...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. ACR, American College of Rheumatology; ADA, adalimumab; CHAQ, Childhood Health Assessment Questionnaire; ETA, etanercept; IL, interleukin; JADAS, Juvenile Arthritis Disease Activity Score; JIA, juvenile idiopathic arthritis; pJIA, polyarticular JIA; QALY, quality-adjusted life year; RR, relative risk; TNF, tumour necrosis factor; RCT, randomised controlled trial. Rather than traditional RCTs, these are both withdrawal trials; all participants receive the drug during an intial ‘lead-in’ phase, then only those showing a response enter the double-blind phase and randomised to either drug or placebo. Since the trial phase is thus targeted to known responders, the outcome is not diluted by refractory cases. ADA is also an effective treatment for inflammatory bowel disease,13 whereas ETA is not.14 On the other hand, in certain settings, clinicians may favour ETA due to a lower risk of tuberculosis.15 Clinical bottom line Both etanercept and adalimumab are safe and effective drugs in the treatment of juvenile idiopathic arthritis (Grade A).