Background/Purpose:

During the last decade the availability of biologic agents for the treatment of juvenile idiopathic arthritis (JIA) increased substantially. Because direct head-to-head trials comparing biologics are lacking, physicians face difficulties to choose between these agents. In order to provide some scientific guidance, we indirectly compared the short-term efficacy of biologic agents.

Methods:

In a systematic review, all available efficacy data from randomized controlled trials performed in JIA were retrieved. The following biologics were included: etanercept, adalimumab, infliximab, abatacept, anakinra, rilonacept, canakinumab and tocilizumab. Indirect between-drug comparisons (based on the Bucher’s method) were conducted only if trials were comparable with regard to design and patients’ characteristics related to treatment outcome.

Results:

Eleven trials that evaluated biologic agents in JIA were selected. Quality of trials varied greatly: earlier trials for registration gained best scores, trials evaluating treatment strategies performed worst. For 5 trials, no match for an indirect comparison could be found due to design and patient characteristics. The remaining trials could be divided into two networks of evidence. Network 1 included withdrawal trials that evaluated etanercept, adalimumab and abatacept in poly-articular course juvenile idiopathic arthritis. Indirect comparisons identified no significant differences in short-term efficacy. Etanercept seemed superior to adalimumab (relative risk (RR) disease flare, etanercept vs. adalimumab, 0.59, 95% CI 0.28-1.24) and abatacept better than adalimumab (RR disease flare, abatacept vs. adalimumab, 0.64, 95% CI 0.34-1.23), especially considering the case-mix of adalimumab-treated patients, associated with better outcomes. Network 2 indirectly compared anakinra, tocilizumab and canakinumab in systemic juvenile idiopathic arthritis and no differences could be identified. Canakinumab tended to be superior to tocilizumab (RR 2.44, 95% CI 0.81-7.37).

Conclusion:

The short-term efficacy of etanercept, adalimumab and abatacept seemed similar for poly-articular course JIA and anakinra, canakinumab and tocilizumab seemed similar for systemic JIA. Because of the observed differences between trials, head-to-head trials comparing 2 biologic agents directly are highly needed. For now, the pediatric rheumatologist has to rely on these indirect comparisons supplemented by observational data derived from cohort studies and safety, practical, and financial arguments.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/efficacy-of-biologic-agents-in-juvenile-idiopathic-arthritis-a-systematic-review-using-indirect-comparisons/