Efficacy and safety of TNF inhibitors in the treatment of juvenile idiopathic arthritis: a systematic literature review

A narrative review of multidisciplinary rehabilitation in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a chronic condition affecting children, marked by persistent joint inflammation driven by innate and adaptive immune responses involving macrophages and T and B lymphocytes. These responses promote tissue damage and inflammation via elevated pro-inflammatory cytokines, while anti-inflammatory cytokines are also present, but without a clear linear relationship. JIA can result in long-term physical disabilities, making a multidisciplinary rehabilitation approach essential to enhance patients' quality of life. This approach includes a collaborative team addressing pain reduction, joint and muscle function improvement, and patient autonomy. Key interventions involve physical therapy to maintain and enhance joint mobility and muscle strength. Evidence suggests that physical exercise may modulate immune responses and pro-inflammatory cascades, critical in JIA pathogenesis. However, further studies are required to determine the most effective exercise protocols for this population and their specific immunomodulatory benefits. A narrative literature review was conducted using PubMed (2014-2024) with the terms "juvenile idiopathic arthritis," "rehabilitation," and "exercise," supplemented by references from systematic reviews and meta-analyses, and additional historical data from Google Scholar. The search yielded 52 relevant articles, primarily involving pediatric subjects under 18 years. These studies highlight the multifaceted benefits of multidisciplinary management in JIA, including improved physical and functional outcomes. Despite promising evidence, further research is warranted to refine exercise protocols tailored to JIA, ensuring optimal therapeutic impact on inflammation and disease progression.

Effects of Multimodal Rheumatologic Complex Treatment in Childhood and Adolescence

BACKGROUND

The aim of this study was to investigate the effects of multimodal rheumatologic complex treatment (MRCT) in childhood and adolescence. MRCT means a high-frequency treatment program of at least 11 h per week.

METHODS

MRCTs in children, carried out between May 2009 and May 2022 at the Department of Pediatrics of the University Hospital in Halle (Saale), were included in this study. The effects of the MRCT were evaluated based on inflammatory activity, functionality (using the Childhood Health Assessment Questionnaire (CHAQ)), subjective statements regarding pain intensity, state of health, and coping with the illness, as well as the objective determination of joint mobility. Data were analyzed retrospectively using t-tests to compare different groups and values before and after treatment.

RESULTS

During the study period, N = 133 MRCTs were conducted in n = 95 children. The most common diagnosis was juvenile idiopathic arthritis (83.2%). The c-reactive protein (CRP) fell from an average of 25.3 mg/L to 7.3 mg/L, and the erythrocyte sedimentation rate (ESR) fell from 29.5 mm in the first hour to 17.9 mm. Pain intensity was reduced from 5.4 to 4.0. The state of health and coping with the illness also improved. The disability index showed a moderate reduction from 0.92 to 0.81. Furthermore, an improvement in joint mobility was observed. Positive effects were also shown in patients with somatoform disorders.

CONCLUSIONS

Due to the positive effects of MRCT on subjective well-being and physical health, the treatment program can be recommended for affected children, including patients with an additional diagnosed somatoform disorder.

Tumor necrosis factor (TNF) inhibitors for juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a rheumatic disorder that causes chronic joint inflammation beginning before the age of 16 years. Pharmacological treatment necessary to prevent joint destruction and functional impairment includes non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids, conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate (MTX), and biologic DMARDs (bDMARDs) such as tumor necrosis factor inhibitors (TNFi), abatacept, anakinra, and tocilizumab. More recently, targeted synthetic DMARDs (tsDMARDs) like tofacitinib, baricitinib, and upadacitinib have been approved for the treatment of JIA.

OBJECTIVES

To assess the benefits and harms of TNFi in children with JIA.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), Embase (via Ovid), and ClinicalTrials.gov and the WHO ICTRP from inception to 28 February 2024, with no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs, and data from the randomized part of withdrawal trials conducted in individuals with JIA where TNFi were compared to placebo, MTX, NSAIDs, other bDMARDs, tsDMARDs, or other TNFi. Our major outcomes were treatment response, pain, function, participant global assessment of well-being (disease activity), remission, withdrawals due to adverse events, and serious adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. At least two review authors performed study selection, data extraction, and risk of bias and GRADE assessment. The primary comparison was TNFi versus placebo. The primary time point was up to 16 weeks and up to the end of the trials for efficacy and safety outcomes, respectively.

MAIN RESULTS

We included nine studies with 678 participants (80% females) with JIA. The mean age of participants ranged from 8 to 15 years, and the mean duration of symptoms ranged from 0.8 years to 6.7 years. Seven studies compared TNFi to placebo (570 participants), and two studies compared TNFi combined with MTX to MTX alone (108 participants). We identified no studies investigating the other predefined comparisons. Only two studies had a low risk of bias in all domains, while five studies had a high risk of bias in at least one domain, predominantly other bias. Two studies were at unclear risk of selection bias, and two studies were at unclear risk of detection bias. TNFi versus placebo Benefits at up to 16 weeks Low-certainty evidence (downgraded for risk of bias and imprecision) suggests that treatment with TNFi may increase the likelihood of achieving a treatment response, defined as pedACR70 (34% compared to 14% with placebo) (risk ratio [RR] 2.47, 95% confidence interval [CI] 1.48 to 4.14; 4 studies, 245 participants). The evidence is very uncertain (downgraded for indirectness and imprecision) for the effect of TNFi on pain, with mean pain scores (visual analogue scale [VAS] 0 to 100, 0 no pain, minimal clinically important difference [MCID] = 15 mm) lower with TNFi (11 mm) compared to placebo (33 mm) (mean difference [MD] 22 mm, 95% CI 50 mm lower to 5.7 mm higher; 2 studies, 72 participants). Similarly, the effect of TNFi on function (Childhood Health Assessment Questionnaire [CHAQ], 0 to 3, 0 normal function) and quality of life (global assessment of well-being, VAS 0 to 100 mm, 0 no disease activity) is very uncertain. Mean function was 0.84 with TNFi and 1 with placebo (MD 0.16 lower, 95% CI 0.39 lower to 0.06 higher; 3 studies, 194 participants; very low-certainty evidence, downgraded for risk of bias and imprecision). The mean participant global assessment of well-being was 23 mm with TNFi and 34 mm with placebo (MD 11 mm lower, 95% CI 23 mm lower to 1 mm higher; 3 studies, 194 participants; very low-certainty evidence, downgraded for indirectness, imprecision, and risk of bias). No study reported data on remission. Harms at any time We are uncertain about the effect of TNFi on withdrawals due to adverse events (3%) compared to placebo (1%) (RR 3.41, 95% CI 0.73 to 15.9; 6 studies, 448 participants). We are also uncertain about the effect of TNFi on serious adverse events (7%) compared to placebo (6%) (RR 1.09, 95% CI 0.53 to 2.22; 6 studies, 448 participants). The certainty of evidence was very low, downgraded for risk of bias and imprecision. TNFi plus MTX versus MTX alone Benefits at 17 to 26 weeks We are uncertain about the effect of TNFi plus MTX on treatment response. Seventy per cent of participants receiving MTX and 90% receiving TNFi plus MTX achieved treatment response (RR 1.29, 95% CI 0.93 to 1.77; 1 study, 40 participants). We are also uncertain about the effect of TNFi plus MTX on remission. Five per cent of participants on MTX monotherapy and 40% on combination therapy were in remission (RR 8.00, 95% CI 1.10 to 58.19; 1 study, 40 participants). No study reported pain, function, or participant global assessment of well-being. Harms at any time We are uncertain about the effect of TNFi plus MTX on withdrawals due to adverse events and serious adverse events. Very low-certainty evidence from two studies shows that 2/53 participants (4%) receiving MTX alone and 3/55 (5%) receiving TNFi plus MTX withdrew due to adverse events (RR 1.31, 95% CI 0.18 to 9.82; 108 participants), and 5/53 (9%) receiving MTX alone and 0/55 receiving TNFi plus MTX reported serious adverse events (RR 0.16, 95% CI 0.02 to 1.32). Due to risk of bias and imprecision, the certainty of evidence was very low across all major outcomes for this comparison.

AUTHORS' CONCLUSIONS

In JIA, TNFi may result in a higher proportion of individuals achieving clinical improvement compared to placebo, but we are uncertain about the effect of TNFi on pain, function, and quality of life. We are also uncertain about the effect of TNFi combined with MTX versus MTX alone on clinical improvement and remission. Evidence for the safety of TNFi compared to placebo or MTX is very uncertain. There are no RCTs comparing TNFi to other treatments. More high-quality studies are warranted to assess the benefits and harms of TNFi in JIA.

Comparative Effectiveness and Safety of the JAK Inhibitors and Biologic Disease-Modifying Antirheumatic Drugs in Treating Children With Nonsystemic Juvenile Idiopathic Arthritis: A Bayesian Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

We evaluated the efficacy and safety profiles of JAK inhibitors (JAKi) and biologic disease-modifying antirheumatic drugs (bDMARDs) when used with or without methotrexate (MTX) for the treatment of nonsystemic forms of juvenile idiopathic arthritis (nsJIA).

METHODS

Randomized clinical trials (RCTs) investigating efficacy and safety outcomes of JAKi or bDMARDs for the nsJIA population up to 2023 were searched in ClinicalTrial.gov, PubMed, EMBASE, and Cochrane databases. Bayesian arm-based network meta-analysis compared efficacy as measured by Juvenile Idiopathic Arthritis-American College of Rheumatology 70 (JIA-ACR70) improvement and safety based on rates of serious adverse events (SAEs) among all therapies.

RESULTS

Eligible studies included 45 citations from 16 RCTs (7 parallel and 9 withdrawal trials) with a total of 1,821 participants that investigated nine bDMARDs, three with and six without MTX co-treatment, and two JAKis (tofacitinib and baricitnib). The reported SAE incidence rates ranged from 0 to 0.3 per person-year of follow-up; none of the pairwise comparisons were statistically significant. The JIA-ACR70 improvement by 16 weeks of treatment ranged from 11.3% to 89.5%. Compared with controls, significant JIA-ACR70 improvements were observed for etanercept, golimumab, and all three combination therapies (adalimumab+MTX, etanercept+MTX, and infliximab+MTX), with odds ratios ranging from 2.97 to 3.99. No significant pairwise comparisons between bDMARDs and JAKi versus bDMARDs were noted.

CONCLUSION

Overall, no significant evidence was found for efficacy and safety profiles in pairwise comparisons of JAKis and bDMARDs. Future studies will expand the meta-analysis by including non-RCT studies and individual participant data.

Juvenile idiopathic arthritis and associated uveitis: A review of pathogenesis, diagnosis, and management

Juvenile idiopathic arthritis (JIA) is the most common rheumatologic disorder in children, posing significant physical and emotional challenges due to its chronic nature and the need for prolonged immunosuppressive therapies. Uveitis is the most common extra-articular manifestation of JIA, and it can be a sight-threatening condition. Despite advances in biologic treatments, JIA continues to present substantial therapeutic challenges, necessitating multiple treatment attempts and close monitoring for secondary failures. JIA-associated uveitis remains one of the most challenging and aggressive types of uveitis, particularly in children, due to its early onset, chronicity, and limited therapeutic responses despite new treatments. Early recognition and prompt treatment of both arthritis and uveitis are essential for achieving sustained remission and preventing complications. Effective management of JIA-uveitis requires a collaborative approach between pediatric rheumatologists and ophthalmologists to ensure timely assessments, regular screenings, and necessary therapy adjustments. This integrated care approach is crucial for achieving optimal outcomes. Therefore, this review aims to extensively analyze the pathogenesis, diagnosis, and therapy of JIA and its associated uveitis.

Biosimilars Versus Originators in Children With Juvenile Idiopathic Arthritis: A Real-World Experience

INTRODUCTION

We aimed to evaluate the efficacy, safety, and immunogenicity profile of Etanercept (ETA) and Adalimumab (ADA) biosimilars (BIOs) compared to their originators in children with juvenile idiopathic arthritis (JIA).

METHOD

Eighty-one JIA children treated with ETA or ADA originators or BIOs were examined at baseline (T0) and after 3- (T1), 6- (T2), 12- (T3), and 24-(T4) months after starting treatment.

RESULTS

Lower Juvenile Arthritis Disease Activity Score 10 (JADAS-10) scores were reported at T1, T2, T3, and T4 in JIA children treated with BIOs than originators (all p < 0.05). At T1 and T3, anti-drugs antibodies levels were lower in children receiving BIOs than originators (p = 0.04 and p = 0.0007, respectively), even after adjustments (both p < 0.05). Relapses were lower for BIOs compared to originators (p < 0.001). Safety profile was comparable between the groups (p > 0.05).

DISCUSSION

A better overall profile of BIOs than originators was demonstrated in JIA children, but larger confirmatory studies are needed.

Intravenous Golimumab in Children With Polyarticular-Course Juvenile Idiopathic Arthritis: Long-Term Extension of an Open-Label Phase III Study

OBJECTIVE

To report pharmacokinetics (PK), immunogenicity, clinical effect, and safety of intravenous (IV) golimumab in children with active polyarticular-course juvenile idiopathic arthritis (pcJIA) who participated in A Study to Evaluate the Pharmacokinetics, Efficacy and Safety of Intravenous Golimumab in Pediatric Participants With Active Polyarticular Course Juvenile Idiopathic Arthritis Despite Methotrexate Therapy (GO-VIVA)'s open-label, long-term extension (LTE) through week 252.

METHODS

GO-VIVA participants who continued IV golimumab (80 mg/m2 every 8 weeks) after week 52 were included. PK and safety were assessed through week 244 (last dose) and week 252, respectively, and clinical response through week 116. Clinical outcomes included JIA-American College of Rheumatology (ACR) responses and clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10). Binary outcomes used nonresponder imputation, and other descriptive analyses used observed data.

RESULTS

Of 112/127 (88.2%) participants entering the LTE, 69 completed the week 252 visit. Median steady-state trough golimumab concentrations were generally maintained from week 52 through week 244 (range 0.3-0.6 μg/mL). Antigolimumab antibody rates were consistent through week 52 (39.2% [49/125]) and week 244 (44.8% [56/125]). Week 52 JIA-ACR 30/50/70/90 response rates (75.6% [96/127], 74% [94/127], 65.4% [83/127], and 48.8% [62/127], respectively) were generally maintained through week 116 (72.4% [92/127], 71.7% [91/127], 63.8% [81/127], and 50.4% [64/127], respectively), when the median cJADAS10 was 1.6 and 56.7% (72/127) of participants achieved cJADAS10 ≤ 5 (minimal disease activity). Rates (per 100 patient-years) of serious adverse events and serious infections through week 252 were 7.7 and 3.9, respectively.

CONCLUSION

GO-VIVA LTE participants experienced adequate PK exposure and stable safety and immunogenicity. The majority of participants experienced no more than minimal residual disease activity. Data suggest IV golimumab treatment provided durable clinical response through week 116, with an acceptable risk-benefit profile.

Neurological Side Effects of TNF-α Inhibitors Revisited: A Review of Case Reports

Over the past two decades, the use of tumor necrosis factor alpha (TNF-α) inhibitors has significantly improved the treatment of patients with immune-mediated inflammatory diseases. Firstly, introduced for rheumatoid arthritis, these inhibitors are currently approved and used for a variety of conditions, including ankylosing spondylitis, Crohn's disease, juvenile idiopathic arthritis, psoriasis, psoriatic arthritis, ulcerative colitis, and chronic uveitis. Despite their immense therapeutic efficacy, TNF-α inhibitors have been associated with neurological adverse effects that bring new clinical challenges. The present review collects data from multiple studies to evaluate the incidence and the relationship between TNF-α inhibitors and neurological side effects and to explore the potential underlying mechanisms of this association. Moreover, it highlights the importance of patient selection, particularly in the case of individuals with a history of demyelinating diseases, raises awareness for clinicians, and calls for ongoing research that will improve TNF-α targeting strategies and offer safer and more effective therapeutic options.

Real-life data of etanercept efficacy and safety in juvenile idiopathic arthritis: a 24-month retrospective study at a single center

OBJECTIVE

The aim of this study was to assess the efficacy and safety of etanercept (ETA) use in juvenile idiopathic arthritis (JIA).

METHODS

The 24-month data of patients with JIA on etanercept in a single center were evaluated retrospectively. Response to treatment was assessed according to 10-joint Juvenile Arthritis Disease Activity Score (JADAS10), and JIA-American College of Rheumatology (ACR) improvement criteria. Safety assessments were based on adverse event (AE) reports.

RESULTS

The study included 152 patients with JIA. The mean age at diagnosis of JIA was 8.5 ± 4.4 years, and treatment with ETA started at a mean age of 11.1 ± 4.4 years. The mean duration of ETA use was 16 ± 11.1 months. The mean JADAS10 score at baseline was 18.5 ± 5.9. By the third month, it had reduced to 8.6 ± 6.6 and by the sixth month to 5.7 ± 6. By the twelfth month, the JADAS10 score was 4.9 ± 6.7, and by the twenty-fourth month, it had worsened to 7.3 ± 7.8. ACR50 response was achieved in 79.6% of patients at 3 months, 67.1% at 6 months, 79.3% at twelfth months, 70.7% at the twenty-fourth month. During ETA treatment, 10 patients required hospitalization for serious infections.

CONCLUSION

Etanercept is a safe and effective option for patients with JIA. However, variations in response between JIA subtypes highlight the need for individualized treatment strategies.

Tumor-necrosis factor α-rich environment alters type-I interferon response to viral stimuli in patients with juvenile idiopathic arthritis by altering myeloid dendritic cell phenotype

The balance between the tumor-necrosis factor α (TNFα) and type-I interferon (T1IFN) pathways is crucial for proper immune function. Dysregulation of either pathway can contribute to autoimmune diseases development. Even though TNFα blockade has shown promising results in various autoimmune diseases, the effect on the balance between TNFα and T1IFN is elusive. We used targeted anti-TNFα therapies in juvenile idiopathic arthritis (JIA) as an experimental approach to study the cross-regulation between TNFα and type-I IFN. We found that TNFα-rich environment affected viral defense through the attenuation of T1IFN responses and affected the phenotype and distribution of myeloid dendritic cells, which are engaged in early viral infections. Anti-TNFα therapy normalized the observed deviations in JIA patients. We hypothesize that the inadequate immune response caused by a high TNFα environment could be projected to more frequent or lengthy viral infections and possibly play a role in the process of JIA disease development.