From the Guidelines
The initial treatment approach for patients with Rheumatoid Arthritis (RA) interstitial lung disease (ILD) should prioritize immunosuppressive therapy, with rituximab being a preferred option, particularly in patients with active inflammatory arthritis, as it may provide benefits for reducing disease activity and potentially improving ILD outcomes, as suggested by the 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline 1. The treatment approach for RA-ILD is complex and requires individualization based on the specific ILD pattern, disease severity, and progression rate.
- Key considerations include:
- The use of glucocorticoids, which should be considered separately from other treatments, and may be used in the short-term, but long-term use should be avoided due to potential adverse effects 1.
- The selection of disease-modifying antirheumatic drugs (DMARDs), such as mycophenolate mofetil or azathioprine, which may be used in combination with glucocorticoids or as an alternative to them.
- The potential benefits and risks of biologic agents, such as rituximab, which may be beneficial in certain cases, particularly when other treatments fail.
- Supportive care measures, including supplemental oxygen, pulmonary rehabilitation, and vaccination against pneumococcal disease and influenza, are also important components of management. The rationale for immunosuppressive therapy is to target the underlying autoimmune inflammation driving the lung injury, while balancing the risks of medication side effects and infections, as emphasized by the ACR/CHEST guideline 1.
- Co-management with pulmonologists is advised for initiation of ILD treatment, particularly to determine the need for treatment in asymptomatic patients with stable and mild ILD.
- Patient preferences and values should be taken into account when making treatment decisions, and shared decision-making is crucial when choosing a medication within the range of recommended options 1.
From the Research
Initial Treatment Approach for RA-ILD
The initial treatment approach for patients with Rheumatoid Arthritis (RA) interstitial lung disease (ILD) is a complex issue, with various studies providing insights into the management of this condition.
- The use of methotrexate in RA-ILD is controversial, but some studies suggest that it may be associated with improved survival 2.
- Glucocorticoids and conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate or leflunomide, as well as treatment with biologic DMARDs, can be effective in managing RA-ILD 3.
- There is limited evidence that rituximab, abatacept, and tocilizumab are better options compared to TNF-inhibitors 3.
- The management of RA-ILD requires a multidisciplinary and individualized approach, taking into account the severity and progression of articular and lung disease, risk factors for the progression of RA-ILD, and the patient's preferences 4.
- Antifibrotic agents may have a possible future role in the treatment of RA-ILD, given the similarities between RA-ILD and idiopathic pulmonary fibrosis 5.
Treatment Options
Treatment options for RA-ILD are complicated by the possible pulmonary toxicity of many disease-modifying anti-rheumatic drugs (DMARDs) and by their unclear efficacy on pulmonary disease.
- Joint and lung involvement should be evaluated independently of each other for treatment purposes 5.
- Methotrexate is recommended as the first-line treatment of RA, but its role in lung disease is contentious 6.
- A correct understanding of the complex pulmonary disease processes in RA is crucial to improve outcomes in this patient group 6.
Key Considerations
Key considerations in the treatment of RA-ILD include:
- The severity and progression of articular and lung disease 4.
- Risk factors for the progression of RA-ILD, such as older age, worse lung function, and a usual interstitial pneumonia pattern on high-resolution computed tomography 4.
- The patient's preferences and the need for a multidisciplinary approach 4.