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Hyldgaard C, Harders S, Blegvad J, Herly M, Masic D, Sofíudóttir BK, Urbonaviciene G, Andersen FD, Isaksen C, Løgstrup B, Ellingsen T. Clinical and preclinical pulmonary disease in newly diagnosed rheumatoid arthritis: a two-year follow-up study. Scand J Rheumatol 2023; 52:601-608. [PMID: 37066633 DOI: 10.1080/03009742.2023.2194105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 03/20/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Pulmonary disease is a major cause of excess mortality among patients with rheumatoid arthritis (RA). Interstitial lung disease (ILD) is a feared complication, but the benefit of screening is unknown. The aim of this study was to assess the frequency of pulmonary disease, including ILD, in early RA. METHOD Patients with newly diagnosed RA were recruited prospectively at a single centre and underwent systematic pulmonary function tests (PFTs) and computed tomography (CT) scans at inclusion and after two years. RESULTS The study included 150 patients (mean age 57 years, 63% female; 59% current or former smokers). Of these, 136 underwent baseline PFTs and 137 CT. Mean forced expiratory volume in one second was 99% predicted and forced vital capacity 106%. Mean diffusing capacity of the lungs for carbon monoxide (DLCO) was 84% predicted. Frequently detected CT abnormalities were pulmonary nodules (42%), bronchiectasis (29%), and emphysema (20%). Two patients had clinically significant ILD and six had mild reticulation suggestive of preclinical ILD. No ILD progression was identified at two-year follow-up. Smoking was associated with DLCO<80% (p=0.004), combined hyperinflation and diffusion impairment (residual volume>120% and DLCO<80%) (p=0.004), and visual emphysema on CT (p<0.001). CONCLUSION Emphysema and bronchiectasis were common, but most patients had mild disease with preserved lung function. Preclinical or clinical ILD was seen in a minority in this early phase of RA. These findings suggest symptom-based screening and primary intervention focusing on smoking cessation rather than screening for ILD at the time of RA diagnosis.
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Affiliation(s)
- C Hyldgaard
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
| | - S Harders
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - J Blegvad
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
| | - M Herly
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - D Masic
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - B K Sofíudóttir
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - G Urbonaviciene
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
| | - F D Andersen
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
| | - C Isaksen
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
| | - B Løgstrup
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Ellingsen
- Diagnostic Center, Silkeborg Regional Hospital, University Clinic for Innovative Patient Pathways, Aarhus University, Silkeborg, Denmark
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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Diesler R, Cottin V. Pulmonary fibrosis associated with rheumatoid arthritis: from pathophysiology to treatment strategies. Expert Rev Respir Med 2022; 16:541-553. [PMID: 35695895 DOI: 10.1080/17476348.2022.2089116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is the most common inflammatory autoimmune disease, characterised by symmetric destructive arthritis and synovitis. Lung involvement is frequent, including in the form of interstitial lung disease (ILD). RA-ILD often presents with a radiologic and pathologic pattern of usual interstitial pneumonia, similar to idiopathic pulmonary fibrosis, highlighting the similarities between the two diseases, but other patterns and pathological associations are described. AREAS COVERED This article reviews the pathogenesis of pulmonary fibrosis in the setting of rheumatoid arthritis as well as the current and future therapeutic options. EXPERT OPINION Pulmonary fibrosis in the setting of RA-ILD is an example of genotype-environment interaction and involves multiple mechanisms including autoimmunity, inflammation and fibrogenesis. Despite that ILD conveys most of the exceeding mortality in RA patients, there are no official guidelines for the management of RA-ILD. Attention should be paid to potential lung toxicity of RA treatment even though some of them might help stabilise the ILD. Current standard of care is often composed of glucocorticoids that may be associated with immunosuppressive therapy. Following the approval of antifibrotic therapy for ILDs with a progressive fibrosing phenotype, current works are evaluating the benefit of such treatment in RA-ILD.
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Affiliation(s)
- Rémi Diesler
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, University of Lyon, INRAE, Lyon, France
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Laria A, Lurati AM, Zizzo G, Zaccara E, Mazzocchi D, Re KA, Marrazza M, Faggioli P, Mazzone A. Interstitial Lung Disease in Rheumatoid Arthritis: A Practical Review. Front Med (Lausanne) 2022; 9:837133. [PMID: 35646974 PMCID: PMC9136053 DOI: 10.3389/fmed.2022.837133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disease, which primarily causes symmetric polyarthritis. An extrarticolar involvement is common, and the commonly involved organ is lungs. Although cardiac disease is responsible for most RA-related deaths, pulmonary disease is also a major contributor, accounting for ~10-20% of all mortality. Pulmonary disease is a common (60-80% of patients with RA) extra-articular complication of RA. Optimal screening, diagnostic, and treatment strategies of pulmonary disease remain uncertain, which have been the focus of an ongoing investigation. Clinicians should regularly assess patients with RA for the signs and symptoms of pulmonary disease and, reciprocally, consider RA and other connective tissue diseases when evaluating a patient with pulmonary disease of an unknown etiology. RA directly affects all anatomic compartments of the thorax, including the lung parenchyma, large and small airways, pleura, and less commonly vessels. In addition, pulmonary infection and drug-induced lung disease associated with immunosuppressive agents used for the treatment of RA may occur.
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Affiliation(s)
- Antonella Laria
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | | | - Gaetano Zizzo
- Asst Ovest Milanese–Internal Medicine Department, Cuggiono Hospital, Milan, Italy
| | - Eleonora Zaccara
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
| | - Daniela Mazzocchi
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | - Katia Angela Re
- Asst Ovest Milanese–Rheumatology Unit, Magenta Hospital, Milan, Italy
| | | | - Paola Faggioli
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
| | - Antonino Mazzone
- Asst Ovest Milanese–Internal Medicine Unit, Legnano Hospital, Milan, Italy
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4
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Lee H, Lee SI, Kim HO. Recent Advances in Basic and Clinical Aspects of Rheumatoid Arthritis-associated Interstitial Lung Diseases. JOURNAL OF RHEUMATIC DISEASES 2022; 29:61-70. [PMID: 37475899 PMCID: PMC10327618 DOI: 10.4078/jrd.2022.29.2.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 07/22/2023]
Abstract
Rheumatoid arthritis (RA) is a common autoimmune disease that mainly affects the joints and systemic organs, such as the skin, eyes, heart, gastrointestinal tract, and lungs. In particular, among various pulmonary involvements, interstitial lung disease (ILD) is closely related to the selection of anti-rheumatic drugs and the long-term prognosis of patients with RA. Although the exact pathogenesis of RA-ILD is not well defined, several mechanistic pathways, similar to those of idiopathic pulmonary fibrosis, have been elucidated recently. Conversely, RA-related autoantibodies, including anti-cyclic citrullinated peptide antibody, are detectable in circulation and in the lungs, even in the absence of articular symptoms. RA-ILD can also predate years before the occurrence of joint symptoms. This evidence supports the fact that local dysregulated mucosal immunity in the lung causes systemic autoimmunity, resulting in clinically evident polyarthritis of RA. Because the early diagnosis of RA-ILD is important, imaging tests, such as computed tomography and pulmonary function tests, are being used for early diagnosis, but there is no clear guideline for the early diagnosis of RA-ILD and selection of optimal disease-modifying anti-rheumatic drugs for the treatment of patients with RA with ILD. In addition, the efficacy of nintedanib, a new anti-fibrotic agent, for RA-ILD treatment, has been investigated recently. This review collectively discusses the basic and clinical aspects, such as pathogenesis, animal models, diagnosis, and treatment, of RA-ILD.
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Affiliation(s)
- Hanna Lee
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sang-Il Lee
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyun-Ok Kim
- Division of Rheumatology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
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夏 芳, 鲁 芙, 吕 慧, 杨 国, 刘 媛. [Clinical characteristics and related factors of systemic lupus erythematosus with interstitial pneumonia]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:266-272. [PMID: 33879896 PMCID: PMC8072446 DOI: 10.19723/j.issn.1671-167x.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate the clinical features, radiologic scores and clinically relevant risk factors prognosis of secondary interstitial lung disease (ILD) in patients with systemic lupus erythematosus (SLE). METHODS In this study, 60 SLE patients in Department of Rheumatology of the First Affiliated Hospital of Baotou Medical College and Taizhou First People's Hospital from January 2015 to March 2019 were retrospectively analyzed. All of those 60 patients with SLE underwent lung high resolution computed tomography (HRCT) examination. We used a 1 ∶1 case-control study. There was a matching of age and gender between the two groups. Thirty patients with SLE related ILD (SLE-ILD) were in the case group, and 30 patients with SLE without ILE (SLE non-ILD) were in the control group. The clinical features, pulmonary function test, radiologic characteristic of SLE patients were collected and were used to analyze SLE-ILD. RESULTS In this study, we reached the following conclusions: First, there were statistically significant differences in chest tightness/shortness of breath, Raynaud's phenomenon, and Velcro rale between SLE-ILD and SLE non-ILD patients (both P < 0.05); Second, hemoglobin (Hb) and albumin (ALB) in the patients of SLE-ILD had a significant decrease compared with the patients of SLE non-ILD. Blood urea nitrogen (BUN), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) increased in SLE-ILD patients compared with SLE non-ILD patients, the difference had statistical significance (P < 0.05); Third, for SLE-ILD patients, the most common type was non-specific interstitial pneumonia (NSIP), followed by usual interstitial pneumonia and lymphocytic interstitial pneumonia; Fourth, there was no significant difference in clinical-radiology-physiology scores between the different ILD types (P>0.05), similarly, the lung HRCT score and lung function between different ILD types had no significant difference (P>0.05); Fifth, multivariate Logistic regression analysis showed that decreased albumin and chest tightness/shortness of breath might be the risk factor for SLE-ILD. CONCLUSION There are statistically significant differences between the SLE-ILD group and SLE non-ILD group in terms of chest tightness/shortness of breath, Velcro rale and Raynaud's phenomenon. Decreased albumin and chest tightness/shortness of breath in SLE patients should be alerted to the occurrence of ILD. NSIP is the most common manifestation of SLE-ILD.
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Affiliation(s)
- 芳芳 夏
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 芙爱 鲁
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 慧敏 吕
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 国安 杨
- 内蒙古科技大学包头医学院第一附属医院中心试验室,内蒙古自治区包头 014010Central Laboratory, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 媛 刘
- 台州市第一人民医院风湿免疫科,浙江台州 318000Department of Rheumatology, Taizhou First People's Hospital, Taizhou 318000, Zhejiang, China
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6
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夏 芳, 鲁 芙, 吕 慧, 杨 国, 刘 媛. [Clinical characteristics and related factors of systemic lupus erythematosus with interstitial pneumonia]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:266-272. [PMID: 33879896 PMCID: PMC8072446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To investigate the clinical features, radiologic scores and clinically relevant risk factors prognosis of secondary interstitial lung disease (ILD) in patients with systemic lupus erythematosus (SLE). METHODS In this study, 60 SLE patients in Department of Rheumatology of the First Affiliated Hospital of Baotou Medical College and Taizhou First People's Hospital from January 2015 to March 2019 were retrospectively analyzed. All of those 60 patients with SLE underwent lung high resolution computed tomography (HRCT) examination. We used a 1 ∶1 case-control study. There was a matching of age and gender between the two groups. Thirty patients with SLE related ILD (SLE-ILD) were in the case group, and 30 patients with SLE without ILE (SLE non-ILD) were in the control group. The clinical features, pulmonary function test, radiologic characteristic of SLE patients were collected and were used to analyze SLE-ILD. RESULTS In this study, we reached the following conclusions: First, there were statistically significant differences in chest tightness/shortness of breath, Raynaud's phenomenon, and Velcro rale between SLE-ILD and SLE non-ILD patients (both P < 0.05); Second, hemoglobin (Hb) and albumin (ALB) in the patients of SLE-ILD had a significant decrease compared with the patients of SLE non-ILD. Blood urea nitrogen (BUN), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) increased in SLE-ILD patients compared with SLE non-ILD patients, the difference had statistical significance (P < 0.05); Third, for SLE-ILD patients, the most common type was non-specific interstitial pneumonia (NSIP), followed by usual interstitial pneumonia and lymphocytic interstitial pneumonia; Fourth, there was no significant difference in clinical-radiology-physiology scores between the different ILD types (P>0.05), similarly, the lung HRCT score and lung function between different ILD types had no significant difference (P>0.05); Fifth, multivariate Logistic regression analysis showed that decreased albumin and chest tightness/shortness of breath might be the risk factor for SLE-ILD. CONCLUSION There are statistically significant differences between the SLE-ILD group and SLE non-ILD group in terms of chest tightness/shortness of breath, Velcro rale and Raynaud's phenomenon. Decreased albumin and chest tightness/shortness of breath in SLE patients should be alerted to the occurrence of ILD. NSIP is the most common manifestation of SLE-ILD.
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Affiliation(s)
- 芳芳 夏
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 芙爱 鲁
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 慧敏 吕
- 内蒙古科技大学包头医学院第一附属医院风湿免疫科,内蒙古自治区包头 014010Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 国安 杨
- 内蒙古科技大学包头医学院第一附属医院中心试验室,内蒙古自治区包头 014010Central Laboratory, First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou 014010, Inner Mongolia, China
| | - 媛 刘
- 台州市第一人民医院风湿免疫科,浙江台州 318000Department of Rheumatology, Taizhou First People's Hospital, Taizhou 318000, Zhejiang, China
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Wang R, Sun Y, Jin X, Wen W, Cao Y. Diosgenin Inhibits Excessive Proliferation and Inflammatory Response of Synovial Fibroblasts in Rheumatoid Arthritis by Targeting PDE3B. Inflammation 2020; 44:946-955. [PMID: 33237390 DOI: 10.1007/s10753-020-01389-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 12/01/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammation that can lead to loss of range of joint abnormalities in severe cases. Diosgenin has anti-inflammatory effects. This paper discussed the effect and mechanism of diosgenin on excessive proliferation and inflammatory response of synovial cells in RA. CCK-8 detected the cell viability, TUNEL assay detected the apoptosis of cells and western blot detected the expression of apoptosis-related proteins. Wound healing was used to detect cell migration and western blot detected the expression of migration-related proteins. ELISA kits were used to detect the levels of inflammatory cytokines in cells. Diosgenin can inhibit the proliferation and migration of RA synovial cells. At the same time, diosgenin could reduce the inflammatory response of RA synovial cells, during which the expression of PDE3B was significantly decreased. By overexpressing PDE3B, we found that diosgenin inhibited the proliferation, migration, and inflammatory response of RA synovial cells by downregulating PDE3B. Diosgenin can inhibit excessive proliferation and inflammatory response of synovial fibroblasts by targeting PDE3B.
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Affiliation(s)
- Roujun Wang
- Department of Diabetes and Endocrinology, Kunming Municipal Hospital of Traditional Chinese Medicine, Kunming, 650500, Yunnan, China
| | - Yumeng Sun
- Department of Diabetes and Endocrinology, Affiliated Traditional Chinese Medicine Hospital of Nantong University, 41 Jianshe Road, Nantong City, 226001, Jiangsu, China
| | - Xiaowen Jin
- Department of Diabetes and Endocrinology, Affiliated Traditional Chinese Medicine Hospital of Nantong University, 41 Jianshe Road, Nantong City, 226001, Jiangsu, China
| | - Weibo Wen
- Department of Diabetes and Endocrinology, The No.1 Affiliated Hospital of Yunnan University of Traditional Chinese Medicine, Kunming, 650021, Yunnan, China
| | - Yongjun Cao
- Department of Diabetes and Endocrinology, Affiliated Traditional Chinese Medicine Hospital of Nantong University, 41 Jianshe Road, Nantong City, 226001, Jiangsu, China.
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Manfredi A, Cassone G, Furini F, Gremese E, Venerito V, Atzeni F, Arrigoni E, Della Casa G, Cerri S, Govoni M, Petricca L, Iannone F, Salvarani C, Sebastiani M. Tocilizumab therapy in rheumatoid arthritis with interstitial lung disease: a multicentre retrospective study. Intern Med J 2020; 50:1085-1090. [DOI: 10.1111/imj.14670] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/29/2019] [Accepted: 10/20/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Andreina Manfredi
- Rheumatology Unit University of Modena and Reggio Emilia, Univeritary Hospital Policlinico of Modena Modena Italy
| | - Giulia Cassone
- Rheumatology Unit University of Modena and Reggio Emilia, Univeritary Hospital Policlinico of Modena Modena Italy
- Clinical and Experimental Medicine PhD Program University of Modena and Reggio Emilia Modena Italy
- Rheumatology Unit IRCCS Arcispedale Santa Maria Nuova, Universitary Hospital Policlinico of Modena Reggio Emilia Italy
| | - Federica Furini
- Department of Medical Sciences, Division of Rheumatology Santa Anna University Hospital Ferrara Italy
| | - Elisa Gremese
- Division of Rheumatology, Institute of Rheumatology Catholic University of the Sacred Heart Rome Italy
| | | | | | - Eugenio Arrigoni
- Rheumatology Unit ERI Medicine, Hospital of Piacenza Piacenza Italy
| | | | - Stefania Cerri
- Respiratory Disease Unit University of Modena and Reggio Emilia, Universitary Hospital Policlinico of Modena Modena Italy
| | - Marcello Govoni
- Department of Medical Sciences, Division of Rheumatology Santa Anna University Hospital Ferrara Italy
| | - Luca Petricca
- Division of Rheumatology, Institute of Rheumatology Catholic University of the Sacred Heart Rome Italy
| | | | - Carlo Salvarani
- Rheumatology Unit University of Modena and Reggio Emilia, Univeritary Hospital Policlinico of Modena Modena Italy
- Rheumatology Unit IRCCS Arcispedale Santa Maria Nuova, Universitary Hospital Policlinico of Modena Reggio Emilia Italy
| | - Marco Sebastiani
- Rheumatology Unit University of Modena and Reggio Emilia, Univeritary Hospital Policlinico of Modena Modena Italy
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Identification of Subclinical Lung Involvement in ACPA-Positive Subjects through Functional Assessment and Serum Biomarkers. Int J Mol Sci 2020; 21:ijms21145162. [PMID: 32708286 PMCID: PMC7404103 DOI: 10.3390/ijms21145162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 12/23/2022] Open
Abstract
Lung involvement is related to the natural history of anti-citrullinated proteins antibodies (ACPA)-positive rheumatoid arthritis (RA), both during the pathogenesis of the disease and as a site of disease-related injury. Increasing evidence suggests that there is a subclinical, early lung involvement during the course of the disease, even before the onset of articular manifestations, which can potentially progress to a symptomatic interstitial lung disease. To date, reliable, non-invasive markers of subclinical lung involvement are still lacking in clinical practice. The aim of this study is to evaluate the diagnostic potential of functional assessment and serum biomarkers in the identification of subclinical lung involvement in ACPA-positive subjects. Fifty ACPA-positive subjects with or without confirmed diagnosis of RA (2010 ARC-EULAR criteria) were consecutively enrolled. Each subject underwent clinical evaluation, pulmonary function testing (PFT) with assessment of diffusion lung capacity for carbon monoxide (DLCO), cardiopulmonary exercise testing (CPET), surfactant protein D (SPD) serum levels dosage and high-resolution computed tomography (HRCT) of the chest. The cohort was composed of 21 ACPA-positive subjects without arthritis (ND), 10 early (disease duration < 6 months, treatment-naïve) RA (ERA) and 17 long-standing (disease duration < 36 months, on treatment) RA (LSRA). LSRA patients had a significantly higher frequency of overall HRCT abnormalities compared to the other groups (p = 0.001). SPD serum levels were significantly higher in ACPA-positive subjects compared with healthy controls (158.5 ± 132.3 ng/mL vs 61.27 ± 34.11 ng/mL; p < 0.0001) and showed an increasing trend from ND subjects to LSRD patients (p = 0.004). Patients with HRCT abnormalities showed significantly lower values of DLCO (74.19 ± 13.2% pred. vs 131.7 ± 93% pred.; p = 0.009), evidence of ventilatory inefficiency at CPET and significantly higher SPD serum levels compared with subjects with no HRCT abnormalities (213.5 ± 157.2 ng/mL vs 117.7 ± 157.3 ng/mL; p = 0.018). Abnormal CPET responses and higher SPD levels were also associated with specific radiological findings. Impaired DLCO and increased SPD serum levels were independently associated with the presence of HRCT abnormalities. Subclinical lung abnormalities occur early in RA-associated autoimmunity. The presence of subclinical HRCT abnormalities is associated with several functional abnormalities and increased SPD serum levels of SPD. Functional evaluation through PFT and CPET, together with SPD assessment, may have a diagnostic potential in ACPA-positive subjects, contributing to the identification of those patients to be referred to HRCT scan.
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Gautam M, Masood MJ, Arooj S, Mahmud MEH, Mukhtar MU. Rheumatoid Arthritis Related Interstitial Lung Disease: Patterns of High-resolution Computed Tomography. Cureus 2020; 12:e6875. [PMID: 32181104 PMCID: PMC7053681 DOI: 10.7759/cureus.6875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background and aim Rheumatoid arthritis (RA) is a chronic inflammatory systemic disease characterized by bilateral involvement of mostly small joints of hands and feet. There can be various extra-articular manifestations of the disease including lung parenchymal disease. Pulmonary involvement in RA patients leads to increased morbidity and mortality. The overall burden of RA related pulmonary disease is underestimated due to the limitation of resources in underdeveloped countries. High-resolution computed tomography (HRCT) is an important tool used to diagnose different abnormalities in RA related interstitial lung disease (ILD). The objective of the study was to evaluate HRCT findings in patients of RA related ILD and categorize the radiological findings according to clinical findings. Method This descriptive prospective observational study was conducted at Mayo Hospital, Lahore from June 2014 to June 2015. Patients of RA suspected of lung disease after selection underwent HRCT chest on 128-slice Hitachi CT scanner (Hitachi Global, Tokyo, Japan) in the radiology department. Images were reconstructed and evaluated by experienced radiologists. Findings were recorded on a questionnaire. Data was analyzed on SPSS version 21 (IBM Corp, Armonk, US). Results Out of the 54 patients scanned, interlobular septal thickening was the most common finding found in 22 of the patients. Ground-glass opacification was recognized in 21 patients, honeycombing in nine and bronchiectasis in two patients. Regarding zonal predilection of disease pattern, lower zones of lungs were found involved in most of the cases. The disease was found to be bilateral in 15 patients. Based on these findings, usual interstitial pneumonitis (UIP) was diagnosed in six patients and non-specific interstitial pneumonitis (NSIP) in 14 others. Conclusion This study concluded that HRCT images are very useful in diagnosing interstitial lung disease related to rheumatoid arthritis.
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Affiliation(s)
| | | | - Sadaf Arooj
- Radiology, King Edward Medical University, Lahore, PAK
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11
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Interstitial Lung Disease in Rheumatoid Arthritis Remains a Challenge for Clinicians. J Clin Med 2019; 8:jcm8122038. [PMID: 31766446 PMCID: PMC6947091 DOI: 10.3390/jcm8122038] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/11/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022] Open
Abstract
Interstitial lung disease (ILD) is a serious complication of rheumatoid arthritis (RA) contributing to significantly increased morbidity and mortality. Other respiratory complications, such as chronic obstructive pulmonary disease and bronchiectasis, are frequent in RA. Infections and drug toxicity are important differential diagnoses and should be considered in the diagnostic work-up of patients with RA presenting with respiratory symptoms. This review provides an overview of the epidemiology and pathogenesis of RA-ILD, the radiological and histopathological characteristics of the disease as well as the current and future treatment options. Currently, there is no available evidence-based therapy for RA-ILD, and immunosuppressants are the mainstay of therapy. Ongoing studies are exploring the role of antifibrotic therapy in patients with progressive fibrotic ILD, which may lead to a new treatment approach for subgroups of patients with RA-ILD.
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12
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Abstract
Pulmonary involvement in patients with rheumatoid arthritis, in particular interstitial lung diseases (RA-ILD) is of great clinical importance. Patients should be asked about symptoms of pulmonary involvement and the lungs should be clinically examined even during the diagnostic procedure and regularly during the course of the disease. Before initiation of a basic pharmacological treatment an X‑ray examination of thoracic organs is obligatory. In cases of conspicuous clinical or radiological findings, extended diagnostic procedures with lung function testing (body plethysmography with diffusion measurement) and high resolution computed tomography (CT) should be performed, depending on the findings. The differential diagnosis of interstitial lung alterations in patients with RA is broad and should consider side effects of the basis medication in addition to infectious causes. The optimal pharmacological treatment of RA-ILD is not sufficiently clarified. The value of methotrexate (MTX) has changed because, in contrast to previous assumptions, a better course could be observed under MTX treatment, at least in mild to moderate courses of RA-ILD. In the case of a clinically relevant RA-ILD, tumor necrosis factor (TNF) blockers should be avoided because a dramatic deterioration of pulmonary function has sometimes been observed. Among biological disease-modifying antirheumatic drugs (DMARD), rituximab and abatacept are currently preferred. The role of Janus kinase (JAK) inhibitors in RA-ILD is currently being discussed but limited data are available. Patients with RA-ILD benefit from a close collaboration between pulmonologists and rheumatologists.
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Affiliation(s)
- A Krause
- Klinik für Innere Medizin, Abteilung Rheumatologie, klinische Immunologie und Osteologie, Immanuel Krankenhaus Berlin, Königstr. 63, 14109, Berlin, Deutschland.
| | - A Rubbert-Roth
- Klinik für Rheumatologie, Kantonsspital St. Gallen, St. Gallen, Schweiz
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13
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Wang D, Zhang J, Lau J, Wang S, Taneja V, Matteson EL, Vassallo R. Mechanisms of lung disease development in rheumatoid arthritis. Nat Rev Rheumatol 2019; 15:581-596. [PMID: 31455869 DOI: 10.1038/s41584-019-0275-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes joint inflammation and damage. Extra-articular manifestations occur in many patients and can include lung involvement in the form of airway or parenchymal inflammation and fibrosis. Although the pathophysiology of articular RA has been extensively investigated, the mechanisms causing airway and parenchymal lung disease are not well defined. Infections, cigarette-smoking, mucosal dysbiosis, host genetics and premature senescence are all potentially important contributors to the development of lung disease in patients with RA. RA-associated lung disease (which can predate the onset of articular disease by many years) probably originates from chronic airway and alveolar epithelial injury that occurs in an individual with a genetic background that permits the development of autoimmunity, leading to chronic inflammation and subsequent airway and lung parenchymal remodelling and fibrosis. Further investigations into the specific mechanisms by which lung disease develops in RA will be crucial for the development of effective therapies. Identifying mechanisms by which environmental and host factors cooperate in the induction of autoimmunity in the lung might also help to establish the order of early events in RA.
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Affiliation(s)
- Dan Wang
- Department of Rheumatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Zhang
- Division of Pulmonary Medicine, Department of Medicine, Chongqing General Hospital, Chongqing, China
| | - Jessica Lau
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Shaohua Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Veena Taneja
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. .,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
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14
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Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med 2019; 40:545-560. [PMID: 31376890 DOI: 10.1016/j.ccm.2019.05.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.
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Affiliation(s)
- Anthony J Esposito
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sarah G Chu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Rachna Madan
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Tracy J Doyle
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Paul F Dellaripa
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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15
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Berman S, Bucher J, Koyfman A, Long BJ. Emergent Complications of Rheumatoid Arthritis. J Emerg Med 2018; 55:647-658. [DOI: 10.1016/j.jemermed.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/03/2018] [Accepted: 07/22/2018] [Indexed: 12/20/2022]
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16
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Pancaldi F, Sebastiani M, Cassone G, Luppi F, Cerri S, Della Casa G, Manfredi A. Analysis of pulmonary sounds for the diagnosis of interstitial lung diseases secondary to rheumatoid arthritis. Comput Biol Med 2018; 96:91-97. [PMID: 29550468 DOI: 10.1016/j.compbiomed.2018.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 01/07/2023]
Abstract
The diagnosis of interstitial lung diseases in patients affected by rheumatoid arthritis is fundamental to improving their survival rate. In particular, the average survival time of patients affected by rheumatoid arthritis with pulmonary implications is approximately 3 years. The gold standard for confirming the diagnosis of this disease is computer tomography. However, it is very difficult to raise diagnosis suspicion because the symptoms of the disease are extremely common in elderly people. The detection of the so-called velcro crackle in lung sounds can effectively raise the suspicion of an interstitial disease and speed up diagnosis. However, this task largely relies on the experience of physicians and has not yet been standardized in clinical practice. The diagnosis of interstitial lung diseases based on thorax auscultation still represents an underexplored field in the study of rheumatoid arthritis. In this study, we investigate the problem of the automatic detection of velcro crackle in lung sounds. In practice, the patient is auscultated using a digital stethoscope and the lung sounds are saved to a file. The acquired digital data are then analysed using a suitably developed algorithm. In particular, the proposed solution relies on the empirical observation that the audio bandwidth associated with velcro crackle is larger than that associated with healthy breath sounds. Experimental results from a database of 70 patients affected by rheumatoid arthritis demonstrate that the developed tool can outperform specialized physicians in terms of diagnosing pulmonary disorders. The overall accuracy of the proposed solution is 90.0%, with negative and positive predictive values of 95.0% and 83.3%, respectively, whereas the reliability of physician diagnosis is in the range of 60-70%. The devised algorithm represents an enabling technology for a novel approach to the diagnosis of interstitial lung diseases in patients affected by rheumatoid arthritis.
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Affiliation(s)
- Fabrizio Pancaldi
- Department of Sciences and Methods for Engineering, University of Modena and Reggio Emilia, Reggio Emilia, Italy.
| | - Marco Sebastiani
- Department of Medical and Surgical Sciences of the University of Modena and Reggio Emilia, Modena, Italy; Rheumatology Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
| | - Giulia Cassone
- Department of Medical and Surgical Sciences of the University of Modena and Reggio Emilia, Modena, Italy; Rheumatology Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
| | - Fabrizio Luppi
- Department of Medical and Surgical Sciences of the University of Modena and Reggio Emilia, Modena, Italy; Respiratory Diseases Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
| | - Stefania Cerri
- Department of Medical and Surgical Sciences of the University of Modena and Reggio Emilia, Modena, Italy; Respiratory Diseases Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
| | - Giovanni Della Casa
- Radiology Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
| | - Andreina Manfredi
- Department of Medical and Surgical Sciences of the University of Modena and Reggio Emilia, Modena, Italy; Rheumatology Unit at Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy.
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Abstract
The treatment of rheumatoid arthritis (RA) has undergone considerable changes over the last 15–20 years. With an expansion in the armamentarium of therapies available for RA comes a wider choice in selecting the best treatment in terms of comparative safety in the presence of comorbidities. Clinicians frequently encounter patients with RA-associated interstitial lung disease with uncontrolled joint disease and have to make decisions about the safest treatments in this context with the eventual goal of joint remission. In this chapter, available evidence is reviewed on the comparative pulmonary safety of non-biologic disease-modifying antirheumatic drugs (nbDMARDs), biologic DMARDs, biosimilars and targeted synthetic DMARDs in RA-ILD. In addition, the potential role for additional immunosuppression in RA-ILD is reviewed as well as overarching recommendations proposed for patient assessment to guide treatment decisions and management.
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18
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Bluett J, Jani M, Symmons DPM. Practical Management of Respiratory Comorbidities in Patients with Rheumatoid Arthritis. Rheumatol Ther 2017; 4:309-332. [PMID: 28808949 PMCID: PMC5696283 DOI: 10.1007/s40744-017-0071-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Indexed: 12/18/2022] Open
Abstract
Lung disease is one of the most common causes of extra-articular morbidity and mortality in patients with rheumatoid arthritis (RA). Development of pulmonary manifestations may be due to the systemic disease itself; to serious respiratory adverse events such as pneumonitis and infections secondary to therapy; or to lifestyle habits such as smoking. Rheumatologists often need to make important treatment decisions and plan future care in RA patients with respiratory comorbidities, despite the absence of clear evidence or consensus. In this review we evaluate the clinical assessment and management of RA-associated interstitial lung disease, bronchiectasis, serious (including opportunistic) infection, and smoking-related diseases. We summarize the international recommendations for the management of such conditions where available, refer to published best practice on the basis of scientific literature, and propose practical management suggestions to aid informed decision-making.
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Affiliation(s)
- James Bluett
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Dermatological and Musculoskeletal Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Meghna Jani
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Dermatological and Musculoskeletal Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Deborah P M Symmons
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Dermatological and Musculoskeletal Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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Hou H, Xing W, Li W. Brahma-related gene 1 induces apoptosis in a p53-dependent manner in human rheumatoid fibroblast-like synoviocyte MH7A. Medicine (Baltimore) 2016; 95:e5241. [PMID: 28002318 PMCID: PMC5181802 DOI: 10.1097/md.0000000000005241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Blocked apoptosis and aggressive inflammatory responses occur in fibroblast-like synoviocyte (FLS) of rheumatoid arthritis (RA) patients. Although Brahma-related gene 1 (BRG1) is considered as a tumor suppressor, few research covers its role in RA. This study aims to reveal effects and potential mechanisms of BRG1 in human FLS cell line MH7A.BRG1 expression in MH7A cells was altered by transfection of overexpression vectors or short hairpin RNAs (shRNAs). Cell viability and apoptosis were detected by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry after transfection. Factors involved in inflammation and apoptosis were quantified by qPCR and Western blot. The interaction between BRG1 and p53 was assessed by immunoprecipitation (IP).Results showed that BRG1 overexpression significantly suppressed MH7A cell viability and induced apoptosis (P < 0.01), and its knockdown had opposite effects. BRG1 reduced mRNA levels of matrix metallopeptidase 3, TIMP metallopeptidase inhibitor 2, cyclooxygenase 2, and interleukin 6, implying its suppressive effects on inflammation. BRG1 interacted with and promoted p53 (P < 0.05). B-cell chronic lymphocytic leukemia/lymphoma 2 was suppressed (P < 0.05), while cytochrome c, caspase 3 (CASP3) and CASP9 were activated (P < 0.01) by BRG1. However, the regulation on these factors was abrogated by p53 knockdown (P < 0.01).These findings suggest that BRG1 may induce apoptosis and suppress inflammation in MH7A cells. Potential functional mechanisms involve the regulation of apoptotic factors by BRG1, which may depend on the recruitment and promotion of p53. This study provides the essential proof for applying BRG1 to the molecular therapy of RA.
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20
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Kelly C, Iqbal K, Iman-Gutierrez L, Evans P, Manchegowda K. Lung involvement in inflammatory rheumatic diseases. Best Pract Res Clin Rheumatol 2016; 30:870-888. [PMID: 27964793 DOI: 10.1016/j.berh.2016.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/05/2016] [Accepted: 10/13/2016] [Indexed: 02/08/2023]
Abstract
This chapter describes the involvement of the lung in systemic inflammatory joint disease (IJD) with a particular focus on rheumatoid arthritis, although the topics of pulmonary involvement in ankylosing spondylitis and psoriatic arthritis are also addressed. Interstitial lung disease is the most lethal pulmonary complication of IJD and the chapter describes recent advances in both our understanding of this complication and the therapeutic options that offer real hope for improved outcomes. Although less well recognised, airways disease is just as common and its association with IJD is described in some detail, with a section devoted to the recent surge in interest in bronchiectasis. Acute pulmonary infection is common in IJD and its management is reviewed in some detail. Although pleural disease is less common than it once was, its treatment is explored. We conclude by reviewing the relationship between the drug therapies employed in IJD and their effects on the lung.
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Affiliation(s)
- Clive Kelly
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK.
| | - Kundan Iqbal
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK
| | | | - Phil Evans
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK
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21
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Picchianti Diamanti A, Markovic M, Argento G, Giovagnoli S, Ricci A, Laganà B, D'Amelio R. Therapeutic management of patients with rheumatoid arthritis and associated interstitial lung disease: case report and literature review. Ther Adv Respir Dis 2016; 11:64-72. [PMID: 27733490 PMCID: PMC5941974 DOI: 10.1177/1753465816668780] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that can present
different extrarticular manifestations involving heart, lungs and kidneys. In
recent years there has been a growing awareness of the central role played by
the lungs in the onset and progression of RA. In particular interstitial lung
disease (ILD) is a common pulmonary manifestation that may be related to the
inflammatory process itself, infectious complications and to the treatments
used. Management of patients with ILD/RA is still a challenge for clinicians,
both synthetic [mainly methotrexate (MTX), leflunomide] and biologic
immunosuppressors [mainly anti-tumor necrosis factor (TNF)α] have in fact been
related to the onset or worsening of lung diseases with conflicting data. Here
we report the case of a 61-year-old male patient with severely active early RA,
previously treated with MTX, who developed subacute ILD, along with a review of
ILD/RA topic. Tocilizumab (humanized monoclonal antibody against the
interleukin-6 receptor) was introduced on the basis of its effectiveness in RA
without concomitant MTX and the ability to overcome the profibrotic effects of
interleukin (IL)-6. After 3 months of treatment the clinical condition of the
patient strongly improved until it reached low disease activity. He no longer
complained of cough and dyspnea and bilateral basal crackles were no more
present. Considering its distinctive features, tocilizumab, in such a
challenging clinical condition, appears to be a safe and effective therapy, thus
it enables RA remission without deteriorating ILD, at 1-year follow up, as
confirmed by ultrasonography of the affected joints and chest high-resolution
computed tomography (HRCT).
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Affiliation(s)
- Andrea Picchianti Diamanti
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Via di Grottarossa 1039, Rome 00189, Italy
| | - Milica Markovic
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Giuseppe Argento
- Radiology Unit, School of Medicine and Psychology, "Sapienza" University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Simonetta Giovagnoli
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Alberto Ricci
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Bruno Laganà
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Raffaele D'Amelio
- Department of Clinical and Molecular Medicine, School of Medicine and Psychology, 'Sapienza' University of Rome, Sant'Andrea University Hospital, Rome, Italy
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22
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Iqbal K, Kelly C. Treatment of rheumatoid arthritis-associated interstitial lung disease: a perspective review. Ther Adv Musculoskelet Dis 2015; 7:247-67. [PMID: 26622326 PMCID: PMC4637848 DOI: 10.1177/1759720x15612250] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting 0.5-1% of the worldwide population. Whilst predominantly causing chronic pain and inflammation in synovial joints, it is also associated with significant extra-articular manifestations in a large proportion of patients. Among the various pulmonary manifestations, interstitial lung disease (ILD), a progressive fibrotic disease of the lung parenchyma, is the commonest and most important, contributing significantly to increased morbidity and mortality. The most frequent patterns of RA-associated ILD (RA-ILD) are usual interstitial pneumonia and nonspecific interstitial pneumonia. New insights during the past several years have highlighted the epidemiological impact of RA-ILD and have begun to identify factors contributing to its pathogenesis. Risk factors include smoking, male sex, human leukocyte antigen haplotype, rheumatoid factor and anticyclic citrullinated protein antibodies (ACPAs). Combined with clinical information, chest examination and pulmonary function testing, high-resolution computed tomography of the chest forms the basis of investigation and allows assessment of subtype and disease extent. The management of RA-ILD is a challenge. Several therapeutic agents have been suggested in the literature but as yet no large randomized controlled trials have been undertaken to guide clinical management. Therapy is further complicated by commonly prescribed drugs of proven articular benefit such as methotrexate, leflunomide (LEF) and anti-tumour necrosis factor α agents having been implicated in both ex novo occurrence and acceleration of existing ILD. Agents that offer promise include immunomodulators such as mycophenolate and rituximab as well as newly studied antifibrotic agents. In this review, we discuss the current literature to evaluate recommendations for the management of RA-ILD and discuss key gaps in our knowledge of this important disease.
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Affiliation(s)
- Kundan Iqbal
- Department of Medicine at Queen Elizabeth Hospital, Gateshead & University of Newcastle upon Tyne Medical School, Newcastle upon Tyne, Tyne and Wear, UK
| | - Clive Kelly
- Department of Medicine at Queen Elizabeth Hospital, Gateshead NE96SX, UK & University of Newcastle upon Tyne Medical School, Newcastle upon Tyne, Tyne and Wear, NE14LP, UK
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Wang T, Zheng XJ, Liang BM, Liang ZA. Clinical features of rheumatoid arthritis-associated interstitial lung disease. Sci Rep 2015; 5:14897. [PMID: 26443305 PMCID: PMC4595674 DOI: 10.1038/srep14897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/11/2015] [Indexed: 02/05/2023] Open
Abstract
Interstitial lung disease (ILD) is the most common extra-articular manifestations of rheumatoid arthritis (RA) in the lung. This study aimed to identify clinical features of RA-associated ILD (RA-ILD). Patients with RA were retrospectively enrolled and sub-classified as RA-ILD or RA without ILD based on high-resolution computed tomography imaging. Pulmonary function testing parameters and levels of RA-related biomarkers, tumour markers, and acute-phase proteins were compared between the two groups. Logistic regression model was used to assess the strength of association between RA-ILD and clinical features of interest. Receiver operating characteristic analysis was performed to assess potential predictive value of clinical features for detecting RA-ILD. Comparison analysis indicated that the percentage of predicted value of total lung capacity, inspiratory capacity, and diffusion capacity of the lung for carbon monoxide (DLCO) were reduced in patients with RA-ILD. Tumour markers CA15–3 and CA125 were increased in patients with RA-ILD. Logistic regression analysis revealed that decreased DLCO was related to the increased likelihood of RA-ILD (OR = 0.94, 95%CI = [0.91, 0.98]). The cut-off point at 52.95 percent of predicted value could sensitively discriminate RA patients with or without ILD. Our study suggested that DLCO value could be a useful tool for detecting ILD in patients with RA.
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Affiliation(s)
- Ting Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, P. R. China
| | - Xing-Ju Zheng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, P. R. China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, P. R. China
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Farrag MA, El-Sayed AM, Mohammed RM, El Bagalatya MF. Evaluation of carbon monoxide diffusing capacity as an early detection of pulmonary involvement in rheumatoid arthritis patients without respiratory symptoms. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2014. [DOI: 10.4103/1687-8426.145721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shen TC, Lin CL, Chen CH, Tu CY, Hsia TC, Shih CM, Hsu WH, Sung FC. Increased risk of chronic obstructive pulmonary disease in patients with rheumatoid arthritis: a population-based cohort study. QJM 2014; 107:537-43. [PMID: 24497528 DOI: 10.1093/qjmed/hcu027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The role of autoimmune pathology in development and progression of chronic obstructive pulmonary disease (COPD) is becoming increasingly popular. Our aim was to assess the association between patients with rheumatoid arthritis (RA) and subsequent COPD risk in a nationwide population. METHOD We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. The RA cohort included patients who were newly diagnosed and recruited between 1998 and 2008. Each patient was randomly frequency-matched for age, sex and the year of index date with people without RA from the general population. The newly diagnosed COPD was followed up until the end of 2010. The relative risks of COPD were estimated using Cox proportional hazard models after adjusting for age, sex, index year and comorbidities. RESULT The overall incidence rate of COPD was 1.74-fold higher in the RA cohort than in the non-RA cohort (5.25 vs. 3.01 per 1000 person-years, 95% confidence interval (CI) = 1.68-1.81). Age-related risk analysis showed an increased incidence of COPD with age in both RA and non-RA cohorts. However, adjusted hazard ratio (HR) maximum was witnessed in the age range of 20-34 years (adjusted HR: 7.67, 95% CI=1.94-30.3), whereas adjusted HR minimum was observed in the oldest age group (>65 years). CONCLUSION Patients with RA have a significantly higher risk of developing COPD than that of the control population. Further, age-related risk analysis indicated much higher adjusted HR in younger patients although COPD incidence increased with age. It can be hypothesized that in addition to cigarette smoke, RA may be a determining factor for COPD incidence and/or facilitates shortening of the time course for developing COPD. However, further investigation is needed to corroborate this hypothesis.
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Affiliation(s)
- T-C Shen
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, TaiwanFrom the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C-L Lin
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, TaiwanFrom the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C-H Chen
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C-Y Tu
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - T-C Hsia
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - C-M Shih
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - W-H Hsu
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - F-C Sung
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou, Department of Public Health, College of Public Health, China Medical University, Taichung and Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
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Shen TC, Lin CL, Wei CC, Tu CY, Li YF. The risk of asthma in rheumatoid arthritis: a population-based cohort study. QJM 2014; 107:435-42. [PMID: 24448376 DOI: 10.1093/qjmed/hcu008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Several studies discussed the relations between asthma and rheumatoid arthritis (RA) but the results were controversial. These studies were either questionnaire based or with small study populations. We aimed to examine the risk of asthma among RA patients in a nationwide population. METHODS We conducted a cohort study using data from the National Health Insurance system of Taiwan. The RA cohort included 27 602 patients who were newly diagnosed and recruited between 1998 and 2008. Each patient was randomly frequency-matched with three people without RA on age group, sex and the year of index date from the general population. The occurrence of asthma was followed up until the end of 2010. The relative risks of asthma were estimated using Cox proportional hazard models after adjusting for age and comorbidities. RESULT The overall incidence rate of asthma was 2.07-fold greater in the RA cohort than in the non-RA cohort (4.56 vs. 2.22 per 1000 person-years, 95% CI = 1.99-2.15). Stratified analyses by gender, age group and comorbidity revealed that the risk of asthma associated with RA was higher in females (adjusted hazard ratio (HR) = 2.18, 95% CI = 1.97-2.41), individuals younger than 40 years old (adjusted HR = 3.26, 95% CI = 2.09-5.11) and without comorbidity (adjusted HR = 2.17, 95% CI = 1.97-2.39). CONCLUSION Patients with RA had a significantly higher risk of developing asthma than healthy people in all sex and age subgroups. Stratified analyses indicated that there was a higher risk in women with RA than in men with RA when compared to their counterpart. Similarly, the HR of asthma associated with RA was higher in younger subjects, although the incidence rate increased with age.
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Affiliation(s)
- T-C Shen
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, TaiwanFrom the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, Taiwan
| | - C-L Lin
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, TaiwanFrom the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, Taiwan
| | - C-C Wei
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, Taiwan
| | - C-Y Tu
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, Taiwan
| | - Y-F Li
- From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital and China Medical University, Taichung 404, Taiwan, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chu Shang Show Chwan Hospital, Nantou 557, Taiwan, Department of Public Health, China Medical University, Taichung 404, Taiwan, Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan, Division of Nephrology, Department of Pediatrics, China Medical University Hospital and China Medical University, Taichung 404, Taiwan and Institute of Biostatistics, China Medical University, Taichung 404, Taiwan
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Watanabe E, Kawamura T, Mochizuki Y, Nakahara Y, Sasaki S, Okamoto A, Higashino T. Consolidation with a twisted appearance along the airways: a report of five cases of interstitial pneumonia. Respir Investig 2014; 52:213-218. [PMID: 24853025 DOI: 10.1016/j.resinv.2013.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 06/03/2023]
Abstract
High-resolution CT showed areas of airspace consolidation with a twisted appearance of the airways, along with areas of peribronchial ground-glass attenuation and traction bronchiectasis, in five patients with interstitial pneumonia. These areas of airspace consolidation were termed "twisted consolidation" (TwC). The five patients included two patients receiving treatment for rheumatoid arthritis (RA), one patient with newly diagnosed RA, and one patient who subsequently showed RA. Three patients showed improvement after steroid administration. An association of TwC with RA is suspected, but further studies are necessary.
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Affiliation(s)
- Etsuko Watanabe
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Yoshiro Mochizuki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Shin Sasaki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Akira Okamoto
- Department of Rheumatology, National Hospital Organization Himeji Medical Center, Hyogo, Japan.
| | - Takanori Higashino
- Department of Radiology, National Hospital Organization Himeji Medical Center, Hyogo, Japan.
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28
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Atzeni F, Boiardi L, Sallì S, Benucci M, Sarzi-Puttini P. Lung involvement and drug-induced lung disease in patients with rheumatoid arthritis. Expert Rev Clin Immunol 2014; 9:649-57. [PMID: 23899235 DOI: 10.1586/1744666x.2013.811173] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and a significant cause of morbidity and mortality. Usual interstitial pneumonia and nonspecific interstitial pneumonia seem to be the most frequent patterns in RA patients with ILD, although the proportion of patients with usual interstitial pneumonia is higher than among patients with other systemic rheumatic autoimmune diseases. RA patients with ILD most frequently present with chronic symptoms of cough and dyspnea when climbing stairs or walking uphill. A physical examination may reveal inhalatory crackles and a pulmonary function test demonstrates restrictive physiology, often with reduced diffusing capacity. High-resolution computed tomography is generally sufficient to confirm a diagnosis of ILD, although a minority of cases may require a surgical lung biopsy. Conventional disease-modifying antirheumatic drugs such as methotrexate (MTX) or leflunomide (LEF) and biological agents such as TNF-blocking agents or rituximab may trigger or aggravate ILD in RA patients, and infections may contribute to increased mortality in such patients. LEF should not be used in patients with a history of MTX pneumonitis. The prevalence of interstitial pneumonia among RA patients treated with anti-TNF agents ranges from 0.5 to 3%; however, as the evidence that anti-TNF increases or decreases the risk of ILD is controversial, it is not clear whether this indicates more severe RA requiring biological therapy or the effect of exposure to potentially toxic drugs such as MTX or LEF. The development of treatment-related ILD is a paradoxical adverse event, and patients should be warned about this rare but serious complication of biological or disease-modifying antirheumatic drug therapy.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, L Sacco University Hospital, Milan, Italy.
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29
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Abstract
Interstitial lung disease (ILD) is a common extra-articular manifestation associated with increased morbidity and mortality in patients with rheumatoid arthritis (RA). Early case reports of serious respiratory adverse events (SRAEs) following treatment with anti-TNF agents have led to concerns about biologic therapy in patients with RA-associated ILD (RA-ILD), and a tendency for biologic agents targeting factors other than TNF to be prescribed in such patients. At present, the appropriateness of such decisions is not clear. Given that the therapeutic goal for RA is remission, clinicians increasingly face the challenge of choosing the optimal biologic agent in patients with RA-ILD and uncontrolled joint disease. However, no evidence-based guidelines exist to guide physicians in deciding whether to commence biologic therapy in this setting, or in selecting which drug is most appropriate. Herein, we review the evidence for the comparative pulmonary safety of anti-TNF agents and non-TNF-targeting biologic agents in RA-ILD. In addition, we propose a framework for assessment of baseline disease severity to guide treatment decisions, and for monitoring during therapy. Because of substantial gaps in the available evidence, we also describe a research agenda aimed at obtaining data that will help inform future clinical practice.
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30
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Exacerbation of combined pulmonary fibrosis and emphysema syndrome during tocilizumab therapy for rheumatoid arthritis. Joint Bone Spine 2013; 80:670-1. [DOI: 10.1016/j.jbspin.2013.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2013] [Indexed: 11/23/2022]
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31
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O'Dwyer DN, Armstrong ME, Cooke G, Dodd JD, Veale DJ, Donnelly SC. Rheumatoid Arthritis (RA) associated interstitial lung disease (ILD). Eur J Intern Med 2013; 24:597-603. [PMID: 23916467 DOI: 10.1016/j.ejim.2013.07.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/04/2013] [Accepted: 07/06/2013] [Indexed: 01/08/2023]
Abstract
Rheumatoid Arthritis (RA) is the most common Connective Tissue Disease (CTD) and represents an increasing burden on global health resources. Interstitial lung disease (ILD) has been recognised as a complication of RA but its potential for mortality and morbidity has arguably been under appreciated for decades. New studies have underscored a significant lifetime risk of ILD development in RA. Contemporary work has identified an increased risk of mortality associated with the Usual Interstitial Pneumonia (UIP) pattern which shares similarity with the most devastating of the interstitial pulmonary diseases, namely Idiopathic Pulmonary Fibrosis (IPF). In this paper, we discuss recent studies highlighting the associated increase in mortality in RA-UIP. We explore associations between radiological and histopathological features of RA-ILD and the prognostic implications of same. We emphasise the need for translational research in this area given the growing burden of RA-ILD. We highlight the importance of the respiratory physician as a key stakeholder in the multidisciplinary management of this disorder. RA-ILD focused research offers the opportunity to identify early asymptomatic disease and define the natural history of this extra articular manifestation. This may provide a unique opportunity to define key regulatory fibrotic events driving progressive disease. We also discuss some of the more challenging and novel aspects of therapy for RA-ILD.
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Affiliation(s)
- David N O'Dwyer
- School of Medicine and Medical Science, College of Life Sciences, UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland; National Pulmonary Fibrosis Referral Centre at St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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32
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The multifaceted aspects of interstitial lung disease in rheumatoid arthritis. BIOMED RESEARCH INTERNATIONAL 2013; 2013:759760. [PMID: 24205507 PMCID: PMC3800606 DOI: 10.1155/2013/759760] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/07/2023]
Abstract
Interstitial lung disease (ILD) is a relevant extra-articular manifestation of rheumatoid arthritis (RA) that may occur either in early stages or as a complication of long-standing disease. RA related ILD (RA-ILD) significantly influences the quoad vitam prognosis of these patients. Several histopathological patterns of RA-ILD have been described: usual interstitial pneumonia (UIP) is the most frequent one, followed by nonspecific interstitial pneumonia (NSIP); other patterns are less commonly observed. Several factors have been associated with an increased risk of developing RA-ILD. The genetic background plays a fundamental but not sufficient role; smoking is an independent predictor of ILD, and a correlation with the presence of rheumatoid factor and anti-cyclic citrullinated peptide antibodies has also been reported. Moreover, both exnovo occurrence and progression of ILD have been related to drug therapies that are commonly prescribed in RA, such as methotrexate, leflunomide, anti-TNF alpha agents, and rituximab. A greater understanding of the disease process is necessary in order to improve the therapeutic approach to ILD and RA itself and to reduce the burden of this severe extra-articular manifestation.
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33
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Asymptomatic preclinical rheumatoid arthritis-associated interstitial lung disease. Clin Dev Immunol 2013; 2013:406927. [PMID: 23983768 PMCID: PMC3747456 DOI: 10.1155/2013/406927] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/29/2013] [Accepted: 07/11/2013] [Indexed: 12/19/2022]
Abstract
Objective. Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and a significant cause of morbidity and mortality. The objective of this study was to define high-resolution chest CT (HRCT) and pulmonary function test (PFT) abnormalities capable of identifying asymptomatic, preclinical forms of RA-ILD that may represent precursors to more severe fibrotic lung disease. Methods. We analyzed chest HRCTs in consecutively enrolled RA patients and subsequently classified these individuals as RA-ILD or RA-no ILD based on the presence/absence of ground glass opacification, septal thickening, reticulation, traction bronchiectasis, and/or honeycombing. Coexisting PFT abnormalities (reductions in percent predicted FEV1, FVC, TLC, and/or DLCO) were also used to further characterize occult respiratory defects. Results. 61% (63/103) of RA patients were classified as RA-ILD based on HRCT and PFT abnormalities, while 39% (40/103) were designated as RA-no ILD. 57/63 RA-ILD patients lacked symptoms of significant dyspnea or cough at the time of HRCT and PFT assessment. Compared with RA-no ILD, RA-ILD patients were older and had longer disease duration, higher articular disease activity, and more significant PFT abnormalities. Conclusion. HRCT represents an effective tool to detect occult/asymptomatic ILD that is highly prevalent in our unselected, university-based cohort of RA patients.
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34
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Verma SK, Mishra AK, Jaiswal AK. Leflunomide-induced chronic cough in a rheumatoid arthritis patient with pulmonary tuberculosis. BMJ Case Rep 2013; 2013:bcr-2012-008373. [PMID: 23378555 DOI: 10.1136/bcr-2012-008373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 40-year-old lady presented with clinicoradiological features suggestive of pulmonary tuberculosis, which was confirmed on sputum smear examination, and was started on four-drug antitubercular treatment. On subsequent visits, she complained of persistent cough, despite improvement in other symptoms. A careful anamnesis revealed that the patient had been taking leflunomide for rheumatoid arthritis for the last 10 years, and this was suspected to be the cause of the cough. The patient became asymptomatic upon stopping the drug, thereby confirming the hypothesis.
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Affiliation(s)
- S K Verma
- Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India.
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35
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Faria ACD, Barbosa WR, Lopes AJ, Pinheiro GDRC, Melo PLD. Contrasting diagnosis performance of forced oscillation and spirometry in patients with rheumatoid arthritis and respiratory symptoms. Clinics (Sao Paulo) 2012; 67:987-94. [PMID: 23018292 PMCID: PMC3438257 DOI: 10.6061/clinics/2012(09)01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/01/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Pulmonary involvement in rheumatoid arthritis is directly responsible for 10% to 20% of all mortality. The best way to improve the prognosis is early detection and treatment. The forced oscillation technique is easy to perform and offers a detailed exam, which may be helpful in the early detection of respiratory changes. This study was undertaken to (1) evaluate the clinical potential of the forced oscillation technique in the detection of early respiratory alterations in rheumatoid arthritis patients with respiratory complaints and (2) to compare the sensitivity of forced oscillation technique and spirometric parameters. METHODS A total of 40 individuals were analyzed: 20 healthy and 20 with rheumatoid arthritis (90% with respiratory complaints). The clinical usefulness of the parameters was evaluated by investigating the sensibility, the specificity and the area under the receiver operating characteristic curve. ClinicalTrials.gov: NCT01641705. RESULTS The early adverse respiratory effects of rheumatoid arthritis were adequately detected by the forced oscillation technique parameters, and a high accuracy for clinical use was obtained (AUC.0.9, Se = 80%, Sp = 95%). The use of spirometric parameters did not obtain an appropriate accuracy for clinical use. The diagnostic performance of the forced oscillation technique parameters was significantly higher than that of spirometry. CONCLUSIONS The results of the present study provide substantial evidence that the forced oscillation technique can contribute to the easy identification of initial respiratory abnormalities in rheumatoid arthritis patients that are not detectable by spirometric exams. Therefore, we believe that the forced oscillation technique can be used as a complementary exam that may help to improve the treatment of breathing disorders in rheumatoid arthritis patients.
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Affiliation(s)
- Alvaro Camilo Dias Faria
- Biomedical Instrumentation Laboratory, Institute of Biology and Faculty of Engineering, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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36
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Prete M, Racanelli V, Digiglio L, Vacca A, Dammacco F, Perosa F. Extra-articular manifestations of rheumatoid arthritis: An update. Autoimmun Rev 2011; 11:123-31. [PMID: 21939785 DOI: 10.1016/j.autrev.2011.09.001] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 09/03/2011] [Indexed: 12/13/2022]
Abstract
Rheumatoid arthritis (RA) is an immune-mediated disease involving chronic low-grade inflammation that may progressively lead to joint destruction, deformity, disability and even death. Despite its predominant osteoarticular and periarticular manifestations, RA is a systemic disease often associated with cutaneous and organ-specific extra-articular manifestations (EAM). Despite the fact that EAM have been studied in numerous RA cohorts, there is no uniformity in their definition or classification. This paper reviews current knowledge about EAM in terms of frequency, clinical aspects and current therapeutic approaches. In an initial attempt at a classification, we separated EAM from RA co-morbidities and from general, constitutional manifestations of systemic inflammation. Moreover, we distinguished EAM into cutaneous and visceral forms, both severe and not severe. In aggregated data from 12 large RA cohorts, patients with EAM, especially the severe forms, were found to have greater co-morbidity and mortality than patients without EAM. Understanding the complexity of EAM and their management remains a challenge for clinicians, especially since the effectiveness of drug therapy on EAM has not been systematically evaluated in randomized clinical trials.
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Affiliation(s)
- Marcella Prete
- Department of Internal Medicine and Clinical Oncology, University of Bari Medical School, Piazza G. Cesare 11, Bari, Italy
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