How to manage rheumatoid arthritis (RA) treatment in a patient who develops pneumonia?

Management of Rheumatoid Arthritis Treatment in Patients with Pneumonia

For patients with rheumatoid arthritis who develop pneumonia, DMARDs should be temporarily paused until the pneumonia resolves, with decisions made on a case-by-case basis depending on the severity of pneumonia and the specific DMARD being used. 1

Assessment and Initial Management

Pneumonia Evaluation

• Obtain lower respiratory tract cultures before initiating antibiotics (but do not delay therapy in critically ill patients) 1
• Either semiquantitative or quantitative culture data can be used for management 1
• Follow local treatment protocols for pneumonia as determined by treating experts 1
• Consider both hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) protocols depending on where the infection was acquired 1

DMARD Management During Pneumonia

Conventional DMARDs

• Methotrexate: Temporarily pause during active pneumonia due to potential immunosuppressive effects 1, 2
• Leflunomide: Consider temporary discontinuation as it has been associated with increased pneumonia risk (HR 1.2) 3
• Sulfasalazine: May be safer to continue as it has not shown increased pneumonia risk (HR 0.7) 3

Biological DMARDs

• TNF inhibitors (adalimumab, etanercept, infliximab):
  • Temporarily discontinue during active infection 1, 4
  • Can generally be resumed after pneumonia resolution 1
  • Note that etanercept and other TNF inhibitors have not shown increased pneumonia risk in some studies 3

JAK Inhibitors and IL-6 Inhibitors

• Temporarily discontinue during active pneumonia 1
• Important caution: IL-6 inhibitors like tocilizumab can mask early symptoms of pneumonia by suppressing inflammatory markers 5
  • Patients may present with minimal symptoms and modest CRP elevation despite severe infection 5

Glucocorticoids

• Low-dose glucocorticoids: Consider continuing if patient is on chronic therapy to prevent adrenal insufficiency 1
• Be aware: Even low-dose prednisone increases pneumonia risk in a dose-dependent manner 3:
  • ≤5 mg/day: HR 1.4

  • 5-10 mg/day: HR 2.1

  • 10 mg/day: HR 2.3

Special Considerations

Pneumocystis Jirovecii Pneumonia (PJP)

• Consider PJP prophylaxis in RA patients on cyclophosphamide or glucocorticoids 1
• PJP in RA patients may have higher mortality rates than in non-RA patients, especially with pre-existing lung disease 6
• PJP can be confused with COVID-19 pneumonia or other types of pneumonia 1

Interstitial Lung Disease (ILD)

• Be vigilant for RA-ILD which can complicate pneumonia management 7, 8
• Pneumonia may trigger progression of pre-existing ILD in RA patients 6
• Consider HRCT for RA patients with persistent respiratory symptoms after pneumonia resolution 1

Resuming RA Treatment After Pneumonia

When to Resume Treatment

• Resume DMARDs when the patient meets criteria for clinical stability:
  • Improvement in cough and dyspnea
  • Afebrile (≤100°F) on two occasions 8 hours apart
  • Decreasing white blood cell count
  • Functioning gastrointestinal tract with adequate oral intake 1

Monitoring After Resumption

• Schedule follow-up within 3-6 months to assess disease activity 2
• Monitor for recurrent infections or respiratory symptoms 2
• Consider PFTs if there is concern for residual lung disease or RA-ILD 1

Common Pitfalls to Avoid

• Failure to recognize masked pneumonia symptoms in patients on IL-6 inhibitors or other biologics that suppress inflammatory markers 5
• Continuing high-risk DMARDs during active pneumonia, which may worsen outcomes 1
• Overlooking drug-induced lung disease that may mimic infectious pneumonia 7
• Not considering PJP in immunosuppressed RA patients with pneumonia 6
• Assuming all DMARDs carry equal risk - prednisone dose-dependently increases pneumonia risk, while some TNF inhibitors and methotrexate may not 3

By following these guidelines, clinicians can appropriately manage RA treatment during pneumonia episodes while minimizing risks to patient outcomes.