INTRODUCTION: Approximately 30% of patients with rheumatoid arthritis (RA) 
respond inadequately to conventional-synthetic disease-modifying anti-rheumatic 
drugs (csDMARDs). However, widespread use of biologic DMARDs (bDMARDs) and 
targeted-synthetic (tsDMARDs) is limited by cost. We formulated updated 
recommendations for eligibility criteria for government-assisted funding of 
bDMARDs/tsDMARDs for RA patients in Singapore.
MATERIALS AND METHODS: Published guidelines regarding use of bDMARD and tsDMARDs 
were reviewed. We excluded those without a systematic literature review, formal 
consensus process or evidence grading. Separately, unpublished national 
reimbursement guidelines were included.
RESULTS: Eleven recommendations regarding choice of disease activity measure, 
initiation, order of selection and continuation of bDMARD/tsDMARDs were 
formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least 
moderately active RA with a Disease Activity Score in 28 joints/erythrocyte 
sedimentation rate (DAS28-ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 
1 of which must be a combination; (c) received an adequate dose regimen of 
≥3 months for each strategy. For the first-line bDMARD/tsDMARD, either tumor 
necrosis factor inhibitors (TNFi), non-TNFi (abatacept, tocilizumab, rituximab), 
or tsDMARDs, may be considered. If a first-line TNFi fails, options include 
another TNFi, non-TNFi biologic or tsDMARDs. If a first-line non-TNFi biologic 
or tsDMARD fails, options include TNFi or another non-TNF biologic or tsDMARD. 
For continued bDMARD/tsDMARD subsidization, a patient must have a documented 
DAS28-ESR every 3 months and at least a moderate European League Against 
Rheumatism response by 6 months.
CONCLUSION: These recommendations are useful for guiding funding decisions, 
making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail 
csDMARDs.