Tofacitinib for the Treatment of Severe Interstitial Lung Disease Related to Rheumatoid Arthritis

Caterina Vacchi, Andreina Manfredi, Giulia Cassone, Stefania Cerri, Giovanni Della Casa, Dario Andrisani, Carlo Salvarani, Marco Sebastiani, Caterina Vacchi, Andreina Manfredi, Giulia Cassone, Stefania Cerri, Giovanni Della Casa, Dario Andrisani, Carlo Salvarani, Marco Sebastiani

Abstract

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterized by chronic symmetrical erosive synovitis and extra-articular manifestations, including interstitial lung disease (ILD), whose treatment is nowadays challenging due to high infectious risk and possible pulmonary iatrogenic toxicity. Janus kinase inhibitors, namely, tofacitinib, baricitinib, and upadacitinib, are the latest drug class for the treatment of RA with a good safety profile. We present the case of a patient with RA-ILD successfully treated with tofacitinib. A 52-year-old man was referred to our multidisciplinary clinic for rheumatic and pulmonary diseases for an active erosive seropositive RA and progressive ILD. Previous treatments were GC, hydroxychloroquine, methotrexate, etanercept, withdrawn after ILD detection, and tocilizumab, discontinued due to relapsing infections. After our evaluation, we proposed rituximab in addition to low-dose GC and hydroxychloroquine, ineffective on joint involvement. Therefore, we proposed tofacitinib which allowed us to control joint involvement, stabilize ILD improving respiratory symptoms, and manage the frequent infectious episodes that occurred initially. The short half-life and rapid-acting of tofacitinib are two helpful characteristics regarding this aspect. Despite limited data from randomized trials and real-life, tofacitinib could represent a safe therapeutic option for RA-ILD patients. Longitudinal studies are required to confirm this encouraging report.

Conflict of interest statement

The authors declare no conflicts of interest.

Copyright © 2021 Caterina Vacchi et al.

Figures

Figure 1
Figure 1
Clinical course and therapeutic strategy. ILD: interstitial lung disease; MTX: methotrexate; ETA: etanercept; TCZ: tocilizumab; RTX: rituximab; VAS: Visual Analogue Scale; FVC: forced vital capacity; DLCO: diffusing capacity of the lung for carbon monoxide; RA: rheumatoid arthritis; CRP: C-reactive protein; RF: rheumatoid factor; ACPA: anticitrullinated protein antibodies; ANA: antinuclear antibodies; ENA: extractable nuclear antigen; ANCA: antineutrophil cytoplasmic antibodies; DAS-28: disease activity score on 28 joints.
Figure 2
Figure 2
Chest high-resolution computed tomography: November 2017 compared to last follow-up, September 2020. Reticular abnormalities, honeycombing aspects, and traction bronchiectasis compatible with usual interstitial pneumonia. Despite an initial progression, interstitial lung disease showed a substantial stability at the last follow-up.

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