Management issues in rheumatoid arthritis-associated interstitial lung disease

Abstract

Purpose of review: Summarize recent evidence on the identification and management of rheumatoid arthritis-associated interstitial lung disease (RA-ILD).

Recent findings: Clinical and subclinical interstitial lung disease (ILD) are frequent extra-articular manifestations of rheumatoid arthritis (RA). Better means of identifying and treating RA-ILD are needed to improve the prognosis, with a median survival of only 3-7 years after diagnosis. Several serum biomarkers are currently being evaluated for their ability to detect RA-ILD. Thorough evaluation and multidisciplinary discussion remains the gold standard for establishing the diagnosis of RA-ILD. Management is challenging with most RA disease-modifying antirheumatic drugs (DMARDs) linked to pneumonitis. Methotrexate is typically avoided in clinically significant ILD, although alternative therapies including leflunomide and biologic DMARDs also carry risks in RA-ILD. Antifibrotics appear to slow the progression of ILD, and a large phase II trial exclusively in RA-ILD is underway. In addition, smoking cessation, pulmonary rehabilitation, oxygen therapy, managing comorbidities, and lung transplantation evaluation are vital to improving patient outcomes in RA-ILD.

Summary: With little high-quality evidence to guide the management of RA-ILD, multidisciplinary teams with expertise in RA-ILD are highly valuable for diagnosing and treating RA-ILD. Clinical and translational research in RA-ILD is needed to fill the many evidence gaps.

Conflict of interest statement

Conflicts of interest: None

Figures

Figure 1.. Approach to the identification of rheumatoid arthritis-associated interstitial lung disease.

The initial presentation of rheumatoid arthritis (RA) or interstitial lung disease (ILD) should prompt evaluation for other signs and symptoms attributable to RA-ILD. Testing for pulmonary and articular manifestations followed by multidisciplinary discussion can establish the diagnosis of RA-ILD. Abbreviations: CT = computed tomography, DLCO = diffusing capacity for carbon monoxide, MRI = magnetic resonance imaging, US = ultrasound

Figure 2.. Approach to the management of rheumatoid arthritis-associated interstitial lung disease.

Management of rheumatoid arthritis-interstitial lung disease (RA-ILD) begins by assessing severity and risk for progression. All patients should receive non-pharmacologic therapies. Those with clinically significant RA-ILD may have their RA disease-modifying therapies adjusted and consideration given to other immunomodulatory therapies and glucocorticoids. If progression occurs despite these therapies, anti-fibrotics and alternative immunomodulatory therapies should be considered. Abbreviations: AZA = azathioprine, COPD = chronic obstructive pulmonary disease, DLCO = diffusing capacity for carbon monoxide, DMARD = disease-modifying anti-rheumatic drug, FVC = forced vital capacity, GERD = gastroesophageal reflux disease, HRCT = high-resolution computed tomography, MMF = mycophenolate mofetil, OSA = obstructive sleep apnea, PFT = pulmonary function tests, TNFi = tumor necrosis factor inhibitor