Learning the hard way: clinical trials in juvenile idiopathic arthritis

There have been unprecedented advances in the treatments and outcomes reported for patients living with juvenile idiopathic arthritis (JIA) over the last 20 years. The future direction of care with multinational collaborations (Paediatric Rheumatology International Trials Organisation (PRINTO), Pediatric Rheumatology Collaborative Study Group (PRCSG), Childhood Arthritis and Rheumatology Research Alliance) and advances in precision medicine will undoubtedly continue to revolutionise our approach to diagnosis, treatment and perhaps ultimately cure of JIA. In this issue of the Annals of the Rheumatic Diseases , Brunner et al report on the use of subcutaneous golimumab for children with active polyarticular course JIA.1 This trial, no doubt associated with immense direct and indirect costs, produced negative results, as it did not achieve its primary end point. Despite this, there is widespread international opinion that golimumab, like other tumour necrosis factor (TNF) inhibitors, is effective and should be added to the therapeutic armamentarium for children with JIA. We must reflect on this outcome as we consider further studies with new agents in the treatment of children with JIA. To date, three trials of anti-TNF agents (etanercept, infliximab and adalimumab),2–4 one of a selective T cell costimulation modulator (abatacept),5 and an interleukin-6 receptor inhibitor6 (tocilizumab) have shown efficacy and safety in the treatment of polyarticular course JIA in spite of the fact that primary end point of efficacy was not met in the infliximab trial. Amarilyo et al 7 published a meta-analysis of randomised withdrawal trials which evaluated the five separate …