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Andronache IT, Şuţa VC, Şuţa M, Ciocodei SL, Vladareanu L, Nicoara AD, Arghir OC. Better Safe than Sorry: Rheumatoid Arthritis, Interstitial Lung Disease, and Medication-A Narrative Review. Biomedicines 2023; 11:1755. [PMID: 37371850 DOI: 10.3390/biomedicines11061755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
It is well known that rheumatoid arthritis (RA) patients are at an increased risk of developing non-infectious pulmonary complications, especially interstitial lung disease (ILD); however, the clinician must keep in mind that lung disease could not only be a manifestation of the underlying condition, but also a consequence of using disease-modifying therapies. New-onset ILD or ILD worsening has also been reported as a possible consequence of both conventional disease-modifying antirheumatic drugs (DMARDs) and biologic agents. This study is a narrative review of the current literature regarding the potential risk of developing interstitial lung disease along with the administration of specific drugs used in controlling rheumatoid arthritis. Its purpose is to fill knowledge gaps related to this challenging patient cohort by addressing various aspects of the disease, including prevalence, disease features, treatment strategies, and patient outcomes.
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Affiliation(s)
- Iulia-Tania Andronache
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
- Department of Rheumatology, Internal Medicine Clinic, "Dr. Alexandru Gafencu" Military Emergency Hospital Constanta, 900527 Constanta, Romania
| | - Victoria-Cristina Şuţa
- 3rd Department-1st Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Maria Şuţa
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Sabina-Livia Ciocodei
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Liliana Vladareanu
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Alina Doina Nicoara
- 3rd Department-1st Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Oana Cristina Arghir
- Doctoral School of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
- 4th Department-2nd Clinical Medical Disciplines, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
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2
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Conway R, Nikiphorou E. Efficacy and safety of conventional synthetic, biologic and targeted synthetic DMARDs in RA-ILD: A narrative review. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_157_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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3
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Izuka S, Yamashita H, Iba A, Takahashi Y, Kaneko H. Acute exacerbation of rheumatoid arthritis-associated interstitial lung disease: clinical features and prognosis. Rheumatology (Oxford) 2021; 60:2348-2354. [PMID: 33241299 DOI: 10.1093/rheumatology/keaa608] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/23/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES RA-associated interstitial lung disease (RA-ILD) is commonly associated with acute exacerbations (ILD-AE). This study examined the clinical characteristics and risk factors of ILD-AE and mortality of RA-ILD. METHODS We retrospectively collected data on 165 RA-ILD patients who visited or were admitted to our hospital between January 2007 and December 2019. We compared the clinical characteristics of patients who did and did not develop ILD-AE and identified variables significantly associated with ILD-AE. We also compared the admission characteristics of those who survived and those who died after admission for ILD-AE. ILD-AE was defined using previously proposed criteria, modified slightly for application to RA-ILD. RESULTS The mean patient age was 73.6 years (s.d. 9.7) and 97 (71.9%) patients were female. Thirty (22.2%) patients developed ILD-AE, 13 (43.3%) of whom died. In univariate analyses, neither the usual interstitial pneumonia (UIP) pattern nor MTX was associated with ILD-AE. In multivariate analyses, the UIP pattern was significantly associated with ILD-AE [odds ratio (OR) 2.55 (95% CI 1.05, 6.20), P = 0.038]. In the Cox proportional hazards model, the UIP pattern [hazard ratio (HR) 4.67 (95% CI 1.02, 21.45), P = 0.048] was significantly associated with death, while MTX use [HR 0.16 (95% CI 0.04, 0.72), P = 0.016] was significantly associated with survival. CONCLUSION Our data suggest that the UIP pattern is related to ILD-AE. Furthermore, both the UIP pattern and non-use of MTX might be related to death from ILD-AE in RA-ILD.
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Affiliation(s)
- Shinji Izuka
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Arisa Iba
- Department of Public Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
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4
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Shao T, Shi X, Yang S, Zhang W, Li X, Shu J, Alqalyoobi S, Zeki AA, Leung PS, Shuai Z. Interstitial Lung Disease in Connective Tissue Disease: A Common Lesion With Heterogeneous Mechanisms and Treatment Considerations. Front Immunol 2021; 12:684699. [PMID: 34163483 PMCID: PMC8215654 DOI: 10.3389/fimmu.2021.684699] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/17/2021] [Indexed: 01/11/2023] Open
Abstract
Connective tissue disease (CTD) related interstitial lung disease (CTD-ILD) is one of the leading causes of morbidity and mortality of CTD. Clinically, CTD-ILD is highly heterogenous and involves rheumatic immunity and multiple manifestations of respiratory complications affecting the airways, vessels, lung parenchyma, pleura, and respiratory muscles. The major pathological features of CTD are chronic inflammation of blood vessels and connective tissues, which can affect any organ leading to multi-system damage. The human lung is particularly vulnerable to such damage because anatomically it is abundant with collagen and blood vessels. The complex etiology of CTD-ILD includes genetic risks, epigenetic changes, and dysregulated immunity, which interact leading to disease under various ill-defined environmental triggers. CTD-ILD exhibits a broad spectra of clinical manifestations: from asymptomatic to severe dyspnea; from single-organ respiratory system involvement to multi-organ involvement. The disease course is also featured by remissions and relapses. It can range from stability or slow progression over several years to rapid deterioration. It can also present clinically as highly progressive from the initial onset of disease. Currently, the diagnosis of CTD-ILD is primarily based on distinct pathology subtype(s), imaging, as well as related CTD and autoantibodies profiles. Meticulous comprehensive clinical and laboratory assessment to improve the diagnostic process and management strategies are much needed. In this review, we focus on examining the pathogenesis of CTD-ILD with respect to genetics, environmental factors, and immunological factors. We also discuss the current state of knowledge and elaborate on the clinical characteristics of CTD-ILD, distinct pathohistological subtypes, imaging features, and related autoantibodies. Furthermore, we comment on the identification of high-risk patients and address how to stratify patients for precision medicine management approaches.
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Affiliation(s)
- Tihong Shao
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Division of Rheumatology/Allergy and Clinical Immunology, University of California, Davis, Davis, CA, United States
| | - Xiaodong Shi
- Rheumatology, First Hospital of Jilin University, Changchun, China
| | - Shanpeng Yang
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Zhang
- Department of Pathology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Xiaohu Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingwei Shu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shehabaldin Alqalyoobi
- Internal Medicine - Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, Greenville, NC, United States
| | - Amir A. Zeki
- University of California (U.C.), Davis, Lung Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, U.C. Davis School of Medicine, University of California, Davis, Davis, CA, United States
| | - Patrick S. Leung
- Division of Rheumatology/Allergy and Clinical Immunology, University of California, Davis, Davis, CA, United States
| | - Zongwen Shuai
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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5
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Does methotrexate cause progressive fibrotic interstitial lung disease? A systematic review. Rheumatol Int 2021; 41:1055-1064. [PMID: 33515067 PMCID: PMC8079289 DOI: 10.1007/s00296-020-04773-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023]
Abstract
The aim is to evaluate the published evidence on whether methotrexate (MTX) use causes progressive fibrotic interstitial lung disease (fILD). This PRISMA-compliant systematic review has been registered electronically with PROSPERO 2018 ID CRD42018087838, Centre of review and dissemination at the University of York. A total of 29 articles met the inclusion criteria. Thirteen articles were found to support the claim that MTX causes fILD. They all had a low Downs and Black quality score (< 6/27). Their ‘risk of bias’ assessment scores indicated serious to critical risk of bias. The 16 articles rejecting the claim that MTX causes fILD were of higher quality as indicated by their Downs and Black score. Their ‘risk of bias’ assessment scores suggested only a low to moderate risk of bias. This systematic literature review supports the finding that MTX does not cause fILD in humans. Three studies suggest that MTX treatment may actually improve outcomes in patients with rheumatoid arthritis (RA) associated fILD by slowing down ILD progression.
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6
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Chen X, Zhang M, Wang T, Li Y, Wei M. Influence factors of extra-articular manifestations in rheumatoid arthritis. Open Med (Wars) 2020; 15:787-795. [PMID: 33313414 PMCID: PMC7706136 DOI: 10.1515/med-2020-0217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/09/2020] [Accepted: 07/13/2020] [Indexed: 11/15/2022] Open
Abstract
Background and objective Extra-articular manifestations (EAMs) are serious outcomes or complications of rheumatoid arthritis (RA) with increasing mortality and morbidity. The purpose was to explore the factors influencing EAMs, tissue-specific/systemic EAMs, and the concurrence of several EAMs. Patients and methods In total, 519 inpatients with RA were enrolled. The clinical characteristics, laboratory parameters, and medications of RA patients and the details of EAMs were recorded carefully. Differences between groups were examined by a Chi-square test, independent samples t test, one-way analysis of variance, Mann-Whitney U test, and Kruskal-Wallis H test. Binary and ordinal logistic regression analyses were performed to determine the relationship between influential factors and EAMs, tissue-specific/systemic EAMs, and the concurrence of several EAMs. Results The morbidity of EAMs was 44.70%. Male sex, age, and traditional Chinese medicine (TCM) were independent influential factors of EAMs, and a number of statistically significant influence factors were found in the multivariate analysis of tissue-specific/systemic EAMs. Finally, age, CRP levels, number of RA-affected types of joints, and TCM were the factors that independently influenced the concurrence of several EAMs. Conclusion Influential factors identified in this study could be recommended in clinical work, which is hopeful to decrease the morbidity and mortality of EAMs in RA.
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Affiliation(s)
- Xing Chen
- Department of Rheumatology and Immunology, The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China.,School of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, 610031, China
| | - Mingmei Zhang
- Department of Rheumatology and Immunology, The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China.,School of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, 610031, China
| | - Tao Wang
- Department of Rheumatology and Immunology, The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China.,School of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, 610031, China
| | - Yunming Li
- Department of Medical Management, Division of Health Services, The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China.,Department of Statistics, College of Mathematics, and School of Medicine, Southwest Jiaotong University, Chengdu, Sichuan Province, 610031, China.,School of Public Health, Southwestern Medical University, LuZhou, Sichuan Province, 646000, China
| | - Meng Wei
- Department of Rheumatology and Immunology, The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China
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7
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Al Nokhatha SA, Harrington R, Conway R. Is methotrexate contra-indicated in lung involvement of rheumatoid arthritis? Joint Bone Spine 2020; 87:535-537. [PMID: 32622034 DOI: 10.1016/j.jbspin.2020.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/04/2020] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Richard Conway
- Department of Rheumatology, St. James's Hospital, Dublin, Ireland.
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8
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Wu EK, Ambrosini RD, Kottmann RM, Ritchlin CT, Schwarz EM, Rahimi H. Reinterpreting Evidence of Rheumatoid Arthritis-Associated Interstitial Lung Disease to Understand Etiology. Curr Rheumatol Rev 2020; 15:277-289. [PMID: 30652645 DOI: 10.2174/1573397115666190116102451] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/19/2018] [Accepted: 01/05/2019] [Indexed: 02/07/2023]
Abstract
Interstitial Lung Disease (ILD) is a well-known complication of rheumatoid arthritis (RA) which often results in significant morbidity and mortality. It is often diagnosed late in the disease process via descriptive criteria. Multiple subtypes of RA-ILD exist as defined by chest CT and histopathology. In the absence of formal natural history studies and definitive diagnostics, a conventional dogma has emerged that there are two major subtypes of RA-ILD (nonspecific interstitial pneumonia (NSIP) and Usual Interstitial Pneumonia (UIP)). These subtypes are based on clinical experience and correlation studies. However, recent animal model data are incongruous with established paradigms of RA-ILD and beg reassessment of the clinical evidence in order to better understand etiology, pathogenesis, prognosis, and response to therapy. To this end, here we: 1) review the literature on epidemiology, radiology, histopathology and clinical outcomes of the various RAILD subtypes, existing animal models, and current theories on RA-ILD pathogenesis; 2) highlight the major gaps in our knowledge; and 3) propose future research to test an emerging theory of RAILD that posits initial rheumatic lung inflammation in the form of NSIP-like pathology transforms mesenchymal cells to derive chimeric disease, and subsequently develops into frank UIP-like fibrosis in some RA patients. Elucidation of the pathogenesis of RA-ILD is critical for the development of effective interventions for RA-ILD.
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Affiliation(s)
- Emily K Wu
- Center for Musculoskeletal Research, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States.,Department of Microbiology & Immunology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Robert D Ambrosini
- Department of Imaging Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - R Matthew Kottmann
- Division of Pulmonary Diseases and Critical Care, Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Christopher T Ritchlin
- Center for Musculoskeletal Research, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States.,Division of Allergy, Immunology, Rheumatology, Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Edward M Schwarz
- Center for Musculoskeletal Research, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States.,Department of Microbiology & Immunology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States.,Department of Orthopaedics, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
| | - Homaira Rahimi
- Center for Musculoskeletal Research, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States.,Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, NY, United States
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9
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Fragoulis GE, Nikiphorou E, Larsen J, Korsten P, Conway R. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Front Med (Lausanne) 2019; 6:238. [PMID: 31709258 PMCID: PMC6819370 DOI: 10.3389/fmed.2019.00238] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/10/2019] [Indexed: 12/20/2022] Open
Abstract
Rheumatoid arthritis (RA) is a type of inflammatory arthritis that affects ~1% of the general population. Although arthritis is the cardinal symptom, many extra-articular manifestations can occur. Lung involvement and particularly interstitial lung disease (ILD) is among the most common. Although ILD can occur as part of the natural history of RA (RA-ILD), pulmonary fibrosis has been also linked with methotrexate (MTX); a condition also known as MTX-pneumonitis (M-pneu). This review aims to discuss epidemiological, diagnostic, imaging and histopathological features, risk factors, and treatment options in RA-ILD and M-pneu. M-pneu, usually has an acute/subacute course characterized by cough, dyspnea and fever. Several risk factors, including genetic and environmental factors have been suggested, but none have been validated. The diagnosis is based on clinical and radiologic findings which are mostly consistent with non-specific interstitial pneumonia (NSIP), more so than bronchiolitis obliterans organizing pneumonia (BOOP). Histological findings include interstitial infiltrates by lymphocytes, histiocytes, and eosinophils with or without non-caseating granulomas. Treatment requires immediate cessation of MTX and commencement of glucocorticoids. RA-ILD shares the same symptomatology with M-pneu. However, it usually has a more chronic course. RA-ILD occurs in about 3-5% of RA patients, although this percentage is significantly increased when radiologic criteria are used. Usual interstitial pneumonia (UIP) and NSIP are the most common radiologic patterns. Several risk factors have been identified for RA-ILD including smoking, male gender, and positivity for anti-citrullinated peptide antibodies and rheumatoid factor. Diagnosis is based on clinical and radiologic findings while pulmonary function tests may demonstrate a restrictive pattern. Although no clear guidelines exist for RA-ILD treatment, glucocorticoids and conventional disease modifying antirheumatic drugs (DMARDs) like MTX or leflunomide, as well as treatment with biologic DMARDs can be effective. There is limited evidence that rituximab, abatacept, and tocilizumab are better options compared to TNF-inhibitors.
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Affiliation(s)
- George E Fragoulis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece.,Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Elena Nikiphorou
- Department of Inflammation Biology, Faculty of Life Sciences & Medicine, Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Jörg Larsen
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Richard Conway
- Department of Rheumatology, Blackrock Clinic, Dublin, Ireland
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10
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Fragoulis GE, Conway R, Nikiphorou E. Methotrexate and interstitial lung disease: controversies and questions. A narrative review of the literature. Rheumatology (Oxford) 2019; 58:1900-1906. [DOI: 10.1093/rheumatology/kez337] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/10/2019] [Indexed: 01/16/2023] Open
Abstract
Abstract
MTX, which is the anchor-drug for the treatment of RA, has been associated with lung injury and in particular with MTX-related pneumonitis (M-pneu). Although the frequency of M-pneu has been reported to range between 0.3 and 11.6%, more recent studies and meta-analyses have challenged that, suggesting that it is less common than previously thought. M-pneu is considered a hypersensitivity reaction usually occuring early after MTX commencement, and to be dose-independent. Furthermore, it does not seem to be truly related to the development of interstitial lung disease observed in some patients as part of the natural history of RA (RA-ILD). On the other hand, there are data suggesting that clinicians should be cautious when commencing MTX in patients with pre-existing lung disease. However, treatment should not be delayed or limited in progressive RA that could lead to RA-ILD, and MTX remains one of the central players in the treat-to-target approach. In this review, we aimed to summarize the current evidence from observational studies and clinical trials on lung disease in MTX-treated RA patients. We focus the discussion on the lack of association between M-pneu and RA-ILD.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Richard Conway
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
| | - Elena Nikiphorou
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, UK
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11
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Quah E, Amoasii C, Mudawi T, Dawson J. Systematic literature review investigating whether methotrexate causes chronic pulmonary fibrosis. Future Healthc J 2019. [DOI: 10.7861/futurehealth.6-2-s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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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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13
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Huang Y, Lin W, Chen Z, Wang Y, Huang Y, Tu S. Effect of tumor necrosis factor inhibitors on interstitial lung disease in rheumatoid arthritis: angel or demon? DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:2111-2125. [PMID: 31308625 PMCID: PMC6616146 DOI: 10.2147/dddt.s204730] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/28/2019] [Indexed: 12/13/2022]
Abstract
Objectives: This study evaluated the correlation between tumor necrosis factor alpha inhibitor (TNF-I) and interstitial lung disease (ILD) in rheumatoid arthritis (RA). We aimed to raise awareness and consummate therapy by summarizing the characteristics of the adverse events of ILD. Methods: A comprehensive search of the PubMed, Embase, Ovid, Cochrane, China National Knowledge Infrastructure, and Wanfang databases was performed from inception to November 2018. Statistical analysis of demographic characteristics, clinical features, and relative risks was performed using Microsoft Excel 2007 and SPSS version 20.0. Results: A total of 7 eligible articles and another 28 case reports were enrolled. The 7 cohort studies demonstrated the tendency that ILD cases might not benefit from TNF-I therapy. TNF-I might be associated with ILD adverse events. The case reports further confirmed these findings, as most (87.5%) of the cases showed that TNF-1 was harmful to patients with ILD and even resulted in a 35% mortality rate. Further investigation revealed that ILD adverse events tended to appear in female patients with a long RA history (p<0.05). The subgroup analysis suggested that early detection and precise treatment are key factors in determining survival or death when an ILD adverse event occurs. A large proportion of ILD adverse events (48.6%) appeared at 2.38±1.03 weeks after the infusion of infliximab. Conclusion: A fresh look at the evidence highlights that TNF-I might be associated with ILD adverse events in RA, which can induce more severe pulmonary symptoms and even result in death. Therefore, more attention should be paid to effective prevention, early diagnosis, and precise management. Notably, further prospective cohort studies are warranted to better interpret the association or causality between TNF-I and ILD.
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Affiliation(s)
- Ying Huang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Weiji Lin
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Zhe Chen
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yu Wang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yao Huang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Shenghao Tu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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14
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Kiely P, Busby AD, Nikiphorou E, Sullivan K, Walsh DA, Creamer P, Dixey J, Young A. Is incident rheumatoid arthritis interstitial lung disease associated with methotrexate treatment? Results from a multivariate analysis in the ERAS and ERAN inception cohorts. BMJ Open 2019; 9:e028466. [PMID: 31061059 PMCID: PMC6501950 DOI: 10.1136/bmjopen-2018-028466] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To assess predictive factors for rheumatoid arthritis interstitial lung disease (RA-ILD) in two early rheumatoid arthritis (RA) inception cohorts with a focus on methotrexate (MTX) exposure. DESIGN Multicentre prospective early RA inception cohort studies; the early RA study (ERAS) and the early RA network (ERAN). SETTING Secondary care, ERAS nine centres, ERAN 23 centres in England, Wales and Ireland. PARTICIPANTS Patients with new diagnosis of RA, n=2701. Standardised data including demographics, drug therapies and clinical outcomes including the presence of RA-ILD were collected at baseline, within 3-6 months, at 12 months and annually thereafter. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was the association of MTX exposure on RA-ILD diagnosis. Secondary outcomes were the association of demographic, comorbid and RA-specific factors on RA-ILD diagnosis and the association of MTX exposure on time to RA-ILD diagnosis. RESULTS Of 92 eligible ILD cases, 39 occurred in 1578 (2.5%) MTX exposed and 53 in 1114 (4.8%) non-MTX exposed cases. The primary analysis of RA-ILD cases only developing after any conventional synthetic disease-modifying antirheumatic drug treatment (n=67) showed MTX exposure not to be associated with incident RA-ILD (OR 0.85, 95% CI 0.49 to 1.49, p=0.578) and a non-significant trend for delayed ILD diagnosis (OR 0.54, 95% CI 0.28 to 1.06, p=0.072). In an extended analysis including RA-ILD cases present at RA diagnosis (n=92), MTX exposure was associated with a significantly reduced risk of incident RA-ILD (OR 0.48, 95% CI 0.3 to 0.79, p=0.004) and longer time to ILD diagnosis (OR 0.41, 95% CI 0.23 to 0.75, p=0.004). Other independent baseline associations with incident RA-ILD were higher age of RA onset, ever smoking, male gender, rheumatoid nodules and longer time from first RA symptom to first outpatient visit. CONCLUSIONS MTX treatment was not associated with an increased risk of RA-ILD diagnosis. On the contrary, evidence suggested that MTX may delay the onset of ILD.
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Affiliation(s)
- Patrick Kiely
- Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK
- Institute of Medical and Biomedical Education, St George’s, University of London, London, UK
| | - A D Busby
- Center for Health Services and Clinical Research and Post Graduate Medicine, University of Hertfordshire, Hatfield, UK
| | - E Nikiphorou
- Department of Academic Rheumatology, King’s College, London, UK
| | - K Sullivan
- Center for Health Services and Clinical Research and Post Graduate Medicine, University of Hertfordshire, Hatfield, UK
| | - D A Walsh
- Department of Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - P Creamer
- Department of Rheumatology, North Bristol NHS Trust, Bristol, UK
| | - J Dixey
- Department of Rheumatology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shrewsbury, UK
| | - A Young
- Center for Health Services and Clinical Research and Post Graduate Medicine, University of Hertfordshire, Hatfield, UK
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Wollatz L, Johnston SJ, Lackie PM, Cox SJ. 3D Histopathology-a Lung Tissue Segmentation Workflow for Microfocus X-ray-Computed Tomography Scans. J Digit Imaging 2018; 30:772-781. [PMID: 28342044 PMCID: PMC5681467 DOI: 10.1007/s10278-017-9966-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Lung histopathology is currently based on the analysis of 2D sections of tissue samples. The use of microfocus X-ray-computed tomography imaging of unstained soft tissue can provide high-resolution 3D image datasets in the range of 2-10 μm without affecting the current diagnostic workflow. Important details of structural features such as the tubular networks of airways and blood vessels are contained in these datasets but are difficult and time-consuming to identify by manual image segmentation. Providing 3D structures permits a better understanding of tissue functions and structural interrelationships. It also provides a more complete picture of heterogeneous samples. In addition, 3D analysis of tissue structure provides the potential for an entirely new level of quantitative measurements of this structure that have previously been based only on extrapolation from 2D sections. In this paper, a workflow for segmenting such 3D images semi-automatically has been created using and extending the ImageJ open-source software and key steps of the workflow have been integrated into a new ImageJ plug-in called LungJ. Results indicate an improved workflow with a modular organization of steps facilitating the optimization for different sample and scan properties with expert input as required. This allows for incremental and independent optimization of algorithms leading to faster segmentation. Representation of the tubular networks in samples of human lung, building on those segmentations, has been demonstrated using this approach.
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Affiliation(s)
- Lasse Wollatz
- Faculty of Engineering and the Environment, University of Southampton, Southampton, SO17 1BJ, UK.
| | - Steven J Johnston
- Faculty of Engineering and the Environment, University of Southampton, Southampton, SO17 1BJ, UK
| | - Peter M Lackie
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - Simon J Cox
- Faculty of Engineering and the Environment, University of Southampton, Southampton, SO17 1BJ, UK
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Burmester GR, McInnes IB, Kremer JM, Miranda P, Vencovský J, Godwood A, Albulescu M, Michaels MA, Guo X, Close D, Weinblatt M. Mavrilimumab, a Fully Human Granulocyte-Macrophage Colony-Stimulating Factor Receptor α Monoclonal Antibody: Long-Term Safety and Efficacy in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2018; 70:679-689. [PMID: 29361199 PMCID: PMC5947536 DOI: 10.1002/art.40420] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/11/2018] [Indexed: 12/15/2022]
Abstract
Objective Mavrilimumab, a human monoclonal antibody, targets granulocyte–macrophage colony‐stimulating factor receptor α. We undertook to determine the long‐term safety and efficacy of mavrilimumab in rheumatoid arthritis patients in 2 phase IIb studies (1071 and 1107) and in 1 open‐label extension study (ClinicalTrials.gov identifier: NCT01712399). Methods In study 1071, patients with an inadequate response to disease‐modifying antirheumatic drugs (DMARDs) received mavrilimumab (30, 100, or 150 mg) or placebo every other week plus methotrexate. In study 1107, patients with an inadequate response to anti–tumor necrosis factor agents and/or DMARDs received 100 mg mavrilimumab every other week or 50 mg golimumab every 4 weeks plus methotrexate. Patients entering the open‐label extension study received 100 mg mavrilimumab every other week plus methotrexate. Long‐term safety and efficacy of mavrilimumab were assessed. Results A total of 442 patients received mavrilimumab (14 of 245 patients from study 1071, 9 of 70 patients from study 1107, and 52 of 397 patients from the open‐label extension study discontinued mavrilimumab treatment throughout the studies). The cumulative safety exposure was 899 patient‐years; the median duration of mavrilimumab treatment was 2.5 years (range 0.1–3.3 years). The most common treatment‐emergent adverse events (AEs) were nasopharyngitis (n = 69; 7.68 per 100 patient‐years) and bronchitis (n = 51; 5.68 per 100 patient‐years). At weeks 74 and 104, 3.5% and 6.2% of patients, respectively, demonstrated reduction in forced expiratory volume in 1 second, while 2.9% and 3.4% of patients, respectively, demonstrated reduction in forced vital capacity (>20% reduction from baseline to <80% predicted). Most pulmonary changes were transient and only infrequently associated with AEs. Mavrilimumab at 100 mg every other week demonstrated sustained efficacy; at week 122, 65.0% of patients achieved a Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP) of <3.2, and 40.6% of patients achieved a DAS28‐CRP of <2.6. Conclusion Long‐term treatment with mavrilimumab maintained response and was well‐tolerated with no increased incidence of treatment‐emergent AEs. Safety data were comparable with those from both phase IIb qualifying studies.
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18
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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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19
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Sparks JA, Barbhaiya M, Karlson EW, Ritter SY, Raychaudhuri S, Corrigan CC, Lu F, Selhub J, Chasman DI, Paynter NP, Ridker PM, Solomon DH. Investigating methotrexate toxicity within a randomized double-blinded, placebo-controlled trial: Rationale and design of the Cardiovascular Inflammation Reduction Trial-Adverse Events (CIRT-AE) Study. Semin Arthritis Rheum 2017; 47:133-142. [PMID: 28284844 PMCID: PMC5765986 DOI: 10.1016/j.semarthrit.2017.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND The role of low dose methotrexate (LDM) in potential serious toxicities remains unclear despite its common use. Prior observational studies investigating LDM toxicity compared LDM to other active drugs. Prior placebo-controlled clinical trials of LDM in inflammatory conditions were not large enough to investigate toxicity. The Cardiovascular Inflammation Reduction Trial (CIRT) is an ongoing NIH-funded, randomized, double-blind, placebo-controlled trial of LDM in the secondary prevention of cardiovascular disease. We describe here the rationale and design of the CIRT-Adverse Events (CIRT-AE) ancillary study which aims to investigate adverse events within CIRT. DESIGN CIRT will randomize up to 7000 participants with cardiovascular disease and no systemic rheumatic disease to either LDM (target dose: 15-20mg/week) or placebo for an average follow-up period of 3-5 years; subjects in both treatment arms receive folic acid 1mg daily for 6 days each week. The primary endpoints of CIRT include recurrent cardio vascular events, incident diabetes, and all-cause mortality, and the ancillary CIRT-AE study has been designed to adjudicate other clinically important adverse events including hepatic, gastrointestinal, respiratory, hematologic, infectious, mucocutaneous, oncologic, renal, neurologic, and musculoskeletal outcomes. Methotrexate polyglutamate levels and genome-wide single nucleotide polymorphisms will be examined for association with adverse events. SUMMARY CIRT-AE will comprehensively evaluate potential LDM toxicities among subjects with cardiovascular disease within the context of a large, ongoing, double-blind, placebo-controlled trial. This information may lead to a personalized approach to monitoring LDM in clinical practice.
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Affiliation(s)
- Jeffrey A Sparks
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Medha Barbhaiya
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Elizabeth W Karlson
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Susan Y Ritter
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Soumya Raychaudhuri
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA
| | - Cassandra C Corrigan
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Fengxin Lu
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA
| | - Jacob Selhub
- Jean Mayer USDA, Human Nutrition Center on Aging, Tufts University, Boston, MA
| | - Daniel I Chasman
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Nina P Paynter
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Paul M Ridker
- Harvard Medical School, Boston, MA; Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women׳s Hospital, Boston, MA
| | - Daniel H Solomon
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women׳s Hospital, Boston, MA; Harvard Medical School, Boston, MA
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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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21
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Association of disease activity with acute exacerbation of interstitial lung disease during tocilizumab treatment in patients with rheumatoid arthritis: a retrospective, case–control study. Rheumatol Int 2016; 36:881-9. [DOI: 10.1007/s00296-016-3478-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 04/05/2016] [Indexed: 01/05/2023]
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22
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Kumar G, Srivastava A, Sharma SK, Rao TD, Gupta YK. Efficacy & safety evaluation of Ayurvedic treatment (Ashwagandha powder & Sidh Makardhwaj) in rheumatoid arthritis patients: a pilot prospective study. Indian J Med Res 2016; 141:100-6. [PMID: 25857501 PMCID: PMC4405924 DOI: 10.4103/0971-5916.154510] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES In the traditional system of medicine in India Ashwagandha powder and Sidh Makardhwaj have been used for the treatment of rheumatoid arthritis. However, safety and efficacy of this treatment have not been evaluated. Therefore, the present study was carried out to evaluate the efficacy and safety of Ayurvedic treatment (Ashwagandha powder and Sidh Makardhwaj) in patients with rheumatoid arthritis. METHODS One hundred and twenty five patients with joint pain were screened at an Ayurvedic hospital in New Delhi, India. Eighty six patients satisfied inclusion criteria and were included in the study. Detailed medical history and physical examination were recorded. Patients took 5g of Ashwagandha powder twice a day for three weeks with lukewarm water or milk. Sidh Makardhwaj (100 mg) with honey was administered daily for the next four weeks. The follow up of patients was carried out every two weeks. The primary efficacy end point was based on American College of Rheumatology (ACR) 20 response. Secondary end points were ACR50, ACR70 responses, change from baseline in disease activity score (DAS) 28 score and ACR parameters. Safety assessments were hepatic function [alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), bilirubin and ß2 microglobulin], renal function (urea and creatinine and NGAL) tests and urine mercury level. RESULTS The study was completed by 90.7 per cent (78/86) patients. Patients with moderate and high disease activity were 57.7 per cent (45/78) and 42.3 per cent (33/78), respectively. All patients were tested positive for rheumatoid factor and increased ESR level. Ashwagandha and Sidh Makardhwaj treatment decreased RA factor. A significant change in post-treatment scores of tender joint counts, swollen joint counts, physician global assessment score, patient global assessment score, pain assessment score, patient self assessed disability index score and ESR level were observed as compared to baseline scores. ACR20 response was observed in 56.4 per cent (44/78) patients (American College of Rheumatology criteria) and moderate response in 39.74 per cent (31/78) patients [European League Against Rheumatism (EULAR) criteria]. Ayurvedic treatment for seven weeks in rheumatoid arthritis patients showed normal kidney and liver function tests. However, increased urinary mercury levels were was observed after treatment. INTERPRETATION & CONCLUSIONS The findings of the present study suggest that this Ayurvedic treatment (Ashwagandha powder and Sidh Makardhwaj) has a potential to be used for the treatment of rheumatoid arthritis. However, due to small sample size, short duration, non randomization and lack of a control group as study limitations, further studies need to be done to confirm these findings.
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Affiliation(s)
| | | | | | | | - Yogendra Kumar Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
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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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High-resolution computed tomography and rheumatoid arthritis: semi-quantitative evaluation of lung damage and its correlation with clinical and functional abnormalities. Radiol Med 2015; 121:181-9. [DOI: 10.1007/s11547-015-0590-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/27/2015] [Indexed: 12/18/2022]
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Wang JX, Du CG. A retrospective study of clinical characteristics of interstitial lung disease associated with rheumatoid arthritis in Chinese patients. Med Sci Monit 2015; 21:708-15. [PMID: 25746669 PMCID: PMC4360747 DOI: 10.12659/msm.890880] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Interstitial lung disease (ILD) in rheumatoid arthritis (RA) is associated with a poor prognosis. The purpose of this study was to assess the characteristics of ILD that are associated with RA. Material/Methods This was a retrospective study of 544 Chinese patients with RA (427 women and 117 men). RA-ILD was diagnosed by high-resolution computed tomography (HRCT). Patients with RA-ILD or with RA alone were compared in terms of age, sex distribution, duration of disease, clinical and laboratory parameters, history of smoking, and medication. Results Based on HRCT imaging, 83 (15.26%) patients with RA were diagnosed with ILD. ILD was more frequent in older patients (59.60±9.66 vs. 50.54±13.76 years, P<0.001), in those with a longer duration of disease (7.46±7.40 vs. 5.27±6.32 years, P=0.013) and in male patients (34.9% vs. 19.1%, P=0.001). RA-ILD was found to be associated with hepatitis B surface antigen (HBsAg) positivity (odds ratio [OR]=2.56, 95% confidence interval [95% CI] 1.02–6.43) and smoking (OR=3.38, 95% CI 1.65–6.95). Higher levels of C-reactive protein (OR=3.59, 95% CI 1.58–8.15), anti-cyclic citrullinated peptide (CCP) (OR=2.24, 95% CI 2.09–4.13), and rheumatoid factor (OR=3.72, 95% CI 1.56–8.86) were detected in association with RA-ILD. RA-ILD was more frequently observed in patients treated with steroids (OR=1.91, 95% CI 1.18–3.09) or Tripterygium wilfordii (OR=2.56, 95% CI 1.21–5.40). Age (OR=2.20, 95% CI 1.04–4.65), age at RA onset (OR=2.55, 95% CI 1.11–5.90), anti-CCP (OR=2.47, 95% CI 1.19–5.17), and steroid use (OR=1.83, 95% CI 1.04–3.20) were independently associated with RA-ILD in multivariate analysis. Conclusions RA-ILD was associated with age, age at RA onset, anti-CCP, and steroid use. Anti-CCP antibodies might be important biomarkers of RA-ILD.
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Affiliation(s)
- Jun-Xiang Wang
- Department of Immunology and Rheumatology, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Chuan-Guo Du
- Department of Radiology, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
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Conway R, Low C, Coughlan RJ, O'Donnell MJ, Carey JJ. Methotrexate and Lung Disease in Rheumatoid Arthritis: A Meta-Analysis of Randomized Controlled Trials. Arthritis Rheumatol 2014; 66:803-12. [DOI: 10.1002/art.38322] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/12/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Richard Conway
- Galway University Hospitals, Merlin Park; Galway Ireland
| | | | | | | | - John J. Carey
- Galway University Hospitals, Merlin Park; Galway Ireland
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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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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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Gómez Carrera L, Bonilla Hernan G. Pulmonary manifestations of collagen diseases. Arch Bronconeumol 2013; 49:249-60. [PMID: 23683373 DOI: 10.1016/j.arbres.2012.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 11/18/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
Abstract
Collagen diseases are a large group of systemic inflammatory diseases of autoimmune etiology. The etiopathogenesis of collagen diseases is multifactorial. There is genetic susceptibility, as many connective tissue disorders show family history, and environmental factors may trigger the disease. Collagen diseases can affect almost all the organs of the body. The respiratory system is one of the most frequently affected, although the prevalence of pulmonary disease is not precisely known for the different collagen disorders. Any structure of the respiratory tract can be affected, but perhaps the most frequent is pulmonary parenchymal disease in the form of pneumonitis, which can be produced in any of the idiopathic interstitial pneumonitis patterns. The pleura, pulmonary vessels, airways and respiratory muscles may also be affected. The frequency of lung disease associated with collagen diseases is on the rise. This due in part to the better diagnostic methods that are available to us today (such as high-resolution computed tomography) and also to the appearance of new forms of pneumonitis associated with the new treatments that are currently used. The objective of this article is to offer a global vision of how collagen diseases can affect the lungs according to the latest scientific evidence.
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Affiliation(s)
- Luis Gómez Carrera
- Servicio de Neumología, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain.
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Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, Culver D, Harrod CG, Hayney MS, Highland KB, Limper AH, Patrick H, Strange C, Whelan T. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 142:e1S-e111S. [PMID: 23131960 PMCID: PMC3610695 DOI: 10.1378/chest.12-1044] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2012] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.
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Affiliation(s)
| | - Keith C Meyer
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Luis Angel
- University of Texas Health Sciences, San Antonio, TX
| | | | - Kevin M Chan
- University of Michigan Health Systems, Ann Arbor, MI
| | | | | | - Mary S Hayney
- University of Wisconsin School of Pharmacy, Madison, WI
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Effective treatment of rheumatoid arthritis-associated interstitial lung disease by B-cell targeted therapy with rituximab. Case Reports Immunol 2012; 2012:272303. [PMID: 25379304 PMCID: PMC4207588 DOI: 10.1155/2012/272303] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/03/2012] [Indexed: 11/17/2022] Open
Abstract
Rheumatoid arthritis- (RA-) associated interstitial lung disease (RA-ILD) is the extra-articular complication with most adverse impact on the quality of life and survival in RA patients. However, treatment options are limited and controlled studies are lacking. Here, we present the case of a 66-year-old patient suffering from severe RA-ILD, which has been successfully treated with Rituximab (RTX). After failure of conventional DMARD therapy, our patient showed sustained improvement of clinical pulmonary parameters as well as joint inflammation following B-cell depletion with RTX. The six-minute-walk test improved from 380 meters to 536 meters and the forced vital capacity from 2.49 liters to 3.49. The disease activity score could be reduced from 7.7 to 2.8. Therefore, RTX might be considered as an alternative treatment for RA-ILD in patients not responding to conventional DMARD therapy.
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Verstappen SMM, Lunt M, Luben RN, Chipping J, Marshall T, Khaw KT, Wareham N, Dixon WG, Bruce IN, Symmons DPM. Demographic and disease-related predictors of abnormal lung function in patients with established inflammatory polyarthritis and a comparison with the general population. Ann Rheum Dis 2012; 72:1517-23. [PMID: 23065733 PMCID: PMC3756524 DOI: 10.1136/annrheumdis-2012-201698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives To identify demographic and clinical predictors of obstructive lung disease (OLD) and restrictive lung disease (RLD) in patients with established inflammatory polyarthritis (IP) and to compare the prevalence of respiratory symptoms in patients with IP and the general population. Method A total of 421 patients with IP underwent a spirometry test 15 years after inclusion in the Norfolk Arthritis Register (NOAR). Logistic regression analyses were performed to assess the predictive ability of demographic and clinical characteristics obtained at inclusion in NOAR and to assess their association with OLD or RLD at 15 years (age- and gender-adjusted). In addition, the prevalence of OLD and RLD was compared with a matched population (1:4) of people participating in the European Prospective Investigation of Cancer-Norfolk, a representative sample of the general population in Norfolk, UK. Results In this IP population, current smoking was the strongest predictor for OLD and functional disability for RLD. In the comparison study, 11.6% had OLD in the IP population and 4.9% in the general population (adjOR 2.01, 95% CI 1.26 to 3.22). The prevalence of RLD was not statistically different between the IP population and the general population (14.6% vs 17.5%; adjOR 0.76, 95% CI 0.53 to 1.10). Conclusions OLD, but not RLD, is more prevalent in the IP population than in the general population. Functional disability is especially associated with RLD whereas smoking is associated with OLD. The latter finding, and the known association between smoking and a poor disease prognosis, underlines the importance of smoking cessation in patients with IP.
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Affiliation(s)
- Suzanne M M Verstappen
- Arthritis Research UK Epidemiology Unit, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
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Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting 1% of the US population. Patients can have extra-articular manifestations of their disease and the lungs are commonly involved. RA can affect any compartment of the respiratory system and high resolution computed tomography (HRCT) of the lung is abnormal in over half of these patients. Interstitial lung disease is a dreaded complication of RA. It is more prevalent in smokers, males, and those with high antibody titers. The pathogenesis is unknown but data suggest an environmental insult in the setting of a genetic predisposition. Smoking may play a role in the pathogenesis of disease through citrullination of protein in the lung leading to the development of autoimmunity. Patients usually present in middle age with cough and dyspnea. Pulmonary function testing most commonly shows reduced diffusion capacity for carbon monoxide and HRCT reveals a combination of reticulation and ground glass abnormalities. The most common pattern on HRCT and histopathology is usual interstitial pneumonia (UIP), with nonspecific interstitial pneumonia seen less frequently. There are no large-scale well-controlled treatment trials. In severe or progressive cases, treatment usually consists of corticosteroids with or without a cytotoxic agent for 6 months or longer. RA interstitial lung disease is progressive; over half of patients show radiographic progression within 2 years. Patients with a UIP pattern on biopsy have a survival similar to idiopathic pulmonary fibrosis.
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Affiliation(s)
- Joshua J Solomon
- Autoimmune Lung Center and interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
| | - Kevin K Brown
- Autoimmune Lung Center and interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
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Colebatch AN, Marks JL, Edwards CJ. Safety of non-steroidal anti-inflammatory drugs, including aspirin and paracetamol (acetaminophen) in people receiving methotrexate for inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis). Cochrane Database Syst Rev 2011:CD008872. [PMID: 22071858 DOI: 10.1002/14651858.cd008872.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Methotrexate is routinely used in the treatment of inflammatory arthritis. There have been concerns regarding the safety of using concurrent non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, or paracetamol (acetaminophen), or both, in these people. OBJECTIVES To systematically appraise and summarise the scientific evidence on the safety of using NSAIDs, including aspirin, or paracetamol, or both, with methotrexate in inflammatory arthritis; and to identify gaps in the current evidence, assess the implications of those gaps and to make recommendations for future research to address these deficiencies. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, second quarter 2010); MEDLINE (from 1950); EMBASE (from 1980); the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE). We also handsearched the conference proceedings for the American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) (2008 to 2009) and checked the websites of regulatory agencies for reported adverse events, labels and warnings. SELECTION CRITERIA Randomised controlled trials and non-randomised studies comparing the safety of methotrexate alone to methotrexate with concurrent NSAIDs, including aspirin, or paracetamol, or both, in people with inflammatory arthritis. DATA COLLECTION AND ANALYSIS Two authors independently assessed the search results, extracted data and assessed the risk of bias of the included studies. MAIN RESULTS Seventeen publications out of 8681 identified studies were included in the review, all of which included people with rheumatoid arthritis using various NSAIDs, including aspirin. There were no identified studies for other forms of inflammatory arthritis.For NSAIDs, 13 studies were included that used concurrent NSAIDs, of which nine studies examined unspecified NSAIDs. The mean number of participants was 150.4 (range 19 to 315), mean duration 2182.9 (range 183 to 5490) days, although the study duration was not always clearly defined, and the studies were mainly of low to moderate quality. Two of these studies reported no evidence for increased risk of methotrexate-induced pulmonary disease; one study assessed the effect of concurrent NSAIDs on renal function and found no adverse effect; one study identified no adverse effect on liver function; three studies demonstrated no increase in methotrexate withdrawal; and one study showed no increase in all adverse events, including major toxic reactions. However, transient thrombocytopenia was demonstrated in one study, specifically when NSAIDs were taken on the same week day as methotrexate. This study was a retrospective review that involved small numbers only and was of moderate quality; these finding have not been replicated since.Four studies looked at specific NSAIDs (etodolac, piroxicam, celecoxib and etoricoxib), with a mean number of participants of 25.8 (range 14 to 50) and mean study duration of 16.8 (range 14 to 23) days. These studies were mainly of moderate quality. The studies were primarily pharmacokinetic studies but also reported adverse events as secondary outcomes. There were no clinically significant adverse effects with concomitant piroxicam or etodolac; and only mild adverse events with celecoxib or etoricoxib, such as nausea and vomiting, and headaches.For aspirin, seven studies provided data on adverse events with the use of aspirin and methotrexate. These studies included a mean number of participants of 100 (range 11 to 232), had a mean duration of 1325 (range 8 to 2928) days and were mainly of low to moderate quality. Two of the studies reported no evidence for increased risk of methotrexate-induced pulmonary disease and two studies showed no increase in all adverse events including major toxic reactions; however, none of these studies specified the dose of aspirin that was used. One study demonstrated that concurrent aspirin adversely affected liver function at a mean dose of 6.84 tablets of aspirin per day, which is a possible daily dose of 2.1 g presuming that 300 mg aspirin tablets were given. A further study described a partially reversible decline in renal function with 2 g daily of aspirin. One study reported no increase in adverse events with 975 g aspirin daily, however the study duration was only one week.For paracetamol, no studies were identified for inclusion. AUTHORS' CONCLUSIONS In the management of rheumatoid arthritis, the concurrent use of NSAIDs with methotrexate appears to be safe provided appropriate monitoring is performed. The use of anti-inflammatory doses of aspirin should be avoided.
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Affiliation(s)
- Alexandra N Colebatch
- Department of Rheumatology, Southampton General Hospital, Southampton; Consultant Rheumatologist Yeovil District Hospital,Somerset, UK.
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Abstract
Methotrexate (MTX) is a safe and well-tolerated drug for the treatment of rheumatic diseases, even if the strictest safety standards are considered. Initial apprehension as to severe pulmonary or hepatic side-effects has not been confirmed. The risk of infection is not elevated compared with other disease-modifying antirheumatic drugs. In addition, a mutagenic potential could not be demonstrated even after long-term application. Therefore, MTX will maintain its significant role in antirheumatic therapy also in the near future.
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Affiliation(s)
- G Keysser
- Department für Innere Medizin, Klinik für Innere Medizin II/Arbeitsbereich Rheumatologie, Universitätsklinik Halle (Saale), Halle (Saale), Germany.
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Rheumatoid arthritis-associated interstitial lung disease: diagnostic dilemma. Pulm Med 2011; 2011:872120. [PMID: 21660199 PMCID: PMC3109679 DOI: 10.1155/2011/872120] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 03/01/2011] [Accepted: 03/24/2011] [Indexed: 12/20/2022] Open
Abstract
Interstitial lung disease (ILD) is an increasingly recognized complication of rheumatoid arthritis (RA) contributing to significantly increased morbidity and mortality. Diagnosis can be challenging since patients are unlikely to report dyspnea due to an overall decrease in physical activity with advanced arthritic symptoms. Additionally, infections, drug toxicity, and environmental toxins can mimic ILD, creating significant diagnostic dilemmas for the clinician. In this paper we will explore an effective clinical algorithm for the diagnosis of RA-ILD. We will also discuss features of drug-related toxicities, infections, and environmental toxins that comprise the main entities in the differential diagnosis of RA-ILD. Finally, we will explore the known and experimental treatment options that may have some benefit in the treatment of RA-ILD.
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How common is methotrexate pneumonitis? A large prospective study investigates. Clin Rheumatol 2011; 31:79-83. [DOI: 10.1007/s10067-011-1758-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 04/15/2011] [Indexed: 02/02/2023]
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Meyer KC, Decker C, Baughman R. Toxicity and monitoring of immunosuppressive therapy used in systemic autoimmune diseases. Clin Chest Med 2011; 31:565-88. [PMID: 20692548 DOI: 10.1016/j.ccm.2010.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Systemic autoimmune diseases may be progressive and lead to organ system dysfunction and premature death. Current treatment paradigms are usually predominantly based on the administration of immunosuppressive and/or immunomodulatory drug therapy. Such therapy can stabilize systemic manifestations of connective tissue disease (CTD) and may put the disease into remission, and many of these agents are commonly used to treat CTD-associated interstitial lung disease (ILD). Although these agents have largely revolutionized the treatment of the systemic autoimmune diseases, adverse reactions, which can be serious and life threatening, to the various immunosuppressive agents used in the treatment of CTD can occur. Treating physicians must be aware of mechanisms of action of various immunosuppressive agents and be able to recognize the potential adverse reactions that may occur with therapy as well as potentially harmful effects on fetal development. Appropriate monitoring may prevent or limit toxicity from these agents, and knowledge of drug-drug interactions is essential when these agents are prescribed.
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Affiliation(s)
- Keith C Meyer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Youssef AA, Machaly SA, El-Dosoky ME, El-Maghraby NM. Respiratory symptoms in rheumatoid arthritis: relation to pulmonary abnormalities detected by high-resolution CT and pulmonary functional testing. Rheumatol Int 2011; 32:1985-95. [PMID: 21461855 DOI: 10.1007/s00296-011-1905-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/13/2011] [Indexed: 02/07/2023]
Abstract
Pulmonary disease is the most frequent and among the most severe extra-articular manifestation of rheumatoid arthritis (RA). However, this issue has not been sufficiently studied in Egyptian patients. The objectives of the present study are to investigate the prevalence and types of pulmonary involvement using high-resolution computed tomography scan (HRCT) and pulmonary function tests (PFT) and evaluate the association between respiratory symptoms and RA-lung disease in a group of Egyptian RA patients. Thirty-six RA patients were recruited; 34 females (94.4%) and 2 males (5.6%) with median age of 48.5 years, and none of them was smoker. Detailed medical and drug histories were obtained. PFT, plain X-ray of the chest, and HRCT were performed to all subjects involved. Nearly 64% of RA patients demonstrated abnormalities in PFT and 47% in HRCT. Mixed restrictive and obstructive pattern was the commonest. Nearly two-thirds of our patients reported one or more pulmonary symptom whether dyspnea, cough, wheezing, or phlegm. Dyspnea was the most frequent symptom. Respiratory symptoms were statistically more common in patients with lung disease. The advanced age, high radiological score, and severity of rheumatoid disease were found to be predictive of lung involvement. Among respiratory symptoms, dyspnea and cough were associated with any pulmonary abnormalities. When specific pulmonary abnormalities were considered, only dyspnea was identified as predictor for restriction. For obstructive abnormality, both cough and wheezing provided valid prediction. We conclude that pulmonary involvement is a common manifestation in Egyptian RA patients, and the pattern of involvement is generally consistent with other studies that were performed worldwide. Specific respiratory symptoms could be used as practical, easy, and cost-effective method, especially in older and with more severe RA patients, to discriminate patients in need of subsequent PFT and HRCT imaging.
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Affiliation(s)
- Amir A Youssef
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Mori S, Koga Y, Sugimoto M. Small airway obstruction in patients with rheumatoid arthritis. Mod Rheumatol 2011; 21:164-73. [PMID: 21136133 PMCID: PMC3071934 DOI: 10.1007/s10165-010-0376-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 10/20/2010] [Indexed: 11/29/2022]
Abstract
This work was intended to evaluate the prevalence of obstructive small-airway disease in patients with rheumatoid arthritis (RA) and its association with clinical characteristics. Pulmonary function testing (PFT) and high-resolution computed tomography (HRCT) were performed on 189 consecutive RA patients. Each case was diagnosed based on abnormal HRCT findings. We defined obstructive dysfunction of small airways as a forced expiratory flow from 25% to 75% of vital capacity (FEF(25-75)) value >1.96 residual standard deviation (RSD) below predicted values. We found 19 patients (10.1%) with an interstitial pneumonia (IP) pattern and 15 (7.9%) with a bronchiolitis pattern; the other 155 (82.0%) had no abnormal HRCT patterns. In patients with neither abnormal pattern, median values of percentage predicted for carbon monoxide diffusing capacity (DL(CO)) and ratio of DL(CO) to alveolar ventilation (DLco/VA) were within the normal range, but median FEF(25-75), forced expiratory flow at 25% of vital capacity (V(25)), and V(25)/height were <70% of predicted values. Forty-seven patients (30.3%) in this group had obstructive small-airway dysfunction. Multivariate logistic regression analysis indicated that this type of abnormality is strongly associated with respiratory symptoms [odds ratio (OR) 5.18; 95% confidence interval (CI) 1.70-15.75; p = 0.012), smoking history (OR 2.78; 95% CI 1.10-6.99; p = 0.03), and disease duration >10 years (OR 2.86; 95% CI 1.27-6.48; p = 0.012). Parenchymal micronodules, bronchial-wall thickening, and bronchial dilatation on HRCT scans were also predictive factors for abnormal FEF(25-75), although these morphological changes were too limited for us to diagnose these patients with the bronchiolitis pattern. Obstructive dysfunction of small airways is apparently common among RA patients, even among those with neither the IP nor the bronchiolitis pattern on HRCT scans. Factors significantly associated with abnormal FEF(25-75) are respiratory symptoms, smoking history, and RA duration.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto, 861-1196, Japan.
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Abstract
Psoriasis, a chronic multifactorial inflammatory disease that develops in genetically predisposed individuals, affects approximately 1.5% of the Spanish population. This disease has a negative impact on patients' quality of life, and long-term therapy is often required to control the symptoms. In addition to the classical systemic treatments (methotrexate, acitretin, cyclosporine, and ultraviolet light), the group of drugs known as biologics (etanercept, infliximab, adalimumab, and ustekinumab) provides the dermatologist with an expanded therapeutic armamentarium, thereby improving the likelihood of controlling psoriasis in patients with severe and/or extensive disease. Methotrexate, a classic antipsoriatic drug, is still very useful either as single-drug therapy or in combination with other systemic drugs, particularly as a rescue therapy or combined with biologics. This article aims to establish the role of methotrexate in the treatment of psoriasis. We considered it of interest to develop guidelines for using methotrexate in the management of psoriasis with a view to ensuring the safe and proper use of this drug in the management of psoriasis. This document was developed by consensus among members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology.
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Azoulay E. Pleuropulmonary Changes Induced by Drugs in Patients with Hematologic Diseases. PULMONARY INVOLVEMENT IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2011. [PMCID: PMC7123804 DOI: 10.1007/978-3-642-15742-4_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patients with hematologic diseases who are being treated with therapy drugs, or receive radiation therapy or blood transfusions may develop a host of potentially fatal infectious and noninfectious pulmonary complications [1]. The increased complexity of multimodality and high-dose treatment regimens with the intended benefit of augmented antineoplastic efficacy and prolonged disease-free survival, the use of a panel of novel drugs to treat malignant and nonmalignant hematologic conditions (e.g., azacytidine, bortezomib, cladribine, dasatinib, fludarabine, imatinib, lenalidomide, rituximab, and thalidomide), total body irradiation (TBI) and hematopietic stem cell transplantation (HSCT) have increased the incidence of severe sometimes life-threatening pulmonary complications.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint Louis, Avenue Claude Vellefaux 1, Paris, 75010 France
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Amital A, Shitrit D, Adir Y. The lung in rheumatoid arthritis. Presse Med 2010; 40:e31-48. [PMID: 21196098 DOI: 10.1016/j.lpm.2010.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/05/2010] [Accepted: 11/08/2010] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.
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Affiliation(s)
- Anat Amital
- Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
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Morganroth PA, Kreider ME, Werth VP. Mycophenolate mofetil for interstitial lung disease in dermatomyositis. Arthritis Care Res (Hoboken) 2010; 62:1496-501. [PMID: 20506189 DOI: 10.1002/acr.20212] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To report our experience using mycophenolate mofetil as first-line treatment for dermatomyositis-associated interstitial lung disease. METHODS We examined the medical records of all 16 dermatomyositis patients with interstitial lung disease seen in our outpatient university hospital dermatology clinic between May 26, 2006, and May 25, 2009. In this retrospective case series, we describe the clinical course of the 4 patients with definitive evidence of interstitial lung disease on radiologic imaging who were treated with mycophenolate mofetil and had pulmonary data available to document their outcome. All of the patients also received prednisone. RESULTS All 3 patients with at least 1 year of followup receiving mycophenolate mofetil experienced complete normalization of pulmonary function tests (including diffusing capacity for carbon monoxide) and resolution of dyspnea. They were also able to reduce their prednisone doses. The only patient with pre- and posttreatment chest computed tomography imaging had total resolution of her interstitial opacities. The patient with only 5 months of posttreatment followup experienced an improvement in diffusing capacity for carbon monoxide from 44% to 77% predicted, but no change in dyspnea. CONCLUSION These promising data indicate that mycophenolate mofetil may be a useful therapy for interstitial lung disease in patients with dermatomyositis, but larger studies are needed to more definitively evaluate the role of this medication in therapy.
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Metotrexato: guía de uso en psoriasis. ACTAS DERMO-SIFILIOGRAFICAS 2010; 101:600-613. [DOI: 10.1016/j.ad.2010.04.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 04/21/2010] [Indexed: 12/31/2022] Open
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Koduri G, Norton S, Young A, Cox N, Davies P, Devlin J, Dixey J, Gough A, Prouse P, Winfield J, Williams P. Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort. Rheumatology (Oxford) 2010; 49:1483-9. [DOI: 10.1093/rheumatology/keq035] [Citation(s) in RCA: 200] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Afeltra A, Zennaro D, Garzia P, Gigante A, Vadacca M, Ruggiero A, Dardes N, Navajas MF, Zobel BB, Amoroso A. Prevalence of interstitial lung involvement in patients with connective tissue diseases assessed with high‐resolution computed tomography. Scand J Rheumatol 2009; 35:388-94. [PMID: 17062440 DOI: 10.1080/03009740600844381] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To assess the prevalence of interstitial lung disease (ILD) in patients with different forms of connective tissue disease (CTD) using non-invasive procedures including high-resolution computed tomography (HRCT) and to evaluate the relationship between the imaging and functional status of the patients. METHODS Eighty-one subjects with CTD (47 inpatients and 34 outpatients) were evaluated with pulmonary function tests (PFT) and radiological investigations. The extent and severity of lung disease was quantified with an HRCT scoring system previously used in patients with systemic sclerosis (SSc). Interstitial lung involvement was defined as predominantly fibrotic or inflammatory based on HRCT abnormalities. RESULTS HRCT abnormalities suggestive of ILD were observed in 69 patients (85.1%), whereas PFT and plain radiograph alterations occurred less frequently (40.7%). The most frequent HRCT abnormalities were septal/subpleural lines and ground-glass appearance whereas lesions consistent with advanced fibrosis were observed in a minority of patients. The HRCT score was higher in patients with abnormal PFT (p<0.001). Thirty-five patients had predominant fibrosis and 34 patients predominantly inflammatory abnormalities. A score of 10 points represented the best compromise between sensitivity and specificity in predicting functional impairment. CONCLUSIONS A high prevalence of ILD was found based on HRCT abnormalities. However, HRCT scans characterized by minor abnormalities have poor specificity for clinically significant disease and functional findings should also be considered. The large number of patients with predominantly inflammatory HRCT abnormalities suggests that many cases of ILD may be diagnosed in a relatively early stage of the disease.
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Affiliation(s)
- A Afeltra
- Department of Clinical Medicine, University Campus Bio-Medico, Rome, Italy.
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