structured, with limited evidence-based guidance to inform individualized post-TNFi decision-making.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective:<\/jats:title>\n                    <jats:p>To develop evidence-informed, profile-based recommendations to guide treatment selection after inadequate response to a first TNFi in RA, combining evidence and expert consensus.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design:<\/jats:title>\n                    <jats:p>Delphi-based consensus study informed by a PRISMA-guided scoping review (ScR) and nominal group methodology.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>A PRISMA-guided ScR of biologic and targeted synthetic biologic disease-modifying antirheumatic drug (tsDMARDs) after TNFi failure was conducted. Patient profiles were identified by a steering committee, and draft recommendations were evaluated through an anonymized Delphi process. A profile-based decision tree integrated direct and indirect evidence, with evidence strength graded using the Oxford Centre for Evidence-Based Medicine approach.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>The ScR included 43 studies, mostly exploratory analyses of randomized trials. Scenarios included age \u2a7e65\u2009years; failure of \u2a7e2 TNFi; monotherapy; rheumatoid factor\/anti-citrullinated peptide antibody status; prominent systemic inflammation; interstitial lung disease (ILD); rheumatoid vasculitis; high cardiovascular (CV) risk or prior CV event; venous thromboembolism (VTE) risk; obesity; high infection risk; osteoporosis; nociplastic pain, depression and fatigue; prior solid cancer; hematologic cancer\/lymphoproliferative disease; non-melanoma skin cancer; and pregnancy.<\/jats:p>\n                    <jats:p>Seventeen recommendations were formulated; 15 achieved consensus. Agreed positions included caution with JAK inhibitors (JAKi) in older patients and in those with CV\/VTE risk; preference for IL-6 receptor inhibitors or JAKi for monotherapy or prominent systemic inflammation; in RA-ILD, use a b\/tsDMARD with a non-TNFi mechanism; rituximab as first choice in rheumatoid vasculitis; abatacept in infection-prone patients; discouraging JAKi in prior malignancy; and TNFi as acceptable during pregnancy. Two statements did not reach consensus: preferential use of non-TNFi in obesity and heightened caution with tofacitinib in osteoporosis or fracture risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>This Delphi-validated, profile-based framework provides a practical tool to support evidence-informed clinical decision-making.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/1759720x261425808","type":"journal-article","created":{"date-parts":[[2026,2,28]],"date-time":"2026-02-28T17:25:06Z","timestamp":1772299506000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["What to do when the first TNF inhibitor fails in rheumatoid arthritis: stratified expert recommendations from a scoping review and Delphi consensus"],"prefix":"10.1177","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1614-8064","authenticated-orcid":false,"given":"Javier","family":"Narv\u00e1ez","sequence":"first","affiliation":[{"name":"Department of Rheumatology (Planta 10-2), Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Feixa Llarga, s\/n, Hospitalet de Llobregat, Barcelona 08907, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosario","family":"Garc\u00eda-Vicu\u00f1a","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Hospital Universitario de la Princesa, IIS-Princesa, School of Medicine, Universidad Aut\u00f3noma de Madrid, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3725-8510","authenticated-orcid":false,"given":"Jes\u00fas","family":"Tornero Molina","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Hospital Universitario de Guadalajara, Guadalajara, Spain"},{"name":"Departamento de Medicina, Universidad de Alcal\u00e1 de Henares, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susana","family":"Romero-Yuste","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos\u00e9 A.","family":"Pereira da Silva","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Centro Hospitalar e Universit\u00e1rio de Coimbra, Coimbra, Portugal"},{"name":"Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (i.CBR), University of Coimbra, Coimbra, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Estibaliz","family":"Loza","sequence":"additional","affiliation":[{"name":"Instituto de Salud Musculoesqueletica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,2,28]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40744-020-00211-w"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1002\/acr2.11621"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0030275"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.3389\/fimmu.2022.814429"},{"key":"e_1_3_3_6_2","first-page":"96","article-title":"Clinical relevance of switching to a second tumour necrosis factor-alpha inhibitor after discontinuation of a first tumour necrosis factor-alpha inhibitor in rheumatoid arthritis: a systematic literature review and meta-analysis","volume":"29","author":"R\u00e9my A","year":"2011","unstructured":"R\u00e9my A, Avouac J, Gossec L, et al. 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