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Narváez J, Díaz Del Campo Fontecha P, Brito García N, Bonilla G, Aburto M, Castellví I, Cano-Jiménez E, Mena-Vázquez N, Nieto MA, Ortiz AM, Valenzuela C, Abad Hernández MÁ, Castrejón I, Correyero Plaza M, Francisco Hernández FM, Hernández Hernández MV, Rodríquez Portal JA. SER-SEPAR recommendations for the management of rheumatoid arthritis-related interstitial lung disease. Part 2: Treatment. REUMATOLOGIA CLINICA 2022; 18:501-512. [PMID: 36064885 DOI: 10.1016/j.reumae.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To develop multidisciplinary recommendations to improve the management of rheumatoid arthritis-related interstitial lung disease (RA-ILD). METHODS Clinical research questions relevant to the objective of the document were identified by a panel of rheumatologists and pneumologists selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Specific recommendations were made. RESULTS Six PICO questions were selected, three of which analysed the safety and effectiveness of glucocorticoids, classical synthetic disease-modifying anti-rheumatic drugs (DMARDs) and other immunosuppressants, biological agents, targeted synthetic DMARDs, and antifibrotic therapies in the treatment of this complication. A total of 12 recommendations were formulated based on the evidence found and/or expert consensus. CONCLUSIONS We present the first official SER-SEPAR document with specific recommendations for RA-ILD management developed to resolve some common clinical questions, reduce clinical healthcare variability, and facilitate decision-making for patients.
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Affiliation(s)
- Javier Narváez
- Servicio de Reumatología, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain
| | - Gema Bonilla
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, Spain
| | - Myriam Aburto
- Servicio de Neumología, Hospital Universitario Galdakao-Usansolo, Bilbao, Spain
| | - Iván Castellví
- Servicio de Reumatología, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Natalia Mena-Vázquez
- Servicio de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - M Asunción Nieto
- Servicio de Neumología, Hospital Clínico San Carlos, Madrid, Spain
| | - Ana María Ortiz
- Servicio de Reumatología, Hospital Universitario de La Princesa, Madrid, Spain
| | - Claudia Valenzuela
- Servicio de Neumología, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Isabel Castrejón
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Correyero Plaza
- Servicio de Reumatología, Hospital Universitario Quironsalud de Pozuelo, Pozuelo de Alarcón, Madrid, Spain
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Vicente-Rabaneda EF, Atienza-Mateo B, Blanco R, Cavagna L, Ancochea J, Castañeda S, González-Gay MÁ. Efficacy and safety of abatacept in interstitial lung disease of rheumatoid arthritis: A systematic literature review. Autoimmun Rev 2021; 20:102830. [PMID: 33887489 DOI: 10.1016/j.autrev.2021.102830] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Interstitial lung disease (ILD) is a serious complication that represents the second leading cause of death in patients with rheumatoid arthritis (RA). Treatment of RA-ILD remains controversial. The absence of randomized clinical trials and specific ACR or EULAR therapeutic guidelines makes it difficult to establish solid therapeutic recommendations on this issue. In this scenario, real-world data is especially valuable. OBJECTIVE To review the literature evidence on the efficacy and safety of abatacept (ABA) for the treatment of rheumatoid arthritis (RA) with associated interstitial lung disease (ILD), given its clinical relevance and the lack of consensus on its therapeutic management. METHODS PUBMED and EMBASE were searched from the date of approval of ABA to the end of 2020 using a combination of RA, ILD and ABA terms following PRISMA guidelines. Identified studies were evaluated by two independent investigators. RESULTS Nine original studies (1 case series and 8 observational studies) were selected for inclusion in the systematic review. No randomized trial or meta-analysis were identified. The mean age of patients ranged from 61.2 to 75 years and the mean RA duration varied from 7.4 to 18 years. Subcutaneous ABA (74.5%-91%) predominated in combination with conventional synthetic DMARDs (csDMARDs) (58%-75%), and it was used as first-line biologic agent in 22.8%-64.9% of the patients. The mean course of ILD ranged from 1 to 6.7 years, being usual and nonspecific interstitial pneumonia the most frequent patterns. Improvement or stabilization of ILD imaging (76.6%-92.7%) and FVC or DLCO (>85%) was described after a mean follow-up of 17.4-47.8 months, regardless of the pattern of lung involvement, being more remarkable in patients with shorter evolution of ILD. ABA led to significantly lower ILD worsening rates than TNF inhibitors (TNFi) and was associated with a 90% reduction in the relative risk of deterioration of ILD at 24 months of follow-up compared to TNFi and csDMARDs. Combination with methotrexate may have a corticoid-sparing effect. No unexpected adverse events were identified. CONCLUSIONS Current evidence suggests that ABA may be a plausible alternative to treat RA patients with ILD. It would be highly desirable to develop prospective randomized controlled studies to confirm these findings.
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Affiliation(s)
- Esther F Vicente-Rabaneda
- Rheumatology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Belén Atienza-Mateo
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain.
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain.
| | - Lorenzo Cavagna
- University and IRCCS Policlinico S. Matteo Foundation, Viale Camillo Golgi 19, 27100 Pavia, Italy.
| | - Julio Ancochea
- Pneumology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 4, 28029 Madrid, Spain.
| | - Santos Castañeda
- Rheumatology Division, Hospital Universitario de la Princesa, IIS-Princesa, C/Diego de León 62, 28006 Madrid, Spain; Cátedra UAM-Roche, EPID-Future, Medicine Department, Universidad Autónoma de Madrid, C/Arzobispo Morcillo 4, 28029 Madrid, Spain.
| | - Miguel Á González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Av. de Valdecilla 25, 39008 Santander, Cantabria, Spain; University of Cantabria, Santander, Spain; University of Witwatersrand, Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, South Africa.
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Targeted therapies in interstitial lung disease secondary to systemic autoimmune rheumatic disease. Current status and future development. Autoimmun Rev 2020; 20:102742. [PMID: 33333235 DOI: 10.1016/j.autrev.2020.102742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/25/2020] [Indexed: 12/22/2022]
Abstract
Autoimmune rheumatic diseases (ARD) are characterized by systemic manifestations and multiple organ involvement, including the lung. Interstitial Lung Disease (ILD) is a cardinal manifestation of lung involvement in patients with ARD and is associated with significant morbidity and mortality. Corticosteroids and immunosuppressive drugs are used as first -line treatment. Targeted therapies, such as biological disease modifying antirheumatic drugs (DMARDS) and anti- fibrotic agents are new treatment options. In this review we discuss the role of targeted therapies in patients with ILD secondary to ARD.
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Fernández-Díaz C, Castañeda S, Melero-González RB, Ortiz-Sanjuán F, Juan-Mas A, Carrasco-Cubero C, Casafont-Solé I, Olivé A, Rodríguez-Muguruza S, Almodóvar-González R, Castellanos-Moreira R, Rodríguez-García SC, Aguilera-Cros C, Villa I, Ordóñez-Palau S, Raya-Alvarez E, Morales-Garrido P, Ojeda-García C, Moreno-Ramos MJ, Bonilla Hernán MG, Hernández Rodríguez I, López-Corbeto M, Andreu JL, Jiménez de Aberásturi JRD, Ruibal-Escribano A, Expósito-Molinero R, Pérez-Sandoval T, López-Robles AM, Carreira-Delgado P, Mena-Vázquez N, Urruticoechea-Arana A, Peralta-Ginés C, Arboleya-Rodríguez L, Narváez García FJ, Palma-Sánchez D, Cervantes Pérez EC, Maiz-Alonso O, Alvarez-Rivas MN, Fernández-Melón J, Vela Casasempere P, Cabezas-Rodríguez I, Castellvi-Barranco I, González-Montagut C, Blanco-Madrigal J, Del Val-Del Amo N, Fito MC, Rodríguez-Gómez M, Salgado-Pérez E, García-Magallón B, Hidalgo-Calleja C, López-Sánchez R, Fernández-Aguado S, Fernández-López JC, Castro-Oreiro S, Serrano-García I, García-Valle A, Romero-Yuste S, Expósito-Pérez L, Pérez-Albadalejo L, García-Aparicio A, Quillis-Marti N, Bernal-Vidal JA, Loricera-García J, Hernández JL, González-Gay MA, Blanco R. Abatacept in interstitial lung disease associated with rheumatoid arthritis: national multicenter study of 263 patients. Rheumatology (Oxford) 2020; 59:3906-3916. [DOI: 10.1093/rheumatology/keaa621] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/01/2020] [Indexed: 01/11/2023] Open
Abstract
Abstract
Objective
To assess the efficacy of abatacept (ABA) in RA patients with interstitial lung disease (ILD) (RA-ILD).
Methods
This was an observational, multicentre study of RA-ILD patients treated with at least one dose of ABA. ILD was diagnosed by high-resolution CT (HRCT). We analysed the following variables at baseline (ABA initiation), 12 months and at the end of the follow-up: Modified Medical Research Council (MMRC) scale (1-point change), forced vital capacity (FVC) or diffusion lung capacity for carbon monoxide (DLCO) (improvement or worsening ≥10%), HRCT, DAS on 28 joints evaluated using the ESR (DAS28ESR) and CS-sparing effect.
Results
We studied 263 RA-ILD patients [150 women/113 men; mean (s.d.) age 64.6 (10) years]. At baseline, they had a median duration of ILD of 1 (interquartile range 0.25–3.44) years, moderate or severe degree of dyspnoea (MMRC grade 2, 3 or 4) (40.3%), FVC (% of the predicted) mean (s.d.) 85.9 (21.8)%, DLCO (% of the predicted) 65.7 (18.3) and DAS28ESR 4.5 (1.5). The ILD patterns were: usual interstitial pneumonia (UIP) (40.3%), non-specific interstitial pneumonia (NSIP) (31.9%) and others (27.8%). ABA was prescribed at standard dose, i.v. (25.5%) or s.c. (74.5%). After a median follow-up of 12 (6–36) months the following variables did not show worsening: dyspnoea (MMRC) (91.9%); FVC (87.7%); DLCO (90.6%); and chest HRCT (76.6%). A significant improvement of DAS28ESR from 4.5 (1.5) to 3.1 (1.3) at the end of follow-up (P < 0.001) and a CS-sparing effect from a median 7.5 (5–10) to 5 (2.5–7.5) mg/day at the end of follow-up (P < 0.001) was also observed. ABA was withdrawn in 62 (23.6%) patients due to adverse events (n = 30), articular inefficacy (n = 27), ILD worsening (n = 3) and other causes (n = 2).
Conclusion
ABA may be an effective and safe treatment for patients with RA-ILD.
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Affiliation(s)
| | - Santos Castañeda
- Rheumatology Cátedra UAM-Roche (EPID-Future) HU La Princesa, IIS-Princesa, UAM, Madrid
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - José L Hernández
- Rheumatology, HU Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander
| | | | - Ricardo Blanco
- Rheumatology, HU Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander
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Cho SK, Doyle TJ, Lee H, Jin Y, Tong AY, Ortiz AJS, Sparks JA, Kim SC. Validation of claims-based algorithms to identify interstitial lung disease in patients with rheumatoid arthritis. Semin Arthritis Rheum 2020; 50:592-597. [PMID: 32480097 DOI: 10.1016/j.semarthrit.2020.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 04/07/2020] [Accepted: 04/15/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To develop and validate claims-based algorithms to identify interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) METHODS: Using Medicare claims data linked with the electronic medical records (2012-2014), we first selected RA patients based on ≥2 diagnostic codes for RA and ≥1 disease-modifying antirheumatic drugs.Then, to identify ILD in RA, we developed eight claims-based algorithms using a combination of ICD-9 diagnosis codes and procedure codes related to the diagnosis or management of ILD. We assessed the positive predictive value (PPV) for each of the eight algorithms relative to confirmed ILD cases using chest computerized tomography or lung biopsy as the gold standard. RESULTS A total of 5,214 RA patients were included in the study, and the ILD cases identified by each algorithm ranged from 181 to 993. The PPV of the diagnosis code-based algorithms ranged from 43.4% (≥1 diagnosis code by any physician) to 52.0% (≥2 diagnosis codes by any physician). When the algorithms further required ≥1 procedure code (e.g., imaging, bronchoscopy), the PPV did not improve. However, the algorithms that required ILD diagnosis codes by specialists (i.e., pulmonologist or rheumatologist) had PPVs of 61.5% with ≥1 code; 72.4% with ≥2 codes. CONCLUSIONS In a cohort of RA patients, our algorithm that required ≥2 ILD diagnosis codes by specialists demonstrated a PPV of 72.4% in ascertaining ILD. Our results support the utility of the claims-based algorithm to identify a population-based cohort of RA patients with ILD using large administrative claims data.
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Affiliation(s)
- Soo-Kyung Cho
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Division of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Tracy J Doyle
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Angela Y Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Adrian J Santiago Ortiz
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jeffrey A Sparks
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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6
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Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease: Lights and Shadows. J Clin Med 2020; 9:jcm9041082. [PMID: 32290218 PMCID: PMC7230307 DOI: 10.3390/jcm9041082] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/29/2020] [Accepted: 04/03/2020] [Indexed: 12/16/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease affecting 0.5–1% of the population worldwide. Interstitial lung disease (ILD) is a serious pulmonary complication of RA and it is responsible for 10–20% of mortality, with a mean survival of 5–8 years. However, nowadays there are no therapeutic recommendations for the treatment of RA-ILD. Therapeutic options for RA-ILD are complicated by the possible pulmonary toxicity of many disease modifying anti-rheumatic drugs (DMARDs) and by their unclear efficacy on pulmonary disease. Therefore, joint and lung involvement should be evaluated independently of each other for treatment purposes. On the other hand, some similarities between RA-ILD and idiopathic pulmonary fibrosis and the results of the recent INBIULD trial suggest a possible future role for antifibrotic agents. From this perspective, we review the current literature describing the pulmonary effects of drugs (immunosuppressants, conventional, biological and target synthetic DMARDs and antifibrotic agents) in patients with RA and ILD. In addition, we suggest a framework for the management of RA-ILD patients and outline a research agenda to fill the gaps in knowledge about this challenging patient cohort.
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Gower J, Labarca G, Enos D, Nova-Lamperti E. Rapid development of severe acute respiratory distress syndrome after abatacept treatment in a patient with rheumatoid arthritis. BMJ Case Rep 2020; 13:13/4/e231725. [PMID: 32265206 DOI: 10.1136/bcr-2019-231725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abatacept is a biological agent that modulates T-cell costimulation by blocking CD28 signalling. This cytotoxic T-lymphocyte-associated antigen-4-Ig fusion protein was approved for treatment of rheumatoid arthritis (RA). However, a few case reports have revealed respiratory failure after abatacept treatment. In this report, we present a patient with RA who developed severe acute respiratory distress syndrome (ARDS) and who passed away 2 months after starting abatacept. A comprehensive analysis including radiology, blood examinations, infectious panel and flow cytometry lymphocyte analysis was done to determine the cause of respiratory failure. Since no infection was detected in this patient, an association between ARDS and abatacept is a strong possibility due to significant adverse reactions to the biological agent. Considering the rapid progression of respiratory failure after abatacept treatment in this report, we suggest that pulmonary function testing and lung structure evaluation be regarded throughout the early stage of treatment of patients with RA.
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Affiliation(s)
- Jorge Gower
- Molecular and Translational Immunology Laboratory, Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, Universidad de Concepcion, Concepcion, Chile
| | - Gonzalo Labarca
- Molecular and Translational Immunology Laboratory, Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, Universidad de Concepcion, Concepcion, Chile
| | - Daniel Enos
- Internal Medicine, Universidad San Sebastian, Los Angeles, Chile
| | - Estefania Nova-Lamperti
- Molecular and Translational Immunology Laboratory, Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, Universidad de Concepcion, Concepcion, Chile
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8
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Cassone G, Manfredi A, Atzeni F, Venerito V, Vacchi C, Picerno V, Furini F, Erre GL, Tomietto P, Fedele AL, Della Casa G, Nucera V, Giannitti C, Salvarani C, Sebastiani M. Safety of Abatacept in Italian Patients with Rheumatoid Arthritis and Interstitial Lung Disease: A Multicenter Retrospective Study. J Clin Med 2020; 9:jcm9010277. [PMID: 31963908 PMCID: PMC7019755 DOI: 10.3390/jcm9010277] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/10/2020] [Accepted: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background: Treatment of rheumatoid arthritis (RA)-related interstitial lung disease (ILD) is challenging, and many conventional and biologic disease-modifying anti-rheumatic drugs (DMARDs) have been associated with ILD development or progression. The aim of this multicentric retrospective study was to analyze the evolution of ILD in Italian RA-ILD patients treated with abatacept (ABA). Methods: All RA-ILD patients treated with ABA for at least six months were retrospectively evaluated. Serology, previous and concurrent therapies, chest high-resolution computer tomography (HRCT), forced vital capacity (FVC), and lung diffusion of carbon monoxide (CO, DLCO) were collected. Results: Forty-four patients were included; HRCT, FVC, and DLCO were analyzed at baseline, at one year, and at the end of follow-up. A remission or a low disease activity of RA was reached in 41/44 patients. Overall, FVC and DLCO remained stable or increased in 86.1% and 91.7% of patients, respectively, while HRCT was stable or improved in 81.4% of them. Previous and concurrent treatments, in particular, methotrexate, serology, age, sex, joint and lung disease duration were not associated with the outcome at univariate analysis. Conclusion: The management of RA-ILD patients remains a critical unmet medical need. Waiting for prospective controlled studies, ABA has shown a good safety profile in our cohort of Italian RA-ILD patients.
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Affiliation(s)
- Giulia Cassone
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (C.V.)
| | - Andreina Manfredi
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy (C.S.)
| | - Fabiola Atzeni
- Rheumatology Unit, University of Messina, 98121 Messina, Italy; (F.A.)
| | - Vincenzo Venerito
- Rheumatology Unit, Interdisciplinary Department of Medicine, University of Bari, 70121 Bari, Italy;
| | - Caterina Vacchi
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (C.V.)
| | - Valentina Picerno
- Rheumatology Institute of Lucania (IReL) and Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, 85100 Potenza, Italy;
| | - Federica Furini
- Department of Medical Sciences, Division of Rheumatology, Santa Anna University Hospital, 44100 Ferrara, Italy;
| | - Gian Luca Erre
- Rheumatology Unit, Azienda Ospedaliero-Universitaria di Sassari, 07010 Sassari, Italy;
| | - Paola Tomietto
- Department of Clinical Medicine, Rheumatology Unit, Azienda Sanitaria Universitaria Integrata di Trieste, 34121 Trieste, Italy;
| | - Anna Laura Fedele
- Rheumatology Unit, Policlinico Gemelli Foundation, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giovanni Della Casa
- Radiology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy
| | - Valeria Nucera
- Rheumatology Unit, University of Messina, 98121 Messina, Italy; (F.A.)
| | | | - Carlo Salvarani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy (C.S.)
| | - Marco Sebastiani
- Chair and Rheumatology Unit, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41121 Modena, Italy (C.S.)
- Correspondence: ; Tel.: +39-059-4225636; Fax: +39-059-4223007
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Karampitsakos T, Vraka A, Bouros D, Liossis SN, Tzouvelekis A. Biologic Treatments in Interstitial Lung Diseases. Front Med (Lausanne) 2019; 6:41. [PMID: 30931306 PMCID: PMC6425869 DOI: 10.3389/fmed.2019.00041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 02/13/2019] [Indexed: 12/17/2022] Open
Abstract
Interstitial lung diseases (ILD) represent a group of heterogeneous parenchymal lung disorders with complex pathophysiology, characterized by different clinical and radiological patterns, ultimately leading to pulmonary fibrosis. A considerable proportion of these disease entities present with no effective treatment, as current therapeutic regimens only slow down disease progression, thus leaving patients, at best case, with considerable functional disability. Biologic therapies have emerged and are being investigated in patients with different forms of ILD. Unfortunately, their safety profile has raised many concerns, as evidence shows that they might cause or exacerbate ILD status in a subgroup of patients. This review article aims to summarize the current state of knowledge on their role in patients with ILD and highlight future perspectives.
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Affiliation(s)
- Theodoros Karampitsakos
- 5th Department of Pneumonology, General Hospital for Thoracic Diseases Sotiria, Athens, Greece
| | - Argyro Vraka
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, Sotiria Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, Sotiria Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Stamatis-Nick Liossis
- Division of Rheumatology, Department of Internal Medicine, Patras University Hospital, University of Patras Medical School, Patras, Greece
| | - Argyris Tzouvelekis
- First Academic Department of Pneumonology, Hospital for Thoracic Diseases, Sotiria Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Kwon OC, Lee EJ, Chang EJ, Youn J, Ghang B, Hong S, Lee CK, Yoo B, Kim YG. IL-17A +GM-CSF + Neutrophils Are the Major Infiltrating Cells in Interstitial Lung Disease in an Autoimmune Arthritis Model. Front Immunol 2018; 9:1544. [PMID: 30013577 PMCID: PMC6036238 DOI: 10.3389/fimmu.2018.01544] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/21/2018] [Indexed: 11/25/2022] Open
Abstract
Objective To gain a better understanding of the pathogenesis of autoimmune arthritis-associated interstitial lung disease (ILD), we sought to identify the characteristics of lung-infiltrating cells in SKG mice with ILD. Methods We injected curdlan in SKG mice at 8 weeks of age, and identified the presence of ILD by PET-MRI at 20 weeks post-injection and histological analysis at 22 weeks post-injection. Lung-infiltrating cells were examined by flow cytometry. Analysis of serum cytokines by the Luminex multiplex cytokine assay was performed at 14 and 22 weeks post-injection, and cytokine profiles before and after the development of ILD were compared. Opal multiplexed immunofluorescent staining of lung tissue was also performed. Results At 20 weeks post-injection, curdlan-treated SKG mice developed not only arthritis but also lung inflammation combined with fibrosis, which was identified by PET-MRI and histological analysis. The majority of inflammatory cells that accumulated in the lungs of curdlan-treated SKG mice were CD11b+Gr1+ neutrophils, which co-express IL-17A and GM-CSF, rather than TNF-α. Compared with 14 weeks post-injection, serum levels of GM-CSF, MCP1, IL-17A, IL-23, TSLP, and soluble IL-7Rα had increased at 22 weeks post-injection, whereas those of IFN-γ, IL-22, IL-6, and TNF-α remained unchanged. Furthermore, IL-23, CXCL5, IL-17A, and GM-CSF, but not TNF-α, were observed in immunofluorescent-stained lung tissue. Conclusion We found that IL-17A+GM-CSF+ neutrophils represented the major inflammatory cells in the lungs of curdlan-treated SKG mice. In addition, GM-CSF and IL-17A appear to play a more important role than TNF-α in ILD development.
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Affiliation(s)
- Oh Chan Kwon
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Eun-Ju Lee
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Eun-Ju Chang
- Department of Biomedical Science, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Jeehee Youn
- Department of Anatomy and Cell Biology, College of Medicine, Hanyang University, Seoul, South Korea
| | - Byeongzu Ghang
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea
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11
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Atzeni F, Gerardi MC, Barilaro G, Masala IF, Benucci M, Sarzi-Puttini P. Interstitial lung disease in systemic autoimmune rheumatic diseases: a comprehensive review. Expert Rev Clin Immunol 2017; 14:69-82. [DOI: 10.1080/1744666x.2018.1411190] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Fabiola Atzeni
- Maurizio Benucci, Rheumatology Unit, San Giovanni Di Dio Hospital, Florence, Italy
| | - Maria Chiara Gerardi
- Rheumatology Unit, Department of Internal Medicine, ASST-Fatebenefratelli L. Sacco University Hospital, Milan, Italy
| | | | | | - Maurizio Benucci
- Rheumatology Unit, Department of Internal Medicine, ASST-Fatebenefratelli L. Sacco University Hospital, Milan, Italy
| | - Piercarlo Sarzi-Puttini
- Rheumatology Unit, Department of Internal Medicine, ASST-Fatebenefratelli L. Sacco University Hospital, Milan, Italy
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12
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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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13
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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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14
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Chen J, Chi S, Li F, Yang J, Cho WC, Liu X. Biologics-induced interstitial lung diseases in rheumatic patients: facts and controversies. Expert Opin Biol Ther 2017; 17:265-283. [PMID: 28117616 DOI: 10.1080/14712598.2017.1287169] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Interstitial lung disease (ILD) is a common, devastating pulmonary complication. An increased number of reports suggesting that biological disease modifying antirheumatic drugs (DMARDs) induced or exacerbated ILDs in rheumatoid arthritis (RA) patients has garnered increased attention. Areas covered: This article discusses ILDs induced by or exacerbated during biological therapy in RA patients. The article summarizes the efficacy and safety of a variety of licensed and off-label biologics clinically used for rheumatic diseases, focusing on the onset or exacerbation of RA-associated ILDs (RA-ILDs) in RA patients treated with biologics targeting tumor necrosis factor, CD20, interleukin 1 (IL-1) and IL-6 receptors. Additionally, the pathogenesis of RA-ILDs is discussed. Expert opinion: To some extent, the possibility of biologic-induced RA-ILDs increases the difficulty in choosing an optimal regimen for RA treatment with biological agents, as the relationship between biological therapy safety and the induction or exacerbation of RA-ILDs has not been established. A framework to assess baseline disease severity, particularly standardizing the evaluation of the pulmonary condition stage in RA patients and monitoring the outcome during the biological therapy treatment, is highly needed and may substantially help guide treatment decisions and predict the treatment benefits.
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Affiliation(s)
- Juan Chen
- a Department of Pulmonary and Critical Care Medicine , General Hospital of Ningxia Medical University , Yinchuan , China
| | - Shuhong Chi
- b Department of Rheumatology , General Hospital of Ningxia Medical University , Yinchuan , China
| | - Feng Li
- c Center of Laboratory Medicine , General Hospital of Ningxia Medical University , Yinchuan , Ningxia , China
| | - Jiali Yang
- c Center of Laboratory Medicine , General Hospital of Ningxia Medical University , Yinchuan , Ningxia , China.,d Human Stem Cell Institute , General Hospital of Ningxia Medical University , Yinchuan , Ningxia , China
| | - William C Cho
- e Department of Clinical Oncology , Queen Elizabeth Hospital , Kowloon , Hong Kong
| | - Xiaoming Liu
- c Center of Laboratory Medicine , General Hospital of Ningxia Medical University , Yinchuan , Ningxia , China.,d Human Stem Cell Institute , General Hospital of Ningxia Medical University , Yinchuan , Ningxia , China
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15
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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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16
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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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17
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Doğu B, Atilla N, Çetin GY, Yılmaz N, Öksüz H. A case of acute respiratory failure in a rheumatoid arthritis patient after the administration of abatacept. Eur J Rheumatol 2016; 3:134-135. [PMID: 27733944 DOI: 10.5152/eurjrheum.2015.0037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/03/2015] [Indexed: 12/15/2022] Open
Abstract
Drug-induced pulmonary disease is an important consideration in the differential diagnosis of patients with rheumatoid arthritis (RA) who present with respiratory symptoms. We report a patient with RA who developed acute respiratory failure two weeks after the administration of abatacept. The clinical findings were consistent with drug-induced acute respiratory failure, most likely acute eosinophilic pneumonia. Pulse steroid was administered at 1000 mg/kg/day in the emergency department. Chest X-ray and arterial blood gas values revealed significant improvement on the second day of hospitalization. However, in the second week, the patient's fever rose up to 40°C, procalcitonin level increased to 15 ng/mL (<0.5 ng/mL is normal), and the patient died because of sepsis in the fourth week. This is the second report of respiratory failure, after the abatacept administration in the literature. We have reported an acute respiratory failure that occurred after use of the biological agent abatacept. With the increasing use of novel immunomodulatory agents, it is important for clinicians and pathologists to add the possibility of a drug reaction to the traditional differentials of acute respiratory failures occurring in these settings.
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Affiliation(s)
- Birsen Doğu
- Department of Anesthesia and Reanimation, Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Nurhan Atilla
- Department of Chest Diseases, Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Gözde Yıldırım Çetin
- Department of Rheumatology, Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Nezir Yılmaz
- Department of Anesthesia and Reanimation, Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
| | - Hafize Öksüz
- Department of Anesthesia and Reanimation, Sütçü İmam University School of Medicine, Kahramanmaraş, Turkey
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18
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Her M, Kavanaugh A. Alterations in immune function with biologic therapies for autoimmune disease. J Allergy Clin Immunol 2016; 137:19-27. [DOI: 10.1016/j.jaci.2015.10.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/21/2015] [Accepted: 10/28/2015] [Indexed: 02/08/2023]
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19
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Abstract
Comprehensive, up-to-date review of RA-associated lung diseases including pathogenesis and managementhttp://ow.ly/FBaNZ
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Affiliation(s)
- Megan Shaw
- Division of Rheumatology, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Bridget F Collins
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Lawrence A Ho
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
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20
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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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21
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Mori S. Management of Rheumatoid Arthritis Patients with Interstitial Lung Disease: Safety of Biological Antirheumatic Drugs and Assessment of Pulmonary Fibrosis. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:41-9. [PMID: 26401101 PMCID: PMC4564070 DOI: 10.4137/ccrpm.s23288] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 02/07/2023]
Abstract
Interstitial lung disease (ILD) is one of the major causes of morbidity and mortality of patients with rheumatoid arthritis (RA). Accompanying the increased number of reports on the development or exacerbation of ILD in RA patients following therapy with biological disease-modifying antirheumatic drugs (DMARDs), RA-associated ILD (RA-ILD) has aroused renewed interest. Although such cases have been reported mainly in association with the use of tumor necrosis factor inhibitors, the use of other biological DMARDs has also become a matter of concern. Nevertheless, it is difficult to establish a causative relationship between the use of biological DMARDs and either the development or exacerbation of ILD. Such pulmonary complications may occur in the natural course of RA regardless of the use of biological DMARDs. Since rheumatologists currently aim to achieve remission in RA patients, the administration of biological DMARDs is increasing, even for those with RA-ILD. However, there are no reliable, evidence-based guidelines for deciding whether biological DMARDs can be safely introduced and continued in RA-ILD patients. A standardized staging system for pulmonary conditions of RA-ILD patients is needed when making therapeutic decisions at baseline and monitoring during biological DMARD therapy. Based on the available information regarding the safety of biological DMARDs and the predictive factors for a worse prognosis, this review discusses candidate parameters for risk evaluation of ILD in RA patients who are scheduled to receive biological antirheumatic therapy.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
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Olivas-Flores EM, Bonilla-Lara D, Gamez-Nava JI, Rocha-Muñoz AD, Gonzalez-Lopez L. Interstitial lung disease in rheumatoid arthritis: Current concepts in pathogenesis, diagnosis and therapeutics. World J Rheumatol 2015; 5:1-22. [DOI: 10.5499/wjr.v5.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/27/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is the most common chronic autoimmune inflammatory joint disease. RA-associated interstitial lung disease (RA-ILD) is a major extra-articular complication and causes symptoms that lead to a deterioration in the quality of life, high utilization of health resources, and an increased risk of earlier mortality. Early in the course of RA-ILD, symptoms are highly variable, making the diagnosis difficult. Therefore, a rational diagnostic strategy that combines an adequate clinical assessment with the appropriate use of clinical tests, including pulmonary function tests and high-resolution computed tomography, should be used. In special cases, lung biopsy or bronchioalveolar lavage should be performed to achieve an early diagnosis. Several distinct histopathological subtypes of RA-ILD are currently recognized. These subtypes also have different clinical presentations, which vary in therapeutic response and prognosis. This article reviews current evidence about the epidemiology of RA-ILD and discusses the varying prevalence rates observed in different studies. Additionally, aspects of RA-ILD pathogenesis, including the role of cytokines and other molecules such as autoantibodies, as well as the evidence linking several drugs used to treat RA with lung damage will be discussed. Some aspects of the clinical characteristics of RA-ILD are noted, and diagnostic strategies are reviewed. Finally, this article analyzes current treatments for RA-ILD, including immunosuppressive therapies and biologic agents, as well as other therapeutic modalities. The prognosis of this severe complication of RA is discussed. Additionally, this paper examines updated evidence from studies identifying an association between drugs used for the treatment of RA and the development of ILD.
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24
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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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25
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Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum 2013; 43:613-26. [PMID: 24231065 DOI: 10.1016/j.semarthrit.2013.09.005] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/25/2013] [Accepted: 09/29/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To review published cases of induced or exacerbated interstitial lung disease (ILD) in rheumatoid arthritis (RA) associated with non-biologic disease-modifying antirheumatic drugs (nbDMARDs) and biologics and to discuss clinical implications in daily practice. METHODS We performed a systematic literature review from 1975 to July 2013 using Medline, Embase, Cochrane, and abstracts from the ACR 2010-2012 and EULAR 2010-2013 annual meetings. Case reports and series that suggest a causative role of nbDMARDs (methotrexate [MTX], leflunomide [LEF], gold, azathioprine [AZA], sulfasalazine [SSZ], and hydroxychloroquine [HCQ]) and biologic agents (TNF inhibitors [TNFi], rituximab [RTX], tocilizumab [TCZ], abatacept [ABA], and anakinra) in causing ILD or worsening a pre-existing ILD in RA patients were included. Results from observational and postmarketing studies as well as reviews on this topic were excluded from the qualitative analysis but still considered to discuss the implication of such drugs in generating or worsening ILD in RA patients. Comparisons were made between MTX-induced ILD in RA and the cases reported with other agents, in terms of clinical presentation, radiological features, and therapeutic management and outcomes. RESULTS The literature search identified 32 articles for MTX, 12 for LEF (resulting in 34 case reports), 3 for gold, 1 for AZA, 4 for SSZ, 27 for TNFi (resulting in 31 case reports), 3 for RTX, 5 for TCZ (resulting in 8 case reports), and 1 for ABA. No case was found for HCQ or anakinra. Common points are noted between LEF- and TNFi-related ILD in RA: ILD is a rare severe adverse event, mostly occurs within the first 20 weeks after initiation of therapy, causes dyspnea mostly in older patients, and can be fatal. Although no definitive causative relationship can be drawn from case reports and observational studies, these data argue for a pulmonary follow-up in RA patients with pre-existing ILD, while receiving biologic therapy or nbDMARDs. CONCLUSION As previously described for MTX, growing evidence highlights that LEF, TNFi, RTX, and TCZ may induce pneumonitis or worsen RA-related pre-existing ILD. Nonetheless, identifying a causal relationship between RA therapy and ILD-induced toxicity clearly appears difficult, partly because it is a rare condition.
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Affiliation(s)
- Camille Roubille
- Osteoarthritis Research Unit, University of Montreal Hospital Research Center (CRCHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Boulos Haraoui
- Department of Medicine, Rheumatic Disease Unit, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Institut de rhumatologie de Montréal, 1551 Ontario St East, Montreal, Quebec, Canada H2L 1S6.
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