People with rheumatoid arthritis could be given access to a wider range of drugs, under new draft guidelines from the health watchdog NICE.
Previous guidelines said patients in England and Wales could be prescribed only one course of anti-TNF drugs to block inflammation.
Campaigners have welcomed the decision - describing the old guidance as "a prescription for pain".
There are an estimated 580,000 people in England and Wales with the disease.
Approximately 87,000 of them have severe rheumatoid arthritis.
Anti-TNF (anti-tumour necrosis factor alpha) therapy drugs - adalimunab, etanercept, infliximab - can slow the progress of disease and help to reduce symptoms such as joint pain, swelling, mobility and fatigue.
The National Institute for Health and Clinical Excellence (NICE) has issued draft guidance which changes the guidance from two years ago in which therapies were cut from five to two.
While there are a succession of drugs which offer some control over the disease in many cases, a small number of patients do not respond to these.
In 2008, NICE said patients would not be able to try a second anti-TNF if their first attempt at anti-TNF therapy failed.
But charities appealed against the decision, saying switching to a second drug was established practice.
In the latest draft guidelines, NICE recommended:
- rituximab as the treatment for patients who have failed on an anti-TNF or who have not responded to other disease-modifying anti-rheumatic drugs
- rituximab should not be given more often than every six months and should only be continued if there is an adequate response
- adalimumab, etanercept, infliximab and abatacept for patients who have failed on one anti-TNF or who have not responded to other disease-modifying anti-rheumatic drugs, and who cannot take rituximab
The drug abatacept (Orencia) had been rejected in 2008.
In March this year, NICE said adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade) could only be used in the context of research, even for those patients who had failed on one anti-TNF.
Dr Carole Longson from NICE said: "Different people respond in different ways to treatment and the committee heard from clinical experts and patients about the importance of having multiple options available.
"We have already recommended the TNF inhibitors adalimumab, etanercept and infliximab for some people with rheumatoid arthritis as options for use after conventional treatments."
Rituximab works when a TNF inhibitor has not worked or has lost its effect, but not all patients can take it, hence why the other four drugs have now been recommended, she said.
"We hope that this wider choice of options will mean that people will be able to manage their rheumatoid arthritis more effectively."
The draft guidance was welcomed by Prof Alan Silman of Arthritis Research UK.
"NICE's decision will enable us to support both researchers and clinicians to move closer to what we regard as the medical equivalent of the Holy Grail - personalised medicine - with choice of treatment being more targeted and tailored towards individual needs.
"A major part of our research programme is to try and establish which patients will do best on which particular drug, and this decision will make that much more practically achievable."
Arthritis Care welcomed the use of the wider range of drugs.
Chief Executive Neil Betteridge said: "Anti-TNFs are a family of drugs, not all of which have the same outcomes for people with [Rheumatoid Arthritis].
"What works well for one individual may not work for another. There is good evidence to show that sometimes people need to switch from one treatment to another, at comparable costs, to find one which is effective."