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Screening for ILD in RA

Patients with rheumatoid arthritis (RA) with risk factors for interstitial lung disease (ILD) or pulmonary symptoms should be evaluated for ILD at baseline RA diagnosis1,2

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RISK FACTORS FOR DEVELOPMENT OF ILD NEED TO BE ASSESSED AT BASELINE RA DIAGNOSIS1,2

Up to 30% of RA patients are affected by ILD1,3-6

Risk factors for development of ILD in patients with RA
Age

  • >60 years7
Sex
Lifestyle
Serological
Clinical

  • Longer disease duration17

  • Higher disease activity1,11,18

  • Decreased functional status1,18

  • Presence of extra-articular manifestations (e.g. rhuematoid nodules)18

  • Elevated ESR15,18

 

Despite RA-ILD being common in patients in their 40s to 50s, patients aged >60 years are at increased risk of developing ILD5,7

  • For each 10-year age increase, the likelihood of ILD increases by 64%15

RA-ILD is approximately four times more common in men than in women.1,8

Smoking increases the risk of ILD in patients with RA,6,9 but it is important to note that RA-ILD can occur in non-smokers too.19

Positive serologies for either RF or anti-CCP antibody are significant predictors for development of ILD in patients with RA.6,10–14

 

 

RA PATIENTS WITH RISK FACTORS FOR ILD OR PRE-EXISTING PULMONARY SYMPTOMS AT BASELINE RA DIAGNOSIS SHOULD BE EVALUATED FOR ILD1,2

Early assessment for ILD using baseline PFTs and HRCT is reasonable to identify ILD in RA1

A history of smoking in a patient with RA-ILD should lead to investigation with a chest X-ray and spirometry in the first instance20

Listening for crackles on lung auscultation may be a useful screen for subclinical ILD in patients with RA, inviting comprehensive lung function assessment20,21

Suggested algorithm to identify RA-ILD in patients with RA1
Suggested algorithm to identify RA-ILD in patients with RA

Reprinted from Clinics in Chest Medicine, 40(3), Esposito, Thoracic Manifestations of Rheumatoid Arthritis, 545-560, ©2022, with permission from Elsevier.

Once you have reached a diagnosis, how should you manage your patients with RA-ILD?
Footnotes
  • CCP, cyclic citrullinated peptide; CT, computed tomography; CTD-ILD, connective tissue disease-associated interstitial lung disease; DLCO, diffusing capacity of the lung for carbon monoxide; ESR, erythrocyte sedimentation rate; HRCT, high-resolution computed tomography; ILD, interstitial lung disease; KL-6, Krebs von den Lungen-6; PFT, pulmonary function test; RA; rheumatoid arthritis; RA-ILD, rheumatoid arthritis-associated interstitial lung disease; RF, rheumatoid factor.

  1. Esposito AJ, Chu SG, Madan R, et al. Thoracic manifestations of rheumatoid arthritis. Clin Chest Med. 2019;40(3):545–560.

  2. Wallace B, Vummidi D, Khanna D. Management of connective tissue diseases associated interstitial lung disease: a review of the published literature. Curr Opin Rheumatol. 2016;28(3):236–245.

  3. Olson AL, Swigris JJ, Sprunger DB, et al. Rheumatoid arthritis-interstitial lung disease associated mortality. Am J Respir Crit Care Med. 2011;183(3):372-378.

  4. Geerts S, Wuyts W, De Langhe E, et al. Connective tissue disease associated interstitial pneumonia: a challenge for both rheumatologists and pulmonologists. Sarcoidosis Vasc Diffuse Lung Dis. 2017;34(4):326–335.

  5. Shaw M, Collins BF, Ho LA, Raghu G. Rheumatoid arthritis-associated lung disease. Eur Respir Rev. 2015;24(135):1–16.

  6. Kelly CA, Saravanan V, Nisar M, et al. Rheumatoid arthritis-related interstitial lung disease: associations, prognostic factors and physiological and radiological characteristics – a large multicentre UK study. Rheumatology (Oxford). 2014;53(9):1676–1682.

  7. Brito Y, Glassberg MK, Ascherman DP. Rheumatoid Arthritis-Associated Interstitial Lung Disease: Current Concepts. Curr Rheumatol Rep. 2017;19:79. doi: 10.1007/s11926-017-0701-5.

  8. Koo SM, Kim SY, Choi SM, et al. Korean guidelines for diagnosis and management of interstitial lung diseases: part 5. Connective tissue disease associated interstitial lung disease. Tuberc Respir Dis (Seoul). 2019;82(4):285–297.

  9. Gochuico BR, Avila NA, Chow CK, et al. Progressive preclinical interstitial lung disease in rheumatoid arthritis. Arch Intern Med. 2008;168(2):159–166.

  10. Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid arthritis. Respir Med. 2012;106(11):1591–1599.

  11. Habib HM, Eisa AA, Arafat WR, et al. Pulmonary involvement in early rheumatoid arthritis patients. Clin Rheumatol. 2011;30:217–221.

  12. Doyle TJ, Patel AS, Hatabu H, et al. Detection of rheumatoid arthritis–interstitial lung disease is enhanced by serum biomarkers. Am J Respir Crit Care Med. 2015;191(12):1403–1412.

  13. Giles JT, Danoff SK, Sokolove J, et al. Association of fine specificity and repertoire expansion of anticitrullinated peptide antibodies with rheumatoid arthritis associated interstitial lung disease. Ann Rheum Dis. 2014;73:1487–1494.

  14. Yin Y, Liang D, Zhao L, et al. Anti-cyclic citrullinated Peptide antibody is associated with interstitial lung disease in patients with rheumatoid arthritis. PLoS One. 2014;9(4):e92449.

  15. Koduri G, Norton S, Young A, et al. Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort. Rheumatology (Oxford). 2010; 49(8):1483–1489.

  16. Avouac J, Cauvet A, Steelandt A, et al. Improving risk-stratification of rheumatoid arthritis patients for interstitial lung disease. PLoS One. 2020;15(5):e0232978. doi:10.1371/journal.pone.0232978.

  17. Ha YJ, Lee YJ, Kang EH. Lung involvements in rheumatic diseases: update on the epidemiology, pathogenesis, clinical features, and treatment. Biomed Res Int. 2018:6930297.

  18. Bongartz T, Nannini C, Medina-Velasquez YF, et al. Incidence and mortality of interstitial lung disease in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2010;62(6):1583–1591.

  19. Ayhan-Ardic FF, Oken O, Yorgancioglu ZR, et al. Pulmonary involvement in lifelong non-smoking patients with rheumatoid arthritis and ankylosing spondylitis without respiratory symptoms. Clin Rheumatol. 2006;24:213–218.

  20. Lake F and Proudman S. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Respir Crit Care Med. 2014;35(2):222–238.

  21. Cottin V and Cordier JF. Subclinical interstitial lung disease: no place for crackles? Am J Respir Crit Care Med. 2012;186(3):289–290.

  22. Iqbal K and Kelly C. Treatment of rheumatoid arthritis-associated interstitial lung disease: a perspective review. Ther Adv Musculoskelet Dis. 2015;7(6):247–267.

  23. Cassone G, Manfredi A, Vacchi C, et al. Treatment of rheumatoid arthritis-associated interstitial lung disease: lights and shadows. J Clin Med. 2020;9(4):1082. doi: 10.3390/jcm9041082.

  24. Ryerson CJ, Cayou C, Topp F, et al. Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: a prospective cohort study. Respir Med. 2014;108(1):203-210. 

  25. Kreuter M, Bendstrup E, Russell A, et al. Palliative care in interstitial lung disease: living well. Lancet Respir Med. 2017;5(12):968-980. 

  26. Maher TM, Wuyts W. Management of Fibrosing Interstitial Lung Diseases. Adv Ther. 2019;doi:10.1007/s12325-019-00992-9. [Epub ahead of print]. 

  27. Sgalla G, Cerri S, Ferrari R, et al. Mindfulness-based stress reduction in patients with interstitial lung diseases: a pilot, single-centre observational study on safety and efficacy. BMJ Open Respir Res. 2015;2(1):e000065. 

  28. Wijsenbeek M, Cottin V. Spectrum of Fibrotic Lung Diseases. N Engl J Med. 2020;383:958–968.

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