Skip to main content
Log in

Research progress in drug therapy of juvenile idiopathic arthritis

  • Review Article
  • Published:
World Journal of Pediatrics Aims and scope Submit manuscript

Abstract

Background

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. With the gradual expansion of the incidence of JIA in the population, the pathogenesis and treatment of JIA were further explored and analyzed, and JIA has achieved some success in drug therapy.

Data sources

A systemic literature search was conducted on PubMed, Cochrane Library, EMBASE, ISI Web of Science, the US National Institutes of Health Ongoing Trials Register, and the EU Clinical Trials Register. Through the searching of clinical trials of JIA in recent years, we summarized the progress of the clinical treatment of JIA.

Results

The main treatment drugs for JIA include non-steroidal anti-inflammatory drugs, glucocorticoids, disease-modifying antirheumatic drugs and biological agents. So far, a variety of biological agents targeting the cytokines and receptors involved in its pathogenesis have been gradually approved for JIA in many countries. The application of biological agents in JIA showed good efficacy and safety, bringing unprecedented experience to children and adolescents with JIA.

Conclusions

The potential and advantages of biologic agents in the treatment of JIA are significant, and the application of biologic agents in the treatment of JIA will be more and more common.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Data availability

All data generated or analysed during this study are included in this published article.

References

  1. Beukelman T, Nigrovic PA. Juvenile idiopathic arthritis: an idea whose time has gone? J Rheumatol. 2019;46:124–6.

    Article  PubMed  Google Scholar 

  2. Zaripova LN, Midgley A, Christmas SE, Beresford MW, Baildam EM, Oldershaw RA. Juvenile idiopathic arthritis: from aetiopathogenesis to therapeutic approaches. Pediatr Rheumatol Online J. 2021;19:135.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Beukelman T, Lougee A, Matsouaka RA, Collier D, Rumsey DG, Schenfeld J, et al. Patterns of etanercept use in juvenile idiopathic arthritis in the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J. 2021;19:131.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Carlsson E, Midgley A, Perkins S, Caamano-Gutierrez E, Gritzfeld JF, Beresford MW, et al. Serum protein signatures differentiate paediatric autoimmune/inflammatory disorders. Clin Immunol. 2021;229:108790.

    Article  CAS  PubMed  Google Scholar 

  5. Adrovic A, Yildiz M, Köker O, Şahin S, Barut K, Kasapçopur Ö. Biologics in juvenile idiopathic arthritis-main advantages and major challenges: a narrative review. Arch Rheumatol. 2020;36:146–57.

    PubMed  PubMed Central  Google Scholar 

  6. Yue X, Huang B, Hincapie AL, Wigle PR, Li Y, Qiu T, et al. Comparative effectiveness and persistence of TNFi and non-TNFi in juvenile idiopathic arthritis: a large paediatric rheumatology centre in the USA. Rheumatology (Oxford). 2021;60:4063–73.

    Article  CAS  Google Scholar 

  7. Papasavvas I, Gehrig B, Herbort CP Jr. Clinical course and treatment paradigms for JIA-related uveitis and pars planitis uveitis using precise ocular investigational methods. Klin Monbl Augenheilkd. 2021;238:458–68.

    Article  PubMed  Google Scholar 

  8. Yue X, Huang B, Hincapie AL, Wigle PR, Qiu T, Li Y, et al. Prescribing patterns and impact of factors associated with time to initial biologic therapy among children with non-systemic juvenile idiopathic arthritis. Paediatr Drugs. 2021;23:171–82.

    Article  PubMed  Google Scholar 

  9. Alzyoud RM, Alsuweiti MO, Almaaitah HQ, Aladaileh BN, Alnoubani MK, Alwahadneh AM. Juvenile idiopathic arthritis in Jordan: single center experience. Pediatr Rheumatol Online J. 2021;19:90.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Jia Y, Li M, Wang H, Zhang M, Wang Y. The peculiar clinical symptoms and treatment of limbic encephalitis associated with AMPA receptor antibody. Eur Neurol. 2021;84:206–11.

    Article  CAS  PubMed  Google Scholar 

  11. Kau CH, Allareddy V, Stoustrup P, Pedersen T, Kinard B, Cron RQ, et al. Management of juvenile idiopathic arthritis: preliminary qualitative findings from the National Dental Practice-Based Research Network. J World Fed Orthod. 2021;10:70–3.

    PubMed  Google Scholar 

  12. Mahmud SA, Binstadt BA. Autoantibodies in the pathogenesis, diagnosis, and prognosis of juvenile idiopathic arthritis. Front Immunol. 2019;9:3168.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  13. Kim JW, Ahn MH, Jung JY, Suh CH, Kim HA. An update on the pathogenic role of neutrophils in systemic juvenile idiopathic arthritis and adult-onset Still’s disease. Int J Mol Sci. 2021;22:13038.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Thomas M, Bonacorsi S, Simon AL, Mallet C, Lorrot M, Faye A, et al. Acute monoarthritis in young children: comparing the characteristics of patients with juvenile idiopathic arthritis versus septic and undifferentiated arthritis. Sci Rep. 2021;11:3422.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Rosenberg AM. Do we need a new classification of juvenile idiopathic arthritis? Clin Immunol. 2020;211:108298.

    Article  CAS  PubMed  Google Scholar 

  16. Foeldvari I, Constantin T, Vojinović J, Horneff G, Chasnyk V, Dehoorne J, et al. Etanercept treatment for extended oligoarticular juvenile idiopathic arthritis, enthesitis-related arthritis, or psoriatic arthritis: 6-year efficacy and safety data from an open-label trial. Arthritis Res Ther. 2019;21:125.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  17. Sestan M, Grguric D, Sedmak M, Frkovic M, Kifer N, Grubic M, et al. Quality of life in children suffering from juvenile idiopathic arthritis-associated uveitis. Rheumatol Int. 2020;40:1117–21.

    Article  PubMed  Google Scholar 

  18. Khraishi M, Millson B, Woolcott J, Jones H, Marshall L, Ruperto N. Reduction in the utilization of prednisone or methotrexate in Canadian claims data following initiation of etanercept in pediatric patients with juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2019;17:64.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Shoop-Worrall SJW, Hyrich KL. Predicting remission remains a challenge in patients with juvenile idiopathic arthritis. J Rheumatol. 2019;46:552–4.

    Article  PubMed  Google Scholar 

  20. Montefiori E, Modenese L, Di Marco R, Magni-Manzoni S, Malattia C, Petrarca M, et al. Linking joint impairment and gait biomechanics in patients with juvenile idiopathic arthritis. Ann Biomed Eng. 2019;47:2155–67.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Scheer T, Klotsche J, Len CA, Foeldvari I. Validation and adaptation of a German screening tool to identify patients at risk of juvenile idiopathic arthritis. Rheumatol Int. 2020;40:643–50.

    Article  CAS  PubMed  Google Scholar 

  22. Silvagni E, Bortoluzzi A, Ciancio G, Govoni M. Biological and synthetic target DMARDs in psoriatic arthritis. Pharmacol Res. 2019;149:104473.

    Article  CAS  PubMed  Google Scholar 

  23. Seaman SC, Hong S, Dlouhy BJ, Menezes AH. Current management of juvenile idiopathic arthritis affecting the craniovertebral junction. Childs Nerv Syst. 2020;36:1529–38.

    Article  PubMed  Google Scholar 

  24. Correll CK. Role of environment in pediatric rheumatic diseases. Rheum Dis Clin North Am. 2022;48:287–304.

    Article  PubMed  Google Scholar 

  25. Kramer M, Tomkins-Netzer O. Cataract risk and topical corticosteroids among children with juvenile idiopathic arthritis-related uveitis. Ophthalmology. 2020;127:S19-20.

    Article  PubMed  Google Scholar 

  26. Stoustrup P, Twilt M, Herlin T. Systemic treatment for temporomandibular joint arthritis in juvenile idiopathic arthritis. J Rheumatol. 2020;47:793–5.

    Article  PubMed  Google Scholar 

  27. Thorne JE, Woreta FA, Dunn JP, Jabs DA. Risk of cataract development among children with juvenile idiopathic arthritis-related uveitis treated with topical corticosteroids. Ophthalmology. 2010;117:1436–41.

    Article  PubMed  Google Scholar 

  28. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72:220–33.

    Article  PubMed  Google Scholar 

  29. Angeles-Han ST, Ringold S, Beukelman T, Lovell D, Cuello CA, Becker ML, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the screening, monitoring, and treatment of juvenile idiopathic arthritis-associated uveitis. Arthritis Rheumatol. 2019;71:864–77.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Rebane K, Aalto K, Haanpää M, Puolakka K, Virta LJ, Kautiainen H, et al. Initiating disease-modifying anti-rheumatic drugs rapidly reduces purchases of analgesic drugs in juvenile idiopathic arthritis. Scand J Rheumatol. 2021;50:28–33.

    Article  CAS  PubMed  Google Scholar 

  31. Naveen R, Jain A, Muhammed H, Gupta L, Misra DP, Lawrence A, et al. Macrophage activation syndrome in systemic lupus erythematosus and systemic-onset juvenile idiopathic arthritis: a retrospective study of similarities and dissimilarities. Rheumatol Int. 2021;41:625–31.

    Article  CAS  PubMed  Google Scholar 

  32. Räisänen L, Viljakainen H, Sarkkola C, Kolho KL. Perinatal risk factors for pediatric onset type 1 diabetes, autoimmune thyroiditis, juvenile idiopathic arthritis, and inflammatory bowel diseases. Eur J Pediatr. 2021;180:2115–23.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  33. Van Gelder RN. Drug costs, effectiveness, and kids in the crossfire: adalimumab in juvenile idiopathic arthritis-associated uveitis. Ophthalmology. 2019;126:425–7.

    Article  PubMed  Google Scholar 

  34. Loganathan S, Banday A, Jindal AK, Sudhakar M, Patra N, Pulipaka S, et al. Tapering doses of methylprednisolone pulse in the treatment of macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Indian J Pediatr. 2021;88:1056.

    Article  PubMed  Google Scholar 

  35. Beverstock A, Kelly A. Severe acute ocular hypertension following pulsed methylprednisolone for juvenile idiopathic arthritis. BMJ Case Rep. 2019;12:e229803.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Solebo AL, Rahi JS, Dick AD, Ramanan AV, Ashworth J, Edelsten C, et al. Areas of agreement in the management of childhood non-infectious chronic anterior uveitis in the UK. Br J Ophthalmol. 2020;104:11–6.

    Article  PubMed  Google Scholar 

  37. Smith CA, Toupin-April K, Jutai JW, Duffy CM, Rahman P, Cavallo S, et al. A systematic critical appraisal of clinical practice guidelines in juvenile idiopathic arthritis using the appraisal of guidelines for research and evaluation II (AGREE II) instrument. PLoS One. 2015;10:e0137180.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  38. Żuber Z, Turowska-Heydel D, Sobczyk M, Banach-Górnicka M, Rusnak K, Piszczek A, et al. Methotrexate efficacy and tolerability after switching from oral to subcutaneous route of administration in juvenile idiopathic arthritis. Reumatologia. 2016;54:19–23.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Ramanan AV, Dick AD, Jones AP, Guly C, Hardwick B, Hickey H, et al. A phase II trial protocol of tocilizumab in anti-TNF refractory patients with JIA-associated uveitis (the APTITUDE trial). BMC Rheumatol. 2018;2:4.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Kim EH, Shin D, Lee J, Jung AR, Roh JL. CISD2 inhibition overcomes resistance to sulfasalazine-induced ferroptotic cell death in head and neck cancer. Cancer Lett. 2018;432:180–90.

    Article  CAS  PubMed  Google Scholar 

  41. Shi S, Guo P, Anwar MI, Zhang W, Zhang W, Yang G. Copper mixed-triazolate frameworks featuring the thiophene-containing ligand towards enhanced photodegradation of organic contaminants in water. J Hazard Mater. 2021;406:124757.

    Article  CAS  PubMed  Google Scholar 

  42. Tanaka Y. Stopping tumour necrosis factor-targeted biological DMARDs in rheumatoid arthritis. Rheumatology. 2016;55(Suppl 2):ii15-22.

    Article  PubMed  Google Scholar 

  43. Chang S, Cao Y. Sulfasalazine maintains blood-brain barrier integrity and relieves lipopolysaccharide-induced inflammation in hCMEC/D3 cells. NeuroReport. 2021;32:672–7.

    Article  CAS  PubMed  Google Scholar 

  44. Yousefi-Ahmadipour A, Ebrahimi-Barough S, Niknia S, Allahverdi A, Mirzahosseini-Pourranjbar A, Tashakori M, et al. Therapeutic effects of combination of platelet lysate and sulfasalazine administration in TNBS-induced colitis in rat. Biomed Pharmacother. 2020;125:109949.

    Article  CAS  PubMed  Google Scholar 

  45. Cellucci T, Guzman J, Petty RE, Batthish M, Benseler SM, Ellsworth JE, et al. Management of juvenile idiopathic arthritis 2015: a position statement from the Pediatric Committee of the Canadian Rheumatology Association. J Rheumatol. 2016;43:1773–6.

    Article  PubMed  Google Scholar 

  46. Tynjälä P, Vähäsalo P, Tarkiainen M, Kröger L, Aalto K, Malin M, et al. Aggressive combination drug therapy in very early polyarticular juvenile idiopathic arthritis (ACUTE-JIA): a multicentre randomised open-label clinical trial. Ann Rheum Dis. 2011;70:1605–12.

    Article  PubMed  CAS  Google Scholar 

  47. van Rossum MA, van Soesbergen RM, Boers M, Zwinderman AH, Fiselier TJ, Franssen MJ, et al. Long-term outcome of juvenile idiopathic arthritis following a placebo-controlled trial: sustained benefits of early sulfasalazine treatment. Ann Rheum Dis. 2007;66:1518–24.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Ting TV, Lovell DJ. Does early sulfasalazine treatment provide long-term benefits to patients with juvenile idiopathic arthritis? Nat Clin Pract Rheumatol. 2008;4:344–5.

    Article  CAS  PubMed  Google Scholar 

  49. Wan Z, Li H, Wu X, Zhao H, Wang R, Li M, et al. Hepatoprotective effect of gentiopicroside in combination with leflunomide and/or methotrexate in arthritic rats. Life Sci. 2021;265:118689.

    Article  CAS  PubMed  Google Scholar 

  50. Zewail M, Nafee N, Helmy MW, Boraie N. Synergistic and receptor-mediated targeting of arthritic joints via intra-articular injectable smart hydrogels containing leflunomide-loaded lipid nanocarriers. Drug Deliv Transl Res. 2021;11:2496–519.

    Article  CAS  PubMed  Google Scholar 

  51. Huang H, Ran H, Liu X, Yu L, Qiu L, Lin Z, et al. Leflunomide ameliorates experimental autoimmune myasthenia gravis by regulating humoral and cellular immune responses. Int Immunopharmacol. 2021;93:107434.

    Article  CAS  PubMed  Google Scholar 

  52. Muhammad T, Zafar M, Quiroga J, Whitehead M. Leflunomide-induced delayed onset colitis. Br J Hosp Med (Lond). 2021;82:1–3.

    Article  Google Scholar 

  53. Ayaz NA, Karadağ ŞG, Çakmak F, Çakan M, Tanatar A, Sönmez HE. Leflunomide treatment in juvenile idiopathic arthritis. Rheumatol Int. 2019;39:1615–9.

    Article  CAS  PubMed  Google Scholar 

  54. Ahlmann M, Hempel G. The effect of cyclophosphamide on the immune system: implications for clinical cancer therapy. Cancer Chemother Pharmacol. 2016;78:661–71.

    Article  CAS  PubMed  Google Scholar 

  55. Teles KA, Medeiros-Souza P, Lima FAC, Araújo BG, Lima RAC. Cyclophosphamide administration routine in autoimmune rheumatic diseases: a review. Rev Bras Reumatol Engl Ed. 2017;57:596–604 (in English, Portuguese).

    Article  PubMed  Google Scholar 

  56. de Castro TC, Terreri MT, Len C, Hilário MO. Treatment of refractory juvenile idiopathic arthritis via pulse therapy using methylprednisolone and cyclophosphamide. Sao Paulo Med J. 2003;121:117–20.

    Article  PubMed  Google Scholar 

  57. Chen CY, Chen LC, Yeh KW, Ou LS, Yang MH, Huang JL. Sequential changes to clinical parameters and adhesion molecules following intravenous pulse cyclophosphamide and methylprednisolone treatment of refractory juvenile idiopathic arthritis. Clin Exp Rheumatol. 2004;22:259–64.

    CAS  PubMed  Google Scholar 

  58. Schulert GS, Grom AA. Pathogenesis of macrophage activation syndrome and potential for cytokine- directed therapies. Annu Rev Med. 2015;66:145–59.

    Article  CAS  PubMed  Google Scholar 

  59. Shimizu M, Mizuta M, Yasumi T, Iwata N, Okura Y, Kinjo N, et al. Validation of classification criteria of macrophage activation syndrome in Japanese patients with systemic juvenile idiopathic arthritis. Arthritis Care Res. 2018;70:1412–5.

    Article  CAS  Google Scholar 

  60. Ruperto N, Ravelli A, Castell E, Gerloni V, Haefner R, Malattia C, et al. Cyclosporine A in juvenile idiopathic arthritis. Results of the PRCSG/PRINTO phase IV post marketing surveillance study. Clin Exp Rheumatol. 2006;24:599–605.

    CAS  PubMed  Google Scholar 

  61. Pal P, Giri PP, Sinha R. Cyclosporine in resistant systemic arthritis-a cheaper alternative to biologics. Indian J Pediatr. 2019;86:590–4.

    Article  PubMed  Google Scholar 

  62. Ye P, Chi X, Cha JH, Luo S, Yang G, Yan X, et al. Potential of E3 ubiquitin ligases in cancer immunity: opportunities and challenges. Cells. 2021;10:3309.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Sathe K, Khubchandani RP. Thalidomide for systemic onset juvenile idiopathic arthritis. Indian Pediatr. 2013;50:237–9.

    Article  CAS  PubMed  Google Scholar 

  64. García-Carrasco M, Fuentes-Alexandro S, Escárcega RO, Rojas-Rodriguez J, Escobar LE. Efficacy of thalidomide in systemic onset juvenile rheumatoid arthritis. Jt Bone Spine. 2007;74:500–3.

    Article  Google Scholar 

  65. Ponticelli C, Moroni G. Hydroxychloroquine in systemic lupus erythematosus (SLE). Expert Opin Drug Saf. 2017;16:411–9.

    Article  CAS  PubMed  Google Scholar 

  66. Jorge A, Ung C, Young LH, Melles RB, Choi HK. Hydroxychloroquine retinopathy-implications of research advances for rheumatology care. Nat Rev Rheumatol. 2018;14:693–703.

    Article  PubMed  Google Scholar 

  67. Nirk EL, Reggiori F, Mauthe M. Hydroxychloroquine in rheumatic autoimmune disorders and beyond. EMBO Mol Med. 2020;12:e12476.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Haapasaari J, Kautiainen H, Isomäki H, Hakala M. Hydroxychloroquine does not decrease serum methotrexate concentrations in children with juvenile idiopathic arthritis. Arthritis Rheum. 2005;52:1621–2.

    Article  PubMed  Google Scholar 

  69. Dumaine C, Bekkar S, Belot A, Cabrera N, Malik S, von Scheven A, et al. Infectious adverse events in children with juvenile idiopathic arthritis treated with biological agents in a real-life setting: data from the JIRcohorte. Jt Bone Spine. 2020;87:49–55.

    Article  CAS  Google Scholar 

  70. Strand V, Balsa A, Al-Saleh J, Barile-Fabris L, Horiuchi T, Takeuchi T, et al. Immunogenicity of biologics in chronic inflammatory diseases: a systematic review. BioDrugs. 2017;31:299–316.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  71. Cabrera N, Lega JC, Kassai B, Wouters C, Kondi A, Cannizzaro E, et al. Safety of biological agents in paediatric rheumatic diseases: a real-life multicenter retrospective study using the JIRcohorte database. Jt Bone Spine. 2019;86:343–50.

    Article  Google Scholar 

  72. Giancane G, Muratore V, Marzetti V, Quilis N, Benavente BS, Bagnasco F, et al. Disease activity and damage in juvenile idiopathic arthritis: methotrexate era versus biologic era. Arthritis Res Ther. 2019;21:168.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Peng Y, Liu X, Duan Z, Duan J, Zhou Y. The association of serum IL-10 levels with the disease activity in systemic-onset juvenile idiopathic arthritis patients. Mediat Inflamm. 2021;2021:6650928.

    Google Scholar 

  74. Thiele F, Klein A, Windschall D, Hospach A, Foeldvari I, Minden K, et al. Comparative risk of infections among real-world users of biologics for juvenile idiopathic arthritis: data from the German BIKER registry. Rheumatol Int. 2021;41:751–62.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  75. Leong JY, Chen P, Yeo JG, Ally F, Chua C, Nur Hazirah S, et al. Immunome perturbation is present in patients with juvenile idiopathic arthritis who are in remission and will relapse upon anti-TNFα withdrawal. Ann Rheum Dis. 2019;78:1712–21.

    Article  CAS  PubMed  Google Scholar 

  76. Verstegen RHJ, McMillan R, Feldman BM, Ito S, Laxer RM. Towards therapeutic drug monitoring of TNF inhibitors for children with juvenile idiopathic arthritis: a scoping review. Rheumatology (Oxford). 2020;59:386–97.

    Article  CAS  Google Scholar 

  77. Ringold S, Angeles-Han ST, Beukelman T, Lovell D, Cuello CA, Becker ML, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis: therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis. Arthritis Care Res. 2019;71:846–63.

    Article  Google Scholar 

  78. Grazziotin LR, Currie G, Kip MMA, IJzerman MJ, Twilt M, Lee R, et al. Health state utility values in juvenile idiopathic arthritis: what is the evidence? Pharmacoeconomics. 2020;38:913–26.

    Article  PubMed  Google Scholar 

  79. Ho ACH, Wong SN, Leung LCK, Chan WKY, Chong PCY, Tse NKC, et al. Biological disease-modifying antirheumatic drugs in juvenile idiopathic arthritis of polyarticular course, enthesitis-related arthritis, and psoriatic arthritis: a consensus statement. Hong Kong Med J. 2020;26:56–65.

    Article  CAS  PubMed  Google Scholar 

  80. Murdaca G, Negrini S, Magnani O, Penza E, Pellecchio M, Gulli R, et al. Update upon efficacy and safety of etanercept for the treatment of spondyloarthritis and juvenile idiopathic arthritis. Mod Rheumatol. 2018;28:417–31.

    Article  CAS  PubMed  Google Scholar 

  81. Alexeeva EI, Namazova-Baranova LS, Bzarova TM, Valieva SI, Denisova RV, Sleptsova TV, et al. Predictors of the response to etanercept in patients with juvenile idiopathic arthritis without systemic manifestations within 12 months: results of an open-label, prospective study conducted at the National Scientific and Practical Center of Children’s Health. Russia Pediatr Rheumatol Online J. 2017;15:51.

    Article  PubMed  Google Scholar 

  82. Arvonen M, Vänni P, Sarangi AN, Tejesvi VM, Vähäsalo P, Aggarwal A, et al. Microbial orchestra in juvenile idiopathic arthritis: sounds of disarray? Immunol Rev. 2020;294:9–26.

    Article  CAS  PubMed  Google Scholar 

  83. Liu DW, Chen JJ, Tang XM, Zhang Y, Zhou J. Infliximab therapy and outcomes in patients with polyarticular juvenile idiopathic arthritis: a single-center study in China. World J Pediatr. 2020;16:68–73.

    Article  CAS  PubMed  Google Scholar 

  84. Favalli EG, Pontikaki I, Becciolini A, Biggioggero M, Ughi N, Romano M, et al. Real-life 10-year retention rate of first-line anti-TNF drugs for inflammatory arthritides in adult- and juvenile-onset populations: similarities and differences. Clin Rheumatol. 2017;36:1747–55.

    Article  PubMed  Google Scholar 

  85. Tarkiainen M, Tynjälä P, Vähäsalo P, Kröger L, Aalto K, Lahdenne P. Health-related quality of life during early aggressive treatment in patients with polyarticular juvenile idiopathic arthritis: results from randomized controlled trial. Pediatr Rheumatol Online J. 2019;17:80.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Lahdenne P, Vähäsalo P, Honkanen V. Infliximab or etanercept in the treatment of children with refractory juvenile idiopathic arthritis: an open label study. Ann Rheum Dis. 2003;62:245–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  87. Visvanathan S, Wagner C, Marini JC, Lovell DJ, Martini A, Petty R, et al. The effect of infliximab plus methotrexate on the modulation of inflammatory disease markers in juvenile idiopathic arthritis: analyses from a randomized, placebo-controlled trial. Pediatr Rheumatol Online J. 2010;8:24.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Horton S, Jones AP, Guly CM, Hardwick B, Beresford MW, Lee RW, et al. Adalimumab in juvenile idiopathic arthritis-associated uveitis: 5-year follow-up of the Bristol participants of the SYCAMORE trial. Am J Ophthalmol. 2019;207:170–4.

    Article  CAS  PubMed  Google Scholar 

  89. Klotsche J, Niewerth M, Haas JP, Huppertz HI, Zink A, Horneff G, et al. Long-term safety of etanercept and adalimumab compared to methotrexate in patients with juvenile idiopathic arthritis (JIA). Ann Rheum Dis. 2016;75:855–61.

    Article  CAS  PubMed  Google Scholar 

  90. Smith JR, Matthews JM, Conrad D, Hall AJ, Niederer RL, Singh-Grewal D, et al. Recommendations for the management of childhood juvenile idiopathic arthritis-type chronic anterior uveitis. Clin Exp Ophthalmol. 2021;49:38–45.

    Article  PubMed  Google Scholar 

  91. Cecchin V, Zannin ME, Ferrari D, Pontikaki I, Miserocchi E, Paroli MP, et al. Longterm safety and efficacy of adalimumab and infliximab for uveitis associated with juvenile idiopathic arthritis. J Rheumatol. 2018;45:1167–72.

    Article  CAS  PubMed  Google Scholar 

  92. William M, Faez S, Papaliodis GN, Lobo AM. Golimumab for the treatment of refractory juvenile idiopathic arthritis-associated uveitis. J Ophthalmic Inflamm Infect. 2012;2:231–3.

    Article  PubMed  PubMed Central  Google Scholar 

  93. Webb K, Wedderburn LR. Advances in the treatment of polyarticular juvenile idiopathic arthritis. Curr Opin Rheumatol. 2015;27:505–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  94. Hersh AO, Prahalad S. Immunogenetics of juvenile idiopathic arthritis: a comprehensive review. J Autoimmun. 2015;64:113–24.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  95. Brunner HI, Ruperto N, Tzaribachev N, Horneff G, Chasnyk VG, Panaviene V, et al. Subcutaneous golimumab for children with active polyarticular-course juvenile idiopathic arthritis: results of a multicentre, double-blind, randomised-withdrawal trial. Ann Rheum Dis. 2018;77:21–9.

    Article  CAS  PubMed  Google Scholar 

  96. Mejbri M, Theodoropoulou K, Hofer M, Cimaz R. Interleukin-1 blockade in systemic juvenile idiopathic arthritis. Paediatr Drugs. 2020;22:251–62.

    Article  PubMed  Google Scholar 

  97. Yasin S, Schulert GS. Systemic juvenile idiopathic arthritis and macrophage activation syndrome: update on pathogenesis and treatment. Curr Opin Rheumatol. 2018;30:514–20.

    Article  CAS  PubMed  Google Scholar 

  98. Miserocchi E, Modorati G, Berchicci L, Pontikaki I, Meroni P, Gerloni V. Long-term treatment with rituximab in severe juvenile idiopathic arthritis-associated uveitis. Br J Ophthalmol. 2016;100:782–6.

    Article  PubMed  Google Scholar 

  99. Krainer J, Siebenhandl S, Weinhäusel A. Systemic autoinflammatory diseases. J Autoimmun. 2020;109:102421.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  100. Jamilloux Y, Gerfaud-Valentin M, Martinon F, Belot A, Henry T, Sève P. Pathogenesis of adult-onset Still’s disease: new insights from the juvenile counterpart. Immunol Res. 2015;61:53–62.

    Article  CAS  PubMed  Google Scholar 

  101. Stevens BE, Torok KS, Li SC, Hershey N, Curran M, Higgins GC, et al. Clinical characteristics and factors associated with disability and impaired quality of life in children with juvenile systemic sclerosis: results from the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry. Arthritis Care Res (Hoboken). 2018;70:1806–13.

    Article  Google Scholar 

  102. Kaegi C, Wuest B, Schreiner J, Steiner UC, Vultaggio A, Matucci A. Systematic review of safety and efficacy of rituximab in treating immune-mediated disorders. Front Immunol. 2019;10:1990.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  103. Nara H, Watanabe R. Anti-inflammatory effect of muscle-derived interleukin-6 and its involvement in lipid metabolism. Int J Mol Sci. 2021;22:9889.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  104. Vecchié A, Del Buono MG, Chiabrando GJ, Dentali F, Abbate A, Bonaventura A. Interleukin-1 and the NLRP3 inflammasome in pericardial disease. Curr Cardiol Rep. 2021;23:157.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Lovell DJ, Giannini EH, Reiff AO, Kimura Y, Li S, Hashkes PJ, et al. Long-term safety and efficacy of rilonacept in patients with systemic juvenile idiopathic arthritis. Arthritis Rheum. 2013;65:2486–96.

    Article  CAS  PubMed  Google Scholar 

  106. Ilowite NT, Prather K, Lokhnygina Y, Schanberg LE, Elder M, Milojevic D, et al. Randomized, double-blind, placebo-controlled trial of the efficacy and safety of rilonacept in the treatment of systemic juvenile idiopathic arthritis. Arthritis Rheumatol. 2014;66:2570–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  107. Smith CJF, Chambers CD. Five successful pregnancies with antenatal anakinra exposure. Rheumatology (Oxford). 2018;57:1271–5.

    Article  CAS  Google Scholar 

  108. Beukelman T, Xie F, Baddley JW, Chen L, Mannion ML, Saag KG, et al. The risk of hospitalized infection following initiation of biologic agents versus methotrexate in the treatment of juvenile idiopathic arthritis. Arthritis Res Ther. 2016;18:210.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  109. Ramírez J, Cañete JD. Anakinra for the treatment of rheumatoid arthritis: a safety evaluation. Expert Opin Drug Saf. 2018;17:727–32.

    Article  PubMed  CAS  Google Scholar 

  110. Quartier P, Allantaz F, Cimaz R, Pillet P, Messiaen C, Bardin C, et al. A multicentre, randomised, double-blind, placebo-controlled trial with the interleukin-1 receptor antagonist anakinra in patients with systemic-onset juvenile idiopathic arthritis (ANAJIS trial). Ann Rheum Dis. 2011;70:747–54.

    Article  CAS  PubMed  Google Scholar 

  111. Ozen S, Demir S, Batu ED. Testing the model for predicting effectiveness of anakinra in systemic juvenile idiopathic arthritis. J Rheumatol. 2019;46:1422–4.

    Article  CAS  PubMed  Google Scholar 

  112. Peitz J, Horneff G. Treatment of systemic-onset juvenile arthritis with canakinumab. Open Access Rheumatol. 2015;7:23–31.

    PubMed  PubMed Central  Google Scholar 

  113. Grom AA. Canakinumab for the treatment of systemic juvenile idiopathic arthritis. Expert Rev Clin Immunol. 2014;10:1427–35.

    Article  CAS  PubMed  Google Scholar 

  114. Ruperto N, Brunner HI, Quartier P, Constantin T, Wulffraat N, Horneff G, et al. Two randomized trials of canakinumab in systemic juvenile idiopathic arthritis. N Engl J Med. 2012;367:2396–406.

    Article  CAS  PubMed  Google Scholar 

  115. Kang S, Tanaka T, Kishimoto T. Therapeutic uses of anti-interleukin-6 receptor antibody. Int Immunol. 2015;27:21–9.

    Article  CAS  PubMed  Google Scholar 

  116. Kearsley-Fleet L, Davies R, Baildam E, Beresford MW, Foster HE, Southwood TR, et al. Factors associated with choice of biologic among children with juvenile idiopathic arthritis: results from two UK paediatric biologic registers. Rheumatology. 2016;55:1556–65.

    Article  PubMed  PubMed Central  Google Scholar 

  117. Calvo-Río V, Santos-Gómez M, Calvo I, González-Fernández MI, López-Montesinos B, Mesquida M, et al. Anti-interleukin-6 receptor tocilizumab for severe juvenile idiopathic arthritis-associated uveitis refractory to anti-tumor necrosis factor therapy: a multicenter study of twenty-five patients. Arthritis Rheumatol. 2017;69:668–75.

    Article  PubMed  CAS  Google Scholar 

  118. Bulatović Ćalasan M, Vastert SJ, Scholman RC, Verweij F, Klein M, Wulffraat NM, et al. Methotrexate treatment affects effector but not regulatory T cells in juvenile idiopathic arthritis. Rheumatology (Oxford). 2015;54:1724–34.

    Article  CAS  Google Scholar 

  119. Leong JY, Guan YJ, Albani S, Arkachaisri T. Recent advances in our understanding of the pathogenesis of juvenile idiopathic arthritis and their potential clinical implications. Expert Rev Clin Immunol. 2018;14:933–44.

    Article  CAS  PubMed  Google Scholar 

  120. Cifaldi L, Prencipe G, Caiello I, Bracaglia C, Locatelli F, De Benedetti F, et al. Inhibition of natural killer cell cytotoxicity by interleukin-6: implications for the pathogenesis of macrophage activation syndrome. Arthritis Rheumatol. 2015;67:3037–46.

    Article  CAS  PubMed  Google Scholar 

  121. Sen ES, Ramanan AV. Juvenile idiopathic arthritis-associated uveitis. Clin Immunol. 2020;211:108322.

    Article  CAS  PubMed  Google Scholar 

  122. Choy EH, De Benedetti F, Takeuchi T, Hashizume M, John MR, Kishimoto T. Translating IL-6 biology into effective treatments. Nat Rev Rheumatol. 2020;16:335–45.

    Article  CAS  PubMed  Google Scholar 

  123. Narazaki M, Kishimoto T. The two-faced cytokine IL-6 in host defense and diseases. Int J Mol Sci. 2018;19:3528.

    Article  PubMed Central  CAS  Google Scholar 

  124. Ringold S, Weiss PF, Beukelman T, DeWitt EM, Ilowite NT, Kimura Y, et al. 2013 update of the 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: recommendations for the medical therapy of children with systemic juvenile idiopathic arthritis and tuberculosis screening among children receiving biologic medications. Arthritis Rheum. 2013;65:2499–512.

    Article  PubMed  PubMed Central  Google Scholar 

  125. De Benedetti F, Brunner HI, Ruperto N, Kenwright A, Wright S, Calvo I, et al. Randomized trial of tocilizumab in systemic juvenile idiopathic arthritis. N Engl J Med. 2012;367:2385–95.

    Article  PubMed  CAS  Google Scholar 

  126. Yazılıtaş F, Özdel S, Şimşek D, Aydoğ Ö, Çakıcı EK, Can GG, et al. Tocilizumab for juvenile idiopathic arthritis: a single-center case series. Sao Paulo Med J. 2019;137:517–22.

    Article  PubMed  Google Scholar 

  127. Rubbert-Roth A, Furst DE, Nebesky JM, Jin A, Berber E. A review of recent advances using tocilizumab in the treatment of rheumatic diseases. Rheumatol Ther. 2018;5:21–42.

    Article  PubMed  PubMed Central  Google Scholar 

  128. Pelechas E, Voulgari PV, Drosos AA. Clinical evaluation of the safety, efficacy and tolerability of sarilumab in the treatment of moderate to severe rheumatoid arthritis. Ther Clin Risk Manag. 2019;15:1073–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  129. Lamb YN, Deeks ED. Sarilumab: a review in moderate to severe rheumatoid arthritis. Drugs. 2018;78:929–40.

    Article  CAS  PubMed  Google Scholar 

  130. Hoeppli RE, Pesenacker AM. Targeting Tregs in juvenile idiopathic arthritis and juvenile dermatomyositis-insights from other diseases. Front Immunol. 2019;10:46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  131. Meng X, Hou X, Wang P, Glessner JT, Qu HQ, March ME, et al. Association of novel rare coding variants with juvenile idiopathic arthritis. Ann Rheum Dis. 2021;80:626–31.

    Article  CAS  PubMed  Google Scholar 

  132. Sen HN, Levy-Clarke G, Faia LJ, Li Z, Yeh S, Barron KS, et al. High-dose daclizumab for the treatment of juvenile idiopathic arthritis-associated active anterior uveitis. Am J Ophthalmol. 2009;148:696–703.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  133. Ferguson ID, Griffin P, Michel JJ, Yano H, Gaffen SL, Mueller RG, et al. T cell receptor-independent, CD31/IL-17A-driven inflammatory axis shapes synovitis in juvenile idiopathic arthritis. Front Immunol. 2018;9:1802.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  134. Alimanovic D, Pedersen TK, Matzen LH, Stoustrup P. Comparing clinical and radiological manifestations of adolescent idiopathic condylar resorption and juvenile idiopathic arthritis in the temporomandibular joint. J Oral Maxillofac Surg. 2021;79:774–85.

    Article  PubMed  Google Scholar 

  135. Chyuan IT, Lai JH. New insights into the IL-12 and IL-23: from a molecular basis to clinical application in immune-mediated inflammation and cancers. Biochem Pharmacol. 2020;175:113928.

    Article  CAS  PubMed  Google Scholar 

  136. Mannion ML, McAllister L, Cron RQ, Stoll ML. Ustekinumab as a therapeutic option for children with refractory enthesitis-related arthritis. J Clin Rheumatol. 2016;22:282–4.

    Article  PubMed  Google Scholar 

  137. Li HW, Zeng HS. Regulation of JAK/STAT signal pathway by miR-21 in the pathogenesis of juvenile idiopathic arthritis. World J Pediatr. 2020;16:502–13.

    Article  PubMed  Google Scholar 

  138. Shibata T, Muto J, Hirano Y, Takama H, Yanagishita T, Ohshima Y, et al. Palmoplantar pustulosis-like eruption following tofacitinib therapy for juvenile idiopathic arthritis. JAAD Case Rep. 2019;5:518–21.

    Article  PubMed  PubMed Central  Google Scholar 

  139. Caporali R, Zavaglia D. Real-world experience with tofacitinib for the treatment of rheumatoid arthritis. Clin Exp Rheumatol. 2019;37:485–95.

    PubMed  Google Scholar 

  140. Li X, Pathadka S, Man KK, Wong ICK, Chan EWY. Budget impact of introducing tofacitinib to the public hospital formulary in Hong Kong, 2017–2021. Hong Kong Med J. 2019;25:201–8.

    CAS  PubMed  Google Scholar 

  141. Huang Z, Lee PY, Yao X, Zheng S, Li T. Tofacitinib treatment of refractory systemic juvenile idiopathic arthritis. Pediatrics. 2019;143:e20182845.

    Article  PubMed  Google Scholar 

  142. Taylor PC, Keystone EC, van der Heijde D, Weinblatt ME, Del Carmen ML, Reyes Gonzaga J, et al. Baricitinib versus placebo or adalimumab in rheumatoid arthritis. N Engl J Med. 2017;376:652–62.

    Article  CAS  PubMed  Google Scholar 

  143. Miserocchi E, Giuffrè C, Cornalba M, Pontikaki I, Cimaz R. JAK inhibitors in refractory juvenile idiopathic arthritis-associated uveitis. Clin Rheumatol. 2020;39:847–51.

    Article  PubMed  Google Scholar 

  144. Ramanan AV, Guly CM, Keller SY, Schlichting DE, de Bono S, Liao R, et al. Clinical effectiveness and safety of baricitinib for the treatment of juvenile idiopathic arthritis-associated uveitis or chronic anterior antinuclear antibody-positive uveitis: study protocol for an open-label, adalimumab active-controlled phase 3 clinical trial (JUVE-BRIGHT). Trials. 2021;22:689.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  145. Harrison CN, Schaap N, Mesa RA. Management of myelofibrosis after ruxolitinib failure. Ann Hematol. 2020;99:1177–91.

    Article  PubMed  PubMed Central  Google Scholar 

  146. Bader-Meunier B, Hadchouel A, Berteloot L, Polivka L, Béziat V, Casanova JL, et al. Effectiveness and safety of ruxolitinib for the treatment of refractory systemic idiopathic juvenile arthritis like associated with interstitial lung disease: a case report. Ann Rheum Dis. 2022;81:e20.

    Article  PubMed  Google Scholar 

  147. Fischer J, Dirks J, Haase G, Holl-Wieden A, Hofmann C, Girschick H, Morbach H. IL-21+ CD4+ T helper cells co-expressing IFN-γ and TNF-α accumulate in the joints of antinuclear antibody positive patients with juvenile idiopathic arthritis. Clin Immunol. 2020;217:108484.

    Article  CAS  PubMed  Google Scholar 

  148. Beukelman T, Patkar NM, Saag KG, Tolleson-Rinehart S, Cron RQ, DeWitt EM, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res. 2011;63:465–82.

    Article  Google Scholar 

  149. Ruperto N, Lovell DJ, Quartier P, Paz E, Rubio-Pérez N, Silva CA, et al. Abatacept in children with juvenile idiopathic arthritis: a randomised, double-blind, placebo-controlled withdrawal trial. Lancet. 2008;372:383–91.

    Article  CAS  PubMed  Google Scholar 

  150. Ruperto N, Lovell DJ, Li T, Sztajnbok F, Goldenstein-Schainberg C, Scheinberg M, et al. Abatacept improves health-related quality of life, pain, sleep quality, and daily participation in subjects with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2010;62:1542–51.

    Article  Google Scholar 

  151. Koç R, Sönmez HE, Çakan M, Karadağ ŞG, Tanatar A, Çakmak F, et al. Drug reactions in children with rheumatic diseases receiving parenteral therapies: 9 years’ experience of a tertiary pediatric rheumatology center. Rheumatol Int. 2020;40:771–6.

    Article  PubMed  CAS  Google Scholar 

  152. Gueudry J, Touhami S, Quartier P, Bodaghi B. Therapeutic advances in juvenile idiopathic arthritis-associated uveitis. Curr Opin Ophthalmol. 2019;30:179–86.

    Article  PubMed  Google Scholar 

  153. Takakura M, Shimizu M, Mizuta M, Inoue N, Tasaki Y, Ohta K, et al. Successful treatment of rituximab- and steroid-resistant nephrotic syndrome with leukocytapheresis. J Clin Apher. 2018;33:409–11.

    Article  PubMed  Google Scholar 

  154. Kearsley-Fleet L, Sampath S, McCann LJ, Baildam E, Beresford MW, Davies R, et al. Use and effectiveness of rituximab in children and young people with juvenile idiopathic arthritis in a cohort study in the United Kingdom. Rheumatology. 2019;58:331–5.

    Article  CAS  PubMed  Google Scholar 

  155. Sakamoto AP, Pinheiro MM, Barbosa CM, Fraga MM, Len CA, Terreri MT. Rituximab use in young adults diagnosed with juvenile idiopathic arthritis unresponsive to conventional treatment: report of 6 cases. Rev Bras Reumatol. 2015;55:536–41 (in English, Portuguese).

    Article  PubMed  Google Scholar 

  156. Milan M, Pace V, Maiullari F, Chirivì M, Baci D, Maiullari S, et al. Givinostat reduces adverse cardiac remodeling through regulating fibroblasts activation. Cell Death Dis. 2018;9:108.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  157. Giovarelli M, Zecchini S, Catarinella G, Moscheni C, Sartori P, Barbieri C, et al. Givinostat as metabolic enhancer reverting mitochondrial biogenesis deficit in Duchenne Muscular Dystrophy. Pharmacol Res. 2021;170:105751.

    Article  CAS  PubMed  Google Scholar 

  158. Vojinovic J, Damjanov N, D’Urzo C, Furlan A, Susic G, Pasic S, et al. Safety and efficacy of an oral histone deacetylase inhibitor in systemic-onset juvenile idiopathic arthritis. Arthritis Rheum. 2011;63:1452–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to express our sincere gratitude to anonymous reviewers for their valuable comments, which have greatly improved this paper.

Funding

There is no funding in this article.

Author information

Authors and Affiliations

Authors

Contributions

LCF developed the concept. ZWJ and DJH drafted the manuscript. All authors have read and approved the final version of the manuscriptfor publication.

Corresponding author

Correspondence to Cai-Feng Li.

Ethics declarations

Ethical approval

Not applicable.

Conflict of interest

No financial or non-financial benefits have been received or will be received from any party related directly or indirectly to the subject of this article. The authors have no conflict of interest to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhao, WJ., Deng, JH. & Li, CF. Research progress in drug therapy of juvenile idiopathic arthritis. World J Pediatr 18, 383–397 (2022). https://doi.org/10.1007/s12519-022-00530-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12519-022-00530-8

Keywords

Navigation