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Disease-Modifying Antirheumatic Drugs (DMARDs) in Children With Juvenile Idiopathic Arthritis (JIA)
Comparative Effectiveness Reviews, No. 28
Alex R Kemper, MD, MPH, MS, Principal Investigator, Remy Coeytaux, MD, PhD, EPC Investigator, Gillian D Sanders, PhD, EPC Investigator, Heather Van Mater, MD, MSc, Clinical Investigator, John W Williams, MD, MPH, EPC Investigator, Rebecca N Gray, DPhil, EPC Editor, R Julian Irvine, MCM, EPC Project Coordinator, and Amy Kendrick, RN, MSN, EPC Project Manager.
Structured Abstract
Objectives:
To summarize the benefits and harms of disease-modifying antirheumatic drugs (DMARDs) compared to conventional treatment (non-steroidal anti-inflammatory drugs [NSAIDs] and/or intra-articular corticosteroids) with or without methotrexate, and of the various DMARDs compared to one another, in children with juvenile idiopathic arthritis (JIA); and to describe selected tools commonly used to measure clinical outcomes associated with JIA.
Data Sources:
MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. Additional studies were identified from the review of reference lists.
Review Methods:
To evaluate efficacy, we included prospective trials that included a comparator and that lasted for at least 3 months. No comparator was required for reports of adverse events or of the clinical outcome measure tools.
Results:
A total of 198 articles were included. There is some evidence that methotrexate is superior to conventional treatment (NSAIDs and/or intra-articular corticosteroids). Among children who have responded to a biologic DMARD, randomized discontinuation trials suggest that continued treatment decreases the risk of having a flare. Although these studies evaluated DMARDs with different mechanisms of action (abatacept, adalimumab, anakinra, etanercept, intravenous immunoglobulin, tocilizumab) and used varying comparators, followup periods, and descriptions of flare, the finding of a reduced risk of flare was precise and consistent. There are few direct comparisons of DMARDs, and insufficient evidence to determine if any specific drug or drug class has greater beneficial effects. Reported rates of adverse events are similar between DMARDs and placebo in nearly all published randomized controlled trials. This review identified 11 incident cases of cancer among several thousand children treated with one or more DMARD. The Childhood Health Assessment Questionnaire (CHAQ) was the most extensively evaluated instrument of those considered. While it demonstrated high reproducibility and internal consistency, it had only moderate correlations with indices of disease activity and quality of life, and poor to moderate responsiveness.
Conclusions:
Few data are available to evaluate the comparative effectiveness of either specific DMARDs or general classes of DMARDs. However, based on the overall number, quality, and consistency of studies, there is moderate strength of evidence to support that DMARDs improve symptoms associated with JIA. Limited data suggest that short-term risk of cancer is low. Future trials are needed to evaluate the effectiveness of DMARDs against both conventional therapy and other DMARDs across categories of JIA, and registries are needed to better understand the risks of these drugs.
Contents
- Preface
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Literature Search and Screening
- Key Question 1 In children with JIA, does treatment with DMARDs, compared to conventional treatment, improve laboratory measures of inflammation or radiological progression, symptoms (e.g., pain, symptom scores), or health status (e.g., functional ability, mortality)?
- Key Question 2 In children with JIA, what are the comparative effects of DMARDs on laboratory markers of inflammation or radiological progression, symptoms (e.g., pain, symptom scores), or health status (e.g., functional ability, mortality)?
- Key Question 3 In children with JIA, does the rate and type of adverse events differ between the various DMARDs or between DMARDs and conventional treatment with or without methotrexate?
- Key Question 4 How do the efficacy, effectiveness, safety, and adverse effects of treatment with DMARDs differ among the various categories of JIA?
- Key Question 5 What are the validity, reliability, responsiveness, and feasibility of the clinical outcomes measures for childhood JIA that are commonly used in clinical trials or within the clinical practice setting?
- Summary and Discussion
- Future Research
- References
- Abbreviations
- Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I. Prepared by: Duke Evidence-based Practice Center, Durham, NC.
Suggested citation:
Kemper AR, Coeytaux R, Sanders GD, Van Mater H, Williams JW, Gray RN, Irvine RJ, Kendrick A. Disease-Modifying Antirheumatic Drugs (DMARDs) in Children With Juvenile Idiopathic Arthritis (JIA). Comparative Effectiveness Review No. 28. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 11-EHC039-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2011. Available at:www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Duke Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products or actions may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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