Can Rheumatoid Arthritis (RA) cause pulmonary damage?

From the Guidelines

Yes, rheumatoid arthritis (RA) can cause lung damage, specifically interstitial lung disease (ILD), which is a significant cause of morbidity and mortality in people with systemic autoimmune rheumatic diseases. This occurs because RA is a systemic autoimmune disease that can affect organs beyond the joints, including the lungs. About 10-20% of RA patients develop clinically significant lung complications, with ILD being one of the most common forms of lung involvement, causing scarring of lung tissue 1. Certain risk factors increase the likelihood of lung complications, including being male, smoking, having longstanding or severe RA, and specific genetic factors. Symptoms may include shortness of breath, persistent cough, chest pain, and fatigue.

Diagnosis and Screening

The diagnosis of ILD in RA patients typically involves pulmonary function tests (PFTs), including spirometry and diffusing capacity for carbon monoxide (DLCO), as well as chest radiograph and high-resolution computed tomography (HRCT) 1. The expert panel recommends that all patients diagnosed with RA should be screened for ILD using PFTs and chest radiograph, with additional diagnostic tools such as HRCT and screening for high-risk or symptomatic patients.

Treatment and Management

Treatment typically involves managing the underlying RA with disease-modifying antirheumatic drugs (DMARDs) like methotrexate, biologics such as TNF inhibitors, or newer medications like JAK inhibitors. However, some RA medications, particularly methotrexate, can occasionally cause lung problems themselves, requiring careful monitoring 1. The 2023 ACR guidelines conditionally recommend adding the antifibrotic treatment nintedanib or pirfenidone as therapeutic options for the management of progressive RA-ILD despite first-line treatment.

Monitoring and Follow-up

Regular lung function tests and chest imaging may be recommended for RA patients, especially those with respiratory symptoms or high-risk factors. The proposed algorithm for ILD diagnosis at baseline and during follow-up includes annual PFTs, HRCT every 2 years, and repeat HRCT if PFTs are abnormal 1. This approach allows for early detection and management of ILD, which is essential for improving outcomes in RA patients.

From the FDA Drug Label

The COPD patients treated with ORENCIA for RA developed adverse events more frequently than those treated with placebo (97% vs 88%, respectively)

The FDA drug label does not directly answer the question of whether Rheumatoid Arthritis (RA) can cause pulmonary damage. However, it does mention that COPD patients with RA may develop more frequent respiratory adverse reactions. This suggests that RA patients with pre-existing pulmonary conditions may be at a higher risk for pulmonary complications, but it does not directly address whether RA can cause pulmonary damage in the absence of pre-existing conditions 2.

From the Research

Pulmonary Damage in Rheumatoid Arthritis (RA)

• Rheumatoid arthritis (RA) is a systemic inflammatory disorder that can cause extra-articular manifestations, including lung involvement 3, 4, 5, 6, 7.
• The most common pulmonary manifestations of RA include interstitial lung disease (ILD), pleural effusion, cricoarytenoiditis, constrictive or follicular bronchiolitis, bronchiectasis, pulmonary vasculitis, and pulmonary hypertension 3, 4, 6.
• RA-ILD is a leading cause of death in patients with RA and is associated with significant morbidity and mortality 3, 5, 7.
• The lungs are one of the most common extra-articular organs involved in RA, with up to 60% to 80% of RA patients experiencing lung involvement 5.
• Respiratory complications are the second leading cause of death due to RA 5.

Diagnosis and Management of RA-ILD

• Patients with RA should be regularly examined for symptoms of pulmonary involvement, and an X-ray examination of thoracic organs is obligatory before initiation of basic pharmacological treatment 4.
• Extended diagnostic procedures, including lung function testing and high-resolution computed tomography (CT), should be performed in cases of suspicious clinical or radiological findings 4.
• The optimal pharmacological treatment of RA-ILD is not sufficiently clarified, but methotrexate (MTX) has been shown to have a positive effect on mild to moderate courses of RA-ILD 4.
• Tumor necrosis factor (TNF) blockers should be avoided in patients with clinically relevant RA-ILD, as they can cause dramatic deterioration of pulmonary function 4.
• Close collaboration between pulmonologists and rheumatologists is essential for the management of RA-ILD 4.