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A 10-year-old boy is seen in the paediatric rheumatology clinic for ongoing management of his polyarticular juvenile idiopathic arthritis (pJIA). He is currently taking methotrexate, but this has not induced full remission; his range of joint movement still restricted, and his inflammatory markers are still elevated. Moreover, the methotrexate is making him very sick; despite taking ondansetron, he is violently ill after each weekly methotrexate dose, often vomiting to the point of epistaxis.
The doctor advises that the next line of management is to try a biological agent, either etanercept (EDA) or adalimumab (ADA). She tells the patient and his mother that both drugs are safe and effective, but that neither has shown to be better than the other. They are provided with some information leaflets about each drug and are told that they can decide which they would prefer.
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