From the Guidelines
Rituximab is a conditionally recommended treatment option for rheumatoid arthritis-associated interstitial lung disease (RA-ILD), according to the 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline 1.
Key Considerations
- The guideline conditionally recommends mycophenolate, azathioprine, rituximab, and cyclophosphamide as first-line ILD treatment options for people with SARD-ILD, including RA-ILD 1.
- For patients with RA-ILD, rituximab is typically administered as an intravenous infusion of 1,000 mg given twice, two weeks apart, with courses repeated every 6 months.
- The medication has shown particular efficacy in stabilizing or improving lung function in RA-ILD patients, especially those with certain antibody profiles such as anti-CCP positivity.
- Rituximab works by depleting B cells, which play a key role in both the autoimmune process of RA and the inflammatory cascade that damages lung tissue in ILD.
Treatment Approach
- Before starting treatment, patients should undergo baseline pulmonary function tests, chest imaging, and screening for hepatitis B due to reactivation risk.
- Common side effects include infusion reactions, increased infection risk, and hypogammaglobulinemia with prolonged use.
- Alternative treatments for RA-ILD include mycophenolate mofetil, cyclophosphamide, or JAK inhibitors, and the optimal choice depends on individual factors including disease severity, comorbidities, and antibody status.
- Treatment decisions should be made through multidisciplinary discussion involving rheumatology and pulmonology expertise to tailor therapy to each patient's specific presentation, as emphasized in the guideline 1.
Patient-Specific Factors
- Patient- and disease-specific factors may lead to selection of a different treatment within the “menu of options” provided, and clinicians must retain the latitude to prescribe recommended medications based on individual patient factors and preferences 1.
- The guideline highlights the importance of shared decision-making, considering factors such as ILD severity, risk factors for progression, other disease manifestations, cost, and toxicity when choosing a medication within the range of recommended options.
From the Research
Treatment Options for RA-ILD
- Rituximab is one of the treatment options for Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD) 2, 3, 4, 5.
- The 2023 American College of Rheumatology/American College of Chest Physicians guideline conditionally recommends mycophenolate, azathioprine, and rituximab for first-line RA-ILD therapy 4.
- Studies have shown that rituximab can improve lung function and slow disease progression in patients with RA-ILD 2, 3.
Efficacy of Rituximab
- A study found that rituximab was associated with an improved trajectory in FVC and Dlco compared to the pretreatment pulmonary function trajectory 2.
- Another study found that rituximab appeared to be an acceptable therapeutic choice for patients with RA-ILD, with most patients remaining stable or improved after treatment 3.
- Rituximab has been shown to be effective in combination with methotrexate for the treatment of RA, with improvements in symptoms and prevention of disease progression 6.
Comparison with Other Treatments
- The efficacy of rituximab compared to other treatments, such as mycophenolate and azathioprine, is not well established 2, 4.
- Antifibrotic medications, such as nintedanib and pirfenidone, may be effective in slowing forced vital capacity decline in RA-ILD, particularly in patients with a usual interstitial pneumonia pattern 4, 5.
- Further research is needed to determine the optimal treatment strategy for RA-ILD and to compare the efficacy of different treatments 4, 5.