“Maybe we’ll get lucky and one of these agents will show some efficacy for ILD,” Dr. Bathon said.
Her approach for now, she said, is just to “balance an agent or two for the joints and one for the lungs and hope for the best.”
Pulmonologist Concerns
Another struggle with RA-ILD patients is that pulmonologists often want to stop RA treatments because of worries they will make the lungs worse. Dr. Bathon said such anxiety risks undertreatment of the arthritis itself.
“I often wonder with ILD whether the de novo appearance of pulmonary symptoms while on RA therapies is a result of the drug versus the emergence of ILD that has been lurking subclinically and finally breaks through, somewhat like an iceberg under the surface,” she said. “It’s growing and growing and growing and finally breaks above the surface and the patient has symptoms. But is it necessarily caused by the drug?”
She did acknowledge, though, that a balance between tumor necrosis factor and fibrotic interferon gamma could be thrown off by TNF inhibitors, effectively increasing interferon gamma levels, which may promote interstitial fibrosis.
“I think there are so many unanswered questions and there are so few data to help us in decisions regarding treatment of RA-ILD,” she said.
Pulmonologists also sometimes worry about methotrexate, but its major lung toxicity is over allergic pneumonitis, “which is pretty rare,” Dr. Bathon said. “Methotrexate shouldn’t be stopped because of concern about allergic pneumonitis.”
Concerns that methotrexate causes ILD, she said, are relatively unfounded: “The data do not support that.” However, when a patient has ILD, you may want to withhold methotrexate to avoid complicating lung function further if superimposed allergic pneumonitis were to occur. But if patients need methotrexate to control their joint disease, “I do not hesitate to put them on it, or keep them on it,” Dr. Bathon said.
“I don’t want to antagonize my ILD colleagues, but we also need to treat the patients’ inflamed joints, and sometimes we just need methotrexate to do that.”
Thomas R. Collins is a freelance writer living in South Florida.
References
- Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart Cf, et al. Comparison of treatment strategies in early rheumatoid arthritis: A randomized trial. Ann Intern Med. 2007 Mar 20;146(6):406–415.
- Moreland LW, O’Dell JR, Paulus HE, et al. A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: The treatment of Early Aggressive Rheumatoid Arthritis Trial. Arthritis Rheum. 2012 Sep;64(9):2824–2835.
- O’Dell JR, Mikuls TR, Taylor TH, et al. Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013 Jul 25;369(4):307–318.
