The anti-TNF agents in combination with methotrexate have provided significant improvement in our ability to impact the outcomes of rheumatoid arthritis. Anecdotal reports have suggested differences in their efficacy and side effect profiles; however, head to head studies of the anti-TNF agents (adalimumab, etanercept, and infliximab) have not and most probably will not be undertaken by the pharmaceutical industry. Utilizing the nationwide Danish DANBIO registry, Hetland and colleagues carried out a direct comparison of responses, remission rates, and drug adherence in 2326 rheumatoid arthritis patients in whom the first biologic treatment was initiated. 29% received adalimumab, 22% received etanercept, and 49% received infliximab. The results were calculated from 8 years of surveillance and negative predictors of treatment response and remission were found to be older age, low functional status as measured by HAQ, and concomitant steroid therapy. Odds ratios for clinical responses and remission and hazard ratios for drug withdrawal and corrected for confounders including age, disease duration, DAS-28, rheumatoid factor positivity, concomitant methotrexate and prednisolone, numbers of previous DMARDs, the investigator sites, and functional status. ACR 70 response rates were seen in 19% of the patients in 6 months; similar odds ratios were seen with EULAR good response, DAS-28 remission, and CDAI remission. Infliximab had the lowest rates of treatment response, disease remission, and drug adherence. Adalimumab had the highest rates of treatment response and disease remission. Etanercept had the longest drug survival rates. Other more recently introduced biologic agents were not included in this evaluation but large databases and registries will continue to help clarify differences among available treatment modalities. Arthur L. Weaver MD, MS