OBJECTIVES: To evaluate the cost-utility of different treatment strategies in the treatment of severe RA after the treatment failure with first anti-TNF therapy (FATT). Before the treatment failure with FATT, patients are assumed to be treated with the FIN-RACo combination (methotrexate, sulfasalazine, hydroxychloroquine, and prednisolone). METHODS: The cost-effectiveness of treatment strategies is compared in a group of hypothetical Finnish RA patients. After the treatment failure with FATT, the patients receive either best supportive care (BSC: intramuscular gold followed by cyclosporine and methotrexate) or one of the following treatments before BSC: rituximab, etanercept, adalimumab or infliximab. Further treatments are added to the most cost-effective strategy in a stepwise manner. The analysis is performed on an Excel-based Markov state transition model using the probabilistic approach. The clinical outcomes related to treatments are estimated from published clinical trials using adjusted indirect comparison. The quality adjusted life-years (QALY) gained are estimated on the basis of Health Utilities Index (HUI-3) and disease severity scores (HAQ). The resource use and costs are obtained from the Finnish treatment practice, a published study of hospitalisations in RA, Finnish Unit Cost list and Finnish Medicine Tariff. RESULTS: The treatment with rituximab dominates adalimumab and etanercept after the failure of FATT as it is more effective and less costly. A QALY gained with rituximab or infliximab costs €32,083 or €38,490 compared to BSC, respectively. The ICERs are €53,606; €54,722 and €37,169 per QALY gained for adding adalimumab, etanercept and infliximab to the rituximab strategy, respectively. According to the cost-effectiveness acceptability frontier only the treatments with rituximab or rituximab followed by infliximab should be considered after the failure of FATT, if €50,000 per QALY gained is used as a willingness-to-pay threshold. CONCLUSIONS: Treatment with rituximab is a cost-effective 2nd line biologic treatment strategy in RA patients in Finland.