Experts Discuss Unique Challenges Posed by Difficult-to-Treat RA

Dr. Smolen.

ACR CONVERGENCE 2020—Patients with rheumatoid arthritis (RA) and concurrent liver disease or interstitial lung disease (ILD), or with treatment-refractory RA, pose treatment challenges, said panelists in the ACR Convergence 2020 session, How I Treat Difficult RA. Each panelist discussed a difficult case and raised big-picture questions on how to best treat patients facing each challenge.

RA & Interstitial Lung Disease

More data are needed to definitively choose the best treatment for RA and ILD, said Joan M. Bathon, MD, professor of medicine and chief of the Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York City. In her talk, Dr. Bathon presented the case of a 65-year-old man found to have RA-ILD, as well as probable heart failure. She used the case as a springboard for treatment questions for combined RA-ILD.

Dr. Bathon reviewed treatment questions that arise with combined RA-ILD, which occurs in about 8% to 15% of RA patients. The condition has significant mortality, with a median survival of 2.5 years. In one study she shared, about 25% of those with RA-ILD died in the first year after diagnosis.¹

One question is whether methotrexate and leflunomide increase the risk for ILD. Study findings with methotrexate have mixed results, and not many studies focused on this for leflunomide. Overall though, these common RA therapies don’t appear to increase the risk for ILD, Dr. Bathon said.

As to whether a disease-modifying anti-rheumatic drug (DMARD) that can be used both for arthritis and ILD exists, the answer is maybe, Dr. Bathon said. She said that, so far, results for tumor necrosis factor inhibitors have been controversial and open-label studies with abatacept suggested a lack of worsening after starting the treatment for RA-ILD. A trial called FaSScinate, which investigated tocilizumab for systemic sclerosis, found less worsening of disease in the tocilizumab-treated group.^2,3 Still, this is another question for which more data and studies are needed, she added.

When discussing whether such antifibrotics as nintedanib or pirfenidone would be more efficacious than a DMARD for RA-ILD, Dr. Bathon pointed out that no direct comparison data exist. For the fibrotic subtype of ILD, she says nintedanib or perfinodone may be most appropriate to use as they target inhibiting growth factors. In clinical practice, Dr. Bathon said she relys on the preferences of the pulmonologist helping to treat her patients with RA-ILD.

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