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Systematic review of disease-modifying antirheumatic drugs for juvenile idiopathic arthritis

Alex R Kemper12*, Heather A Van Mater1, Remy R Coeytaux23, John W Williams245 and Gillian D Sanders24

Author Affiliations

1 Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA

2 Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA

3 Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA

4 Department of Medicine, Duke University School of Medicine, Durham, NC, USA

5 Center for Health Services Research In Primary Care, Durham VA Medical Center, Durham, NC, USA

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BMC Pediatrics 2012, 12:29  doi:10.1186/1471-2431-12-29

Published: 15 March 2012



Treatment of juvenile idiopathic arthritis (JIA) with disease-modifying antirheumatic drugs (DMARDs) may improve outcomes compared to conventional therapy (e.g., non-steroidal anti-inflammatory drugs, intra-articular corticosteroids). The purpose of this systematic review was to evaluate the comparative effectiveness and safety of DMARDs versus conventional therapy and versus other DMARDs.


A systematic evidence review of 156 reports identified in MEDLINE®, EMBASE®, and by hand searches. There is some evidence that methotrexate is superior to conventional therapy. Among children who have responded to a biologic DMARD, randomized discontinuation trials suggest that continued treatment decreases the risk of having a flare. However, these studies evaluated DMARDs with different mechanisms of action (abatacept, adalimumab, anakinra, etanercept, intravenous immunoglobulin, tocilizumab) and used varying comparators and follow-up periods. Rates of serious adverse events are similar between DMARDs and placebo in published trials. This review identified 11 incident cases of cancer among several thousand children treated with one or more DMARD.


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 JIA-associated symptoms. Limited data suggest that short-term risk of cancer is low.

Juvenile rheumatoid arthritis; Disease-modifying antirheumatic drugs; Comparative effectiveness research; Systematic review