Beruflich Dokumente
Kultur Dokumente
4
8
(
%
)
80
90
70
60
40
30
10
50
20
0
No Methotrexate Methotrexate
Placebo Adalimumab Placebo Adalimumab
C
100
P
a
t
i
e
n
t
s
w
i
t
h
A
C
R
P
e
d
i
R
e
s
p
o
n
s
e
(
%
)
80
90
70
60
40
30
10
50
20
0
0 8 16 24 56 72 104
ACR Pedi 30
ACR Pedi 50
ACR Pedi 70
ACR Pedi 90
ACR Pedi 100
Weeks
100
P
a
t
i
e
n
t
s
w
i
t
h
A
C
R
P
e
d
i
R
e
s
p
o
n
s
e
s
a
t
W
k
1
6
(
%
)
80
90
70
60
40
30
10
50
20
0
Adalimumab Monotherapy Adalimumab and Methotrexate
AUTHOR:
FIGURE:
JOB:
4-C
H/T
RETAKE
SIZE
ICM
CASE
EMail
Line
H/T
Combo
Revised
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.
REG F
Enon
1st
2nd
3rd
Lovell
2 of 2
05-22-08
ARTIST: ts
35821 ISSUE:
ACR Pedi 30 ACR Pedi 50 ACR Pedi 70 ACR Pedi 90
74
91
46
71
26
28
94
64
The New England Journal of Medicine
Downloaded from nejm.org on December 10, 2013. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.
Adalimumab in Juvenile Rheumatoid Arthritis
n engl j med 359;8 www.nejm.org august 21, 2008
817
ease flares were significantly less frequent among
children receiving adalimumab than among those
receiving placebo. Disease flare was defined con-
servatively in this study, with a relatively small de-
gree of worsening exceeding the threshold for a
flare. Therefore, many patients met the criteria for
a disease flare while showing substantial improve-
ment as compared with baseline disease activity.
The ACR Pedi scores at week 48, which defined all
patients who had disease flares as having no re-
sponse, were significantly greater for patients
treated with adalimumab than for those receiving
placebo, both among patients receiving metho-
trexate and among all patients regardless of wheth-
er they received methotrexate, but not among pa-
tients not receiving methotrexate. Of patients
treated with adalimumab, 30% not receiving meth-
otrexate and 42% receiving methotrexate had an
ACR Pedi 90 response, a measure that we believe
has not previously been included in an efficacy trial
of juvenile rheumatoid arthritis (Table 3). During
2 further years of adalimumab treatment in the
open-label extension phase, ACR Pedi responses
were sustained, including achievement of ACR Pedi
100 responses by 40% of the patients.
The study was not statistically powered to de-
tect differences between patients receiving and
those not receiving methotrexate; however, the
proportions of patients with ACR Pedi 30, 50, 70,
or 90 responses were somewhat higher among
those receiving adalimumab in combination with
methotrexate than among those receiving adali-
mumab without methotrexate. Although these re-
sults are consistent with findings of studies in
adult patients with rheumatoid arthritis,
8,14
any
differences between patients in the two strata
(those receiving and those not receiving metho-
trexate) are difficult to interpret, because the pa-
tients underwent randomization within each stra-
tum but not across strata. Eleven of 86 patients not
receiving methotrexate withdrew from the study
before undergoing randomization, because of lack
of efficacy of adalimumab.
A small percentage of patients withdrew be-
cause of adverse events. The most frequently
reported adverse events were infections and injec-
tion-site reactions. Serious adverse events consid-
ered possibly drug-related by the investigator
occurred in 14 patients, 7 of whom had serious
infections. No deaths, opportunistic infections,
malignant conditions, demyelinating diseases, or
lupuslike reactions occurred in this study. The size
of the study population and the length of the study
were not sufficient to determine the risks of rare
adverse events.
Approximately 16% of the patients had at least
one positive test for anti-adalimumab antibody
during the study. This percentage is greater than
the 5% observed during clinical trials of adult pa-
tients with rheumatoid arthritis.
14
There were no
increases in discontinuations of the study drug or
adverse events associated with the presence of anti-
adalimumab antibody. Positive anti-adalimumab
antibody tests were less frequent among patients
receiving concomitant methotrexate than among
those receiving adalimumab monotherapy, a find-
ing consistent with the findings of trials in adult
patients with rheumatoid arthritis.
Conducting placebo-controlled trials in pediat-
ric populations requires special consideration of
Table 3. ACR Pedi 30, 50, 70, and 90 Responses of Patients Receiving Placebo or Adalimumab with or without
Methotrexate at Week 48.*
ACR Pedi Response No Methotrexate Methotrexate
Placebo
(N =28)
Adalimumab
(N = 30) P Value
Placebo
(N = 37)
Adalimumab
(N = 38) P Value
percent percent
30 32 57 0.06 38 63 0.03
50 32 53 0.10 38 63 0.03
70 29 47 0.16 27 63 0.002
90 18 30 0.28 27 42 0.17
* A patient who had a flare according to the protocol definition was classified as having no response from that point forward,
regardless of the patients American College of Rheumatology Pediatric (ACR Pedi) response at that time. ACR Pedi 30, 50,
70, and 90 responses are defined as improvements of at least 30%, 50%, 70%, and 90%, respectively, in at least three
of the six core criteria for juvenile rheumatoid arthritis, with worsening of 30% or more in no more than one criterion.
The New England Journal of Medicine
Downloaded from nejm.org on December 10, 2013. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.
The new engl and journal o f medicine
n engl j med 359;8 www.nejm.org august 21, 2008
818
T
a
b
l
e
4
.
S
u
m
m
a
r
y
o
f
A
d
v
e
r
s
e
E
v
e
n
t
s
p
e
r
P
a
t
i
e
n
t
-
Y
e
a
r
o
f
E
x
p
o
s
u
r
e
.
V
a
r
i
a
b
l
e
M
e
t
h
o
t
r
e
x
a
t
e
N
o
M
e
t
h
o
t
r
e
x
a
t
e
O
p
e
n
-
L
a
b
e
l
L
e
a
d
-
i
n
P
h
a
s
e
D
o
u
b
l
e
-
B
l
i
n
d
P
h
a
s
e
O
p
e
n
-
L
a
b
e
l
E
x
t
e
n
s
i
o
n
P
h
a
s
e
O
p
e
n
-
L
a
b
e
l
L
e
a
d
-
i
n
P
h
a
s
e
D
o
u
b
l
e
-
B
l
i
n
d
P
h
a
s
e
O
p
e
n
-
L
a
b
e
l
E
x
t
e
n
s
i
o
n
P
h
a
s
e
a
d
a
l
i
m
u
m
a
b
(
N
=
8
5
;
2
7
.
3
p
a
t
i
e
n
t
-
y
e
a
r
s
)
p
l
a
c
e
b
o
(
N
=
3
7
;
1
5
.
0
p
a
t
i
e
n
t
-
y
e
a
r
s
)
a
d
a
l
i
m
u
m
a
b
(
N
=
3
8
;
1
8
.
3
p
a
t
i
e
n
t
-
y
e
a
r
s
)
a
d
a
l
i
m
u
m
a
b
(
N
=
7
1
;
1
2
7
.
4
p
a
t
i
e
n
t
-
y
e
a
r
s
)
a
d
a
l
i
m
u
m
a
b
(
N
=
8
6
;
2
9
.
3
p
a
t
i
e
n
t
-
y
e
a
r
s
)
p
l
a
c
e
b
o
(
N
=
2
8
;
1
0
.
6
p
a
t
i
e
n
t
-
y
e
a
r
s
)
a
d
a
l
i
m
u
m
a
b
(
N
=
3
0
;
1
4
.
4
p
a
t
i
e
n
t
-
y
e
a
r
s
)
a
d
a
l
i
m
u
m
a
b
(
N
=
5
7
;
1
0
2
.
6
p
a
t
i
e
n
t
-
y
e
a
r
s
)
n
o
.
o
f
e
v
e
n
t
s
(
n
o
.
o
f
e
v
e
n
t
s
p
e
r
p
a
t
i
e
n
t
-
y
e
a
r
)
A
n
y
a
d
v
e
r
s
e
e
v
e
n
t
4
2
2
(
1
5
.
5
)
1
5
5
(
1
0
.
3
)
2
3
4
(
1
2
.
8
)
6
9
4
(
5
.
4
)
4
4
7
(
1
5
.
3
)
1
5
3
(
1
4
.
4
)
1
7
1
(
1
1
.
9
)
5
8
1
(
5
.
7
)
M
o
s
t
f
r
e
q
u
e
n
t
l
y
r
e
p
o
r
t
e
d
a
d
v
e
r
s
e
e
v
e
n
t
s
R
e
l
a
t
e
d
t
o
i
n
j
e
c
t
i
o
n
-
s
i
t
e
r
e
a
c
t
i
o
n
1
4
2
(
5
.
2
)
5
7
(
3
.
8
)
7
3
(
4
.
0
)
2
2
4
(
1
.
8
)
1
6
6
(
5
.
7
)
2
0
(
1
.
9
)
7
1
(
4
.
9
)
1
4
9
(
1
.
4
)
C
o
n
t
u
s
i
o
n
1
4
(
0
.
5
)
7
(
0
.
5
)
1
2
(
0
.
7
)
4
(
<
0
.
1
)
7
(
0
.
2
)
5
(
0
.
5
)
2
(
0
.
1
)
7
(
0
.
1
)
N
a
s
o
p
h
a
r
y
n
g
i
t
i
s
6
(
0
.
2
)
6
(
0
.
4
)
5
(
0
.
3
)
9
(
0
.
1
)
2
(
0
.
1
)
5
(
0
.
5
)
0
7
(
0
.
1
)
U
p
p
e
r
r
e
s
p
i
r
a
t
o
r
y
t
r
a
c
t
i
n
f
e
c
t
i
o
n
9
(
0
.
3
)
5
(
0
.
3
)
6
(
0
.
3
)
3
2
(
0
.
2
)
1
1
(
0
.
4
)
6
(
0
.
6
)
6
(
0
.
4
)
4
2
(
0
.
4
)
V
i
r
a
l
i
n
f
e
c
t
i
o
n
9
(
0
.
3
)
3
(
0
.
2
)
7
(
0
.
4
)
2
6
(
0
.
2
)
8
(
0
.
3
)
4
(
0
.
4
)
8
(
0
.
6
)
9
(
0
.
1
)
V
o
m
i
t
i
n
g
4
(
0
.
2
)
2
(
0
.
1
)
4
(
0
.
2
)
5
(
<
0
.
1
)
2
(
0
.
1
)
1
(
0
.
1
)
0
4
(
<
0
.
1
)
E
x
c
o
r
i
a
t
i
o
n
5
(
0
.
2
)
1
(
0
.
1
)
1
0
(
0
.
6
)
1
2
(
0
.
1
)
5
(
0
.
2
)
2
(
0
.
2
)
6
(
0
.
4
)
8
(
0
.
1
)
S
e
r
i
o
u
s
a
d
v
e
r
s
e
e
v
e
n
t
s
,
p
o
s
s
i
b
l
y
r
e
l
a
t
e
d
t
o
s
t
u
d
y
d
r
u
g
*
3
(
0
.
1
)
1
(
0
.
1
)
0
7
(
0
.
1
)
4
(
0
.
1
)
0
0
2
(
<
0
.
1
)
A
b
d
o
m
i
n
a
l
p
a
i
n
0
0
0
1
(
<
0
.
1
)
0
0
0
0
B
r
o
n
c
h
o
p
n
e
u
m
o
n
i
a
0
0
0
0
0
0
0
1
(
<
0
.
1
)
G
a
s
t
r
o
d
u
o
d
e
n
i
t
i
s
0
1
(
0
.
1
)
0
0
0
0
0
0
H
e
m
a
t
o
c
h
e
z
i
a
0
0
0
1
(
<
0
.
1
)
0
0
0
0
H
e
r
p
e
s
s
i
m
p
l
e
x
i
n
f
e
c
t
i
o
n
0
0
0
0
1
(
<
0
.
1
)
0
0
0
H
e
r
p
e
s
z
o
s
t
e
r
i
n
f
e
c
t
i
o
n
0
0
0
1
(
<
0
.
1
)
0
0
0
1
(
<
0
.
1
)
H
y
d
r
o
c
e
p
h
a
l
u
s
0
0
0
1
(
<
0
.
1
)
0
0
0
0
J
u
v
e
n
i
l
e
r
h
e
u
m
a
t
o
i
d
a
r
t
h
r
i
t
i
s
d
i
s
e
a
s
e
f
l
a
r
e
1
(
<
0
.
1
)
0
0
1
(
<
0
.
1
)
2
(
0
.
1
)
0
0
0
L
e
u
k
o
p
e
n
i
a
1
(
<
0
.
1
)
0
0
0
0
0
0
0
N
e
u
t
r
o
p
e
n
i
a
1
(
<
0
.
1
)
0
0
0
0
0
0
0
P
h
a
r
y
n
g
i
t
i
s
0
0
0
1
(
<
0
.
1
)
0
0
0
0
P
n
e
u
m
o
n
i
a
0
0
0
0
1
(
<
0
.
1
)
0
0
0
V
i
r
a
l
i
n
f
e
c
t
i
o
n
0
0
0
1
(
<
0
.
1
)
0
0
0
0
A
d
v
e
r
s
e
e
v
e
n
t
s
l
e
a
d
i
n
g
t
o
d
i
s
c
o
n
t
i
n
u
a
t
i
o
n
o
f
d
r
u
g
5
(
0
.
2
)
0
0
2
(
<
0
.
1
)
7
(
0
.
2
)
0
0
2
(
<
0
.
1
)
A
r
t
h
r
a
l
g
i
a
0
0
0
0
1
(
<
0
.
1
)
0
0
0
D
i
z
z
i
n
e
s
s
0
0
0
0
1
(
<
0
.
1
)
0
0
0
H
y
d
r
o
c
e
p
h
a
l
u
s
0
0
0
1
(
<
0
.
1
)
0
0
0
0
The New England Journal of Medicine
Downloaded from nejm.org on December 10, 2013. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.
Adalimumab in Juvenile Rheumatoid Arthritis
n engl j med 359;8 www.nejm.org august 21, 2008
819
the ethical issues associated with denying active
treatment during a double-blind phase. At the time
the adalimumab trial was designed, two other tri-
als of TNF antagonists in pediatric patients were
ongoing. Our trial of adalimumab was designed
after considering both parallel and randomized
approaches to withdrawal, in consultation with the
Food and Drug Administration (FDA). The FDA
and the study designers agreed that the blinded,
randomized medication-withdrawal design pro-
vided acceptable scientific rigor while minimizing
exposure to placebo in this population of children
with severe, active juvenile rheumatoid arthritis
and that the primary end point should be a com-
parison, in the no-methotrexate stratum, between
the percentages of patients with disease flares in
the group receiving adalimumab and the group
receiving placebo during the double-blind phase.
Although the double-blind phase, and thus the
primary end-point analysis, was conducted in pa-
tients who had a response, the open-label lead-in
approach is generalizable to clinical practice, given
that treatment decisions are made in an open-
label setting after a reasonable trial with a new
active treatment. If a patient does not have a re-
sponse to an active treatment after a period of time
(16 weeks or so, as in the current trial), a physician
will probably consider other treatment options.
For patients who do have a response, treatment
will be continued.
Adalimumab, alone or in combination with
methotrexate, appears to be an efficacious option
for the treatment of children with polyarticular
juvenile rheumatoid arthritis. Responses were sus-
tained through 2 years of continued treatment.
Supported by a research grant from Abbott Laboratories.
Dr. Lovell reports receiving consulting fees from Abbott Lab-
oratories, Amgen, Bristol-Myers Squibb, Centocor, Pfizer, Hoff-
mannLa Roche, Novartis, Regeneron, and Xoma and speakers
fees from Amgen and Wyeth Pharmaceuticals. Dr. Reiff reports
receiving consulting and lecture fees from Amgen, Wyeth Phar-
maceuticals, Pfizer, and Abbott Laboratories and serving as a
clinical investigator for Abbott Laboratories, Amgen, and Re-
generon. Dr. Jung reports receiving consulting fees from Pfizer
and lecture fees from Talecris. Dr. Sandborg reports receiving
grant support from Immunex and Abbott Laboratories, as well
as unrestricted continued medical education grants from Abbott
Laboratories, Barr Pharmaceuticals, Bristol-Myers Squibb, Cen-
tocor, HoffmannLa Roche, and Amgen. Dr. Vehe reports re-
ceiving lecture fees from Abbott Laboratories. Dr. Horneff re-
ports receiving consulting and lecture fees from Wyeth
Pharmaceuticals. Dr. Huppertz reports receiving consulting fees
from Wyeth Pharmaceuticals, Essex Pharmaceuticals, and Ab-
bott Laboratories; lecture fees from Wyeth Pharmaceuticals and
Essex Pharmaceuticals; and support for attendance at scientific
meetings from Wyeth Pharmaceuticals and Essex Pharmaceuti-
cals. Dr. Mouy reports receiving consulting fees from Abbott
Laboratories. Dr. Olson reports receiving grant support from
J
u
v
e
n
i
l
e
r
h
e
u
m
a
t
o
i
d
a
r
t
h
r
i
t
i
s
1
(
<
0
.
1
)
0
0
0
4
(
0
.
1
)
0
0
2
(
<
0
.
1
)
L
e
u
k
o
p
e
n
i
a
1
(
<
0
.
1
)
0
0
0
0
0
0
0
A
l
a
n
i
n
e
a
m
i
n
o
t
r
a
n
s
f
e
r
a
s
e
e
l
e
v
a
t
i
o
n
1
(
<
0
.
1
)
0
0
0
0
0
0
0
A
s
p
a
r
t
a
t
e
a
m
i
n
o
t
r
a
n
s
f
e
r
a
s
e
e
l
e
v
a
t
i
o
n
1
(
<
0
.
1
)
0
0
0
0
0
0
0
N
e
u
t
r
o
p
e
n
i
a
1
(
<
0
.
1
)
0
0
0
0
0
0
0
P
n
e
u
m
o
n
i
a
0
0
0
0
1
(
<
0
.
1
)
0
0
0
V
i
r
a
l
i
n
f
e
c
t
i
o
n
0
0
0
1
(
<
0
.
1
)
0
0
0
0
*
S
e
r
i
o
u
s
a
d
v
e
r
s
e
e
v
e
n
t
s
w
e
r
e
d
e
a
t
h
o
r
a
n
y
e
v
e
n
t
t
h
a
t
w
a
s
l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g
;
r
e
q
u
i
r
e
d
h
o
s
p
i
t
a
l
i
z
a
t
i
o
n
o
r
p
r
o
l
o
n
g
a
t
i
o
n
o
f
e
x
i
s
t
i
n
g
h
o
s
p
i
t
a
l
i
z
a
t
i
o
n
;
r
e
s
u
l
t
e
d
i
n
p
e
r
s
i
s
t
e
n
t
o
r
s
i
g
n
i
f
i
c
a
n
t
d
i
s
a
b
i
l
i
-
t
y
,
c
o
n
g
e
n
i
t
a
l
a
n
o
m
a
l
y
,
o
r
s
p
o
n
t
a
n
e
o
u
s
o
r
e
l
e
c
t
i
v
e
a
b
o
r
t
i
o
n
;
o
r
r
e
q
u
i
r
e
d
m
e
d
i
c
a
l
o
r
s
u
r
g
i
c
a
l
i
n
t
e
r
v
e
n
t
i
o
n
t
o
p
r
e
v
e
n
t
a
n
o
t
h
e
r
s
e
r
i
o
u
s
o
u
t
c
o
m
e
.
I
n
a
d
d
i
t
i
o
n
t
o
t
h
e
s
e
r
i
o
u
s
a
d
v
e
r
s
e
e
v
e
n
t
s
l
i
s
t
e
d
,
t
h
e
f
o
l
l
o
w
i
n
g
s
e
r
i
o
u
s
a
d
v
e
r
s
e
e
v
e
n
t
s
a
l
s
o
o
c
c
u
r
r
e
d
(
i
n
1
p
a
t
i
e
n
t
e
a
c
h
,
e
x
c
e
p
t
w
h
e
r
e
n
o
t
e
d
)
b
u
t
w
e
r
e
n
o
t
c
o
n
s
i
d
e
r
e
d
t
o
b
e
p
o
s
s
i
b
l
y
r
e
l
a
t
e
d
t
o
t
h
e
s
t
u
d
y
d
r
u
g
:
a
b
d
o
m
i
n
a
l
p
a
i
n
,
a
b
o
r
t
i
o
n
,
a
d
e
n
o
i
d
a
l
a
n
d
t
o
n
s
i
l
l
a
r
h
y
p
e
r
t
r
o
p
h
y
(
2
p
a
t
i
e
n
t
s
)
,
a
r
t
h
r
i
t
i
s
(
2
p
a
t
i
e
n
t
s
)
,
a
p
p
e
n
d
i
c
i
t
i
s
(
2
p
a
t
i
e
n
t
s
)
,
d
i
a
b
e
t
i
c
k
e
t
o
a
c
i
d
o
s
i
s
,
f
e
m
u
r
f
r
a
c
t
u
r
e
,
u
n
s
p
e
c
i
f
i
e
d
i
n
j
u
r
y
,
m
a
l
a
b
s
o
r
p
t
i
o
n
,
j
o
i
n
t
c
o
n
t
r
a
c
t
u
r
e
,
j
o
i
n
t
d
i
s
l
o
c
a
t
i
o
n
,
j
u
v
e
n
i
l
e
r
h
e
u
m
a
t
o
i
d
a
r
t
h
r
i
t
i
s
d
i
s
e
a
s
e
f
l
a
r
e
(
1
2
p
a
t
i
e
n
t
s
)
,
o
s
t
e
o
a
r
t
h
r
i
t
i
s
,
s
p
e
e
c
h
d
i
s
o
r
d
e
r
,
r
e
t
i
n
a
l
d
e
t
a
c
h
m
e
n
t
,
u
r
i
n
a
r
y
t
r
a
c
t
i
n
f
e
c
t
i
o
n
,
a
n
d
v
o
m
i
t
i
n
g
.
T
h
e
p
a
t
i
e
n
t
e
n
t
e
r
e
d
t
h
e
s
t
u
d
y
w
i
t
h
a
v
e
n
t
r
i
c
u
l
a
r
p
e
r
i
t
o
n
e
a
l
s
h
u
n
t
i
n
p
l
a
c
e
b
e
c
a
u
s
e
o
f
p
r
e
e
x
i
s
t
i
n
g
h
y
d
r
o
c
e
p
h
a
l
u
s
a
n
d
h
a
d
c
o
n
c
u
r
r
e
n
t
v
i
r
a
l
i
n
f
e
c
t
i
o
n
a
n
d
s
h
u
n
t
m
a
l
f
u
n
c
t
i
o
n
.
V
a
l
u
e
s
r
e
t
u
r
n
e
d
t
o
n
o
r
m
a
l
w
i
t
h
i
n
w
e
e
k
s
a
f
t
e
r
d
i
s
c
o
n
t
i
n
u
a
t
i
o
n
o
f
s
t
u
d
y
d
r
u
g
.
The New England Journal of Medicine
Downloaded from nejm.org on December 10, 2013. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.
n engl j med 359;8 www.nejm.org august 21, 2008
820
Adalimumab in Juvenile Rheumatoid Arthritis
Abbott Laboratories. Dr. Giannini reports receiving consulting
fees from Abbott Laboratories, Genzyme, Regeneron, Bristol-
Myers Squibb, HoffmannLa Roche, Pfizer, and Centocor; lec-
ture fees from Genzyme; and grant support from Amgen, Ab-
bott Laboratories, Bristol-Myers Squibb, Genzyme, and Pfizer.
Drs. Medich, Carcereri-De-Prati, and McIlraith report being
employed by Abbott Laboratories. No other potential conflict of
interest relevant to this article was reported.
We thank Carine Wouters, M.D. (Belgium), Isabelle Kone-
Paut, M.D., and Anne-Marie Prieur, M.D. (France), Hartmut Mi-
chels, M.D. (Germany), Richard Vesely, M.D. (Slovak Republic),
Maria Luz Gamir, M.D. (Spain), and Thomas Atkinson, M.D.,
Elizabeth Chalom, M.D., Christos Gabriel, M.D., Gloria Hig-
gins, Ph.D., M.D., Norman Ilowite, M.D., Olcay Jones, M.D.,
Ph.D., and Leonard Stein, M.D. (United States) for their partici-
pation in the trial; Lori Lush, Pharm.D., at JK Associates and
Michael A. Nissen, E.L.S., at Abbott Laboratories for their edito-
rial support; and Kaushik Patra, Ph.D., and Ashish Kumar,
Ph.D., both at Abbott Laboratories, for their help with data man-
agement and statistical analysis.
References
appendix
From the Cincinnati Childrens Hospital Medical Center, Cincinnati (D.J.L., E.H.G.); Istituto di Ricovero e Cura a Carattere Scientifico
G. Gaslini, Pediatric Rheumatology International Trials Organisation, Genoa, Italy (N.R., A.M.); Arthritis Associates of South Florida,
Delray Beach (S.G.); Childrens Hospital, Los Angeles (A.R.); Creighton University Medical Center and Childrens Hospital, Omaha, NE
(L.J.); Revmatologick stav (K.J.) and First Faculty of Medicine and General Faculty Hospital (D.N.) both in Prague, Czech Republic;
Hpital Necker Enfants Malades, Paris (R.M.); Stanford University Medical Center, Stanford, CA (C.S.); University of Utah Health Sci-
ences Center, Salt Lake City (J.B.); Ghent University Hospital, Ghent, Belgium (D.E.); Hamburger Zentrum fr Kinder- und Jugend-
rheumatologie, Hamburg, Germany (I.F.); Istituto Gaetano Pini, Milan (V.G.); the National Institute of Rheumatic Diseases, Piestany,
Slovak Republic (J.R.); Charit University Hospital, Berlin (K.M.); University of Minnesota, Minneapolis (R.K.V.); Larabida Hospital,
University of Chicago, Chicago (L.W.W.); Zentrum fr Allgemeine Pdiatrie und Neonatologie, Sankt Augustin, Germany (G.H.); Klini-
kum Bremen-Mitte, Bremen, Germany (H.-I.H.); University of Kansas Medical Center, Kansas City (N.Y.O.); Abbott Laboratories, Par-
sippany, NJ (J.R.M.); and Abbott Laboratories, Ludwigshafen, Germany (R.C.-D.-P., M.J.M.).
Ravelli A, Martini A. Juvenile idio- 1.
pathic arthritis. Lancet 2007;369:767-78.
Giannini EH, Brewer EJ, Kuzmina N, 2.
et al. Methotrexate in resistant juvenile
rheumatoid arthritis: results of the U.S.A.
U.S.S.R. double-blind, placebo-controlled
trial. N Engl J Med 1992;326:1043-9.
Ruperto N, Murray KJ, Gerloni V, et al. 3.
A randomized trial of parenteral metho-
trexate comparing an intermediate dose
with a higher dose in children with juve-
nile idiopathic arthritis who failed to re-
spond to standard doses of methotrexate.
Arthritis Rheum 2004;50:2191-201.
Genovese MC, Bathon JM, Fleis- 4.
chmann RM, et al. Longterm safety, ef-
ficacy, and radiographic outcome with
etanercept treatment in patients with
early rheumatoid arthritis. J Rheumatol
2005;32:1232-42.
Keystone EC, Kavanaugh AF, Sharp JT, 5.
et al. Radiographic, clinical, and function-
al outcomes of treatment with adalimu-
mab (a human anti-tumor necrosis factor
monoclonal antibody) in patients with ac-
tive rheumatoid arthritis receiving con-
comitant methotrexate therapy: a random-
ized, placebo-controlled, 52-week trial.
Arthritis Rheum 2004;50:1400-11.
Maini RN, Breedveld FC, Kalden JR, et 6.
al. Sustained improvement over two years
in physical function, structural damage,
and signs and symptoms among patients
with rheumatoid arthritis treated with in-
f liximab and methotrexate. Arthritis
Rheum 2004;50:1051-65.
Lovell DJ, Giannini EH, Reiff A, et al. 7.
Etanercept in children with polyarticular
juvenile rheumatoid arthritis. N Engl J
Med 2000;342:763-9.
Breedveld FC, Weisman MH, Ka- 8.
vanaugh AF, et al. The PREMIER study: a
multicenter, randomized, double-blind
clinical trial of combination therapy with
adalimumab plus methotrexate versus
methotrexate alone or adalimumab alone
in patients with early, aggressive rheuma-
toid arthritis who had not had previous
methotrexate treatment. Arthritis Rheum
2006;54:26-37.
van de Putte LBA, Atkins C, Malaise 9.
M, et al. Efficacy and safety of adalimum-
ab as monotherapy in patients with rheu-
matoid arthritis for whom previous disease
modifying antirheumatic drug treatment
has failed. Ann Rheum Dis 2004;63:508-
16.
Weinblatt ME, Keystone EC, Furst DE, 10.
et al. Adalimumab, a fully human anti-
tumor necrosis factor monoclonal anti-
body, for the treatment of rheumatoid ar-
thritis in patients taking concomitant
methotrexate: the ARMADA trial. Arthri-
tis Rheum 2003;48:35-45. [Erratum, Ar-
thritis Rheum 2003;48:855.]
Weinblatt ME, Keystone EC, Furst DE, 11.
Kavanaugh AF, Chartash EK, Segurado
OG. Long term efficacy and safety of
adalimumab plus methotrexate in pa-
tients with rheumatoid arthritis: ARMADA
4 year extended study. Ann Rheum Dis
2006;65:753-9.
Moher D, Schulz KF, Altman D. The 12.
CONSORT statement: revised recommen-
dations for improving the quality of re-
ports of parallel-group randomized trials.
JAMA 2001;285:1987-91.
Giannini EH, Ruperto N, Ravelli A, 13.
Lovell DJ, Felson DR, Martini A. Prelimi-
nary definition of improvement in juve-
nile arthritis. Arthritis Rheum 1997;40:
1202-9.
Humira (adalimumab). North Chicago, 14.
IL: Abbott Laboratories, 2008 (package
insert).
Copyright 2008 Massachusetts Medical Society.
The New England Journal of Medicine
Downloaded from nejm.org on December 10, 2013. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.