OBJECTIVES: To review and analyse evidence on the changes in dose of adalimumab, etanercept and infliximab over time in adult patients with rheumatoid arthritis (RA) and the associated impact on treatment costs. METHODS: MEDLINE, EMBASE and NHS-EED were systematically searched to identify English language randomised controlled trials, cohort studies and observational studies published between January 1993 and December 2009. Conference abstracts were also hand searched from EULAR (2002 onwards) and ACR (2006 onwards). Studies were selected using predefined criteria, using two independent reviewers. Data pertaining to dose change were then analysed through pair-wise, random effects meta-analyses carried out in a frequentist framework with heterogeneity assessed using the I2 statistic. Associated cost data were extracted and the impact of change in dose on cost was investigated. RESULTS: Forty-five articles met the selection criteria with 23 containing dose change data and 26 containing cost data. A significantly greater proportion of patients on infliximab had a dose escalation compared to those on etanercept (odds ratio 0.17 95% CI 0.07, 0.43; p<0.001) or adalimumab (odds ratio 0.25 95% CI 0.2, 0.3; p<0.001). On average, 43.3% of infliximab patients, 7.3% of etanercept patients and 10.9% of adalimumab patients had their dose increased. RA related costs were on average 36% higher in patients who had their infliximab dose increased compared to 4% in patients on etanercept. No suitable data for adalimumab were available. CONCLUSIONS: A significantly greater proportion of infliximab patients required dose escalation compared to etanercept and adalimumab patients. There is some evidence to suggest that the escalation in dose required to maintain clinical benefit, results in substantially higher costs of treating RA.