Sorafenib in Advanced Hepatocellular Carcinoma

n engl j med 359;23 www.nejm.org december 4, 2008 2497 idiopathic arthritis (www.emea.europa.eu/pdfs/ human/ewp/042204en.pdf). We agree with Taddio and Marchetti that etanercept is a valid and important treatment option for children with juvenile idiopathic arthritis. However, direct-comparison studies of the antiTNF agents in children with juvenile idiopathic arthritis are lacking, and the available studies have not shown clear differences in efficacy or safety among the anti-TNF agents in adults with rheumatoid arthritis.2-4 Thus, we do not agree that trials of biologic treatments should be performed only in patients with juvenile idiopathic arthritis in whom treatment with etanercept has failed or that infliximab and adalimumab, as compared with etanercept, are associated with a higher risk of serious infections and malignant conditions. Testing the anti-TNF therapies in approximately similar populations of patients with juvenile idiopathic arthritis allows patients, parents, and physicians to make the decision about the use of these therapies. Our trial of adalimumab also provides information about the use or nonuse of methotrexate as background therapy in children with juvenile idiopathic arthritis. The assay used for detection of anti-adalimumab antibodies in this trial was an enzyme-linked immunosorbent assay that has been used for more than 11 years in the adalimumab-development program, and it has been accepted by regulatory agencies worldwide. In the study of juvenile idiopathic arthritis, serum adalimumab levels were slightly decreased if anti-adalimumab antibodies were detected; however, this patient population still showed a strong clinical response (unpublished data).