From the Guidelines
Simponi is not the best choice for RA-ILD, as the 2024 ACR/CHEST guideline conditionally recommends against TNFi, including Simponi, as a first-line ILD treatment option. According to the guideline 1, for people with SARD-ILD, including RA-ILD, mycophenolate, azathioprine, rituximab, and cyclophosphamide are conditionally recommended as first-line ILD treatment options. The guideline also conditionally recommends against leflunomide, methotrexate, TNFi, and abatacept as first-line ILD treatment options for people with SARD-ILD.
Some key points to consider in the treatment of RA-ILD include:
- The use of glucocorticoids as a first-line ILD treatment for people with SARD-ILD other than SSc-ILD 1
- The consideration of tocilizumab as a first-line ILD treatment option for people with SSc-ILD and MCTD-ILD 1
- The conditional recommendation against nintedanib as a first-line ILD treatment option for people with SjD-ILD, IIM-ILD, and MCTD-ILD 1
- The lack of consensus on the use of nintedanib as a first-line ILD treatment option for people with RA-ILD 1
In clinical practice, the treatment of RA-ILD should be individualized based on the patient's specific disease activity, ILD severity, comorbidities, and previous treatment responses. Rituximab or other non-TNFi biologics may be preferred over Simponi due to their potential benefits for lung involvement and better safety profiles. Mycophenolate mofetil may also be considered as a steroid-sparing agent for the ILD component.
From the Research
Treatment Options for RA-ILD
- The available literature supports that methotrexate, leflunomide, abatacept, and rituximab play beneficial roles in the prevention and treatment of RA-ILD 2.
- Abatacept may be an effective and safe treatment for patients with RA-ILD, with significant improvement in DAS28ESR and a CS-sparing effect 3.
- There are no therapeutic recommendations for the treatment of RA-ILD, and therapeutic options are complicated by the possible pulmonary toxicity of many disease-modifying anti-rheumatic drugs (DMARDs) and their unclear efficacy on pulmonary disease 4.
Incidence and Complications of ILD
- The incidence of ILD in users of tocilizumab, rituximab, abatacept, and anti-tumor necrosis factor α agents has been investigated, with no significant differences in the risk of ILD and its complications between RA patients receiving anti-TNFα agents and those receiving alternate MOA agents 5.
- Recent methotrexate exposure was associated with reduced ILD hospitalization, whereas being male and having had a hospitalization for asthma or ILD/pneumonia in the 12 months prior to index were associated with increased hospitalization risk 5.
Prevalence and Risk Factors of RA-ILD
- RA-ILD is associated with worse physical function, lower quality of life, and increased mortality, and is comprised of heterogeneous subtypes characterized by inflammation and fibrosis 6.
- Novel RA-ILD risk factors include the MUC5B promotor variant, articular disease activity, autoantibodies, and biomarkers of damaged pulmonary parenchyma 6.
- Treatment should focus on controlling RA disease activity, which emerging data suggest may reduce RA-ILD risk, and immunomodulatory and antifibrotic drugs may also treat RA-ILD 6.
Simponi (Golimumab) in RA-ILD Treatment
- There is no direct evidence in the provided studies to support the use of Simponi (golimumab) as the best choice for RA-ILD treatment.