Be vigilant for restrictive lung disease in RA

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Publish date: October 4, 2016

Author(s): Kari Oakes

– Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

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ACPA-Positive & ACPA-Negative Patients with RA: The Difference Begins in the Lungs

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January 4, 2016 • By Lara C. Pullen, PhD
The Rheumatologist

Rheumatoid arthritis (RA) is characterized by chronic inflammation in the joints. Approximately two-thirds of patients with RA have anti-citrullinated protein antibodies (ACPA), and these individuals are more likely to have an aggressive disease phenotype. Results from recent studies have suggested that citrullinated proteins may emerge in extra-articular sites and contribute to RA pathogenesis. Some investigators have suggested that the emergence of these citrullinated proteins may precede RA because ACPA can be found in the peripheral blood several years before the onset of RA. Researchers have also noted that patients with seropositive, active RA are also more likely to have inflammation in the lungs.
A new study from Stockholm, Sweden, further strengthens the link between the lungs and ACPA-positive RA. Gudrun Reynisdottir, a graduate student at the Karolinska University Hospital and Institutet, and colleagues published the results of their analysis of 24 patients online on Nov. 3 in the Annals of the Rheumatic Diseases.1 They analyzed the bronchial tissue and bronchoalveolar lavage (BAL) of untreated patients with early RA who did not have concomitant lung disease. Although these patients were within a year of diagnosis, their lungs had signs of immune cell accumulation and activation. The results suggest that early inflammatory events in the lungs are a critical initiating factor for the development of ACPA-positive RA.

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No increased risk of lung disease with methotrexate in Psoriatic Arthritis PsA

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Methotrexate is not associated with an increased risk of pulmonary disease in patients taking it for the treatment of psoriatic arthritis, psoriasis, or inflammatory bowel disease, a meta-analysis has found.

The analysis of results from seven double-blind, randomized, controlled studies, involving a total of 1,640 participants, showed no increased risk of total adverse respiratory events – infectious or noninfectious – or pulmonary deaths in patients taking methotrexate, compared with controls, according to Dr. Richard Conway of the department of rheumatology at Galway (Ireland) University Hospitals and his coauthors.

Methotrexate has previously been implicated as a cause of lung toxicity, and the prevalence of methotrexate-related interstitial lung disease has been reported as high as 11.6% in rheumatoid arthritis, but studies of methotrexate-induced lung disease are confounded by the higher risk of pulmonary infections among patients with rheumatoid arthritis, the authors said (BMJ 2015 [doi:10.1136/bmj.h1269]).

“These findings, coupled with those of a previous study in rheumatoid arthritis, suggest that methotrexate-related lung disease is rare, if it exists at all,” the investigators wrote.

The investigators had no specific source of funding for the study and had no conflicts of interest to declare.