TheBritish Society for Rheumatology Biologics Register-RA study (BSRBR-RA) reported that 6% of bDMARD patients fulfilled RefRA criteria (owing to lack of efficacy and/or toxicity with at least three bDMARDs) in patients whose first bDMARD was a TNF inhibitor (TNFi) [10], whereas other authors have estimated the problem to be as high as 10–20% [6, 7]. Here, TNF is linked to rheumatoid arthritis.