Rheumatoid arthritis-interstitial lung disease: manifestations and current concepts in pathogenesis and management

Alteration of telomere length and mtDNA copy number in interstitial lung disease associated with rheumatoid arthritis

Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA). The inflammatory response in lung disease is characterized by severe oxidative stress, which enhances cellular senescence. Telomeric shortening and mitochondria dysregulation represent two hallmarks of cellular senescence. The maintenance of telomere length (TL) and mitochondrial DNA (mtDNA) copy number is preserved by many proteins, such as TERF1 and TFAM, respectively. Our aim was to evaluate the TL, the mtDNA copy number and the expression of two regulator gene factors in RA patients with (RA-ILD) and without lung involvement (RA-NILD). Eighty-five RA patients and 21 healthy subjects were enrolled. Relative TL, mtDNA copy number, and expression analysis of TERF1 and TFAM genes were measured using qPCR assay. All RA patients present a statistically significant telomere shortening; in particular, RA-ILD patients show shorter TL compared to both controls and RA-NILD. Patients with Usual Interstitial Pneumonia pattern show a more evident shortening of TL. Lastly, both RA-ILD and RA-NILD patients present a significant decrease in mtDNA copy number compared to controls. The analysis of regulatory genes showed an increase in TERF1 expression in RA patients compared to controls, also after stratification in the two subgroups, and a decrease in TFAM expression in RA patients compared to controls. These results show that the alteration of TL and mtDNA copy number in RA patients is more evident in the presence of ILD. The hypothesis is that, in these patients, oxidative stress could accelerate the shortening of telomeres and the decrease of mtDNA copy number.

The association between social determinants of health and all-cause, cardiovascular mortality in US rheumatoid arthritis: a cohort study of NHANES

BACKGROUND

Rheumatoid arthritis (RA) imposes a significant burden on healthcare systems. This study investigates the impact of social determinants of health (SDoH) on the prognosis of RA patients, aiming to inform interventions that improve health outcomes.

METHODS

The National Health and Nutrition Examination Survey (NHANES) 2005-2018 included 2,024 RA participants. SDoH was assessed based on the five domains outlined in the Healthy People 2030 framework, with the cumulative number of adverse SDoH calculated. Cox regression analysis, subgroup analysis, and Kaplan-Meier survival analysis were employed to evaluate the associations between SDoH and all-cause mortality as well as cardiovascular mortality among RA patients, adjusting for potential confounding factors.

RESULTS

Over a median follow-up of 79 months, 449 deaths (19%) occurred, including 120 cardiovascular deaths. Each 1-point increase in cumulative SDoH score was linked to a 24% higher risk of all-cause mortality (HR: 1.24; 95% CI: 1.16-1.32; p < 0.001) and a 25% higher risk of cardiovascular mortality (HR: 1.25; 95% CI: 1.13-1.39; p < 0.001). Exposure to five or more adverse SDoH was associated with a higher risk of all-cause mortality (HR: 3.94; 95% CI: 2.20-7.06; p < 0.001) as well as cardiovascular mortality (HR: 3.98; 95% CI: 1.22-12.97; p = 0.020). Significant interactions were found between SDoH and age, income, and education level.

CONCLUSION

Adverse SDoH, particularly when accumulated, are associated with increased mortality risks in RA patients, emphasizing the need for targeted interventions to mitigate these effects.

SLAMF7-expressing B cells as crucial mediators in the pathogenesis of rheumatoid arthritis-interstitial lung disease

The regulatory factors involved in rheumatoid arthritis (RA) complicated with interstitial lung disease (ILD) (RA-ILD) remain unknown. Due to the cross-sectional nature of our study, our aim was to explore the role of the signalling lymphocytic activation molecule family (SLAMF) in RA-ILD by analysing synovial and lung samples from the Gene Expression Omnibus, animal models, and clinical samples.We collected peripheral blood mononuclear cells from patients for flow cytometry analysis of B cells, SLAMF1 protein, and SLAMF7 protein. The dataset analysis indicated a marked upregulation of SLAMF1 and SLAMF7 expression in RA synovial tissues and RA-ILD lung tissues. The same expression trend was further validated in a collagen-induced arthritis-ILD model. This suggests that B cells expressing SLAMF1 and SLAMF7 may contribute significantly to the development of lung fibrosis. Flow cytometry analysis demonstrated that SLAMF7 expression in B cells was substantially higher in RA-ILD patients than in those with RA alone. Similarly, SLAMF7 proteins were highly expressed in the plasma of patients with RA-ILD. These results suggest that SLAMF7 could be pivotal in the development and progression of RA-ILD.

Formyl-peptide receptor type 2 activation mitigates heart and lung damage in inflammatory arthritis

Rheumatoid arthritis (RA) is associated with heart and lung dysfunction. Current therapies fail to attenuate such complications. Here, we identify formyl-peptide receptor type 2 (FPR2) as a therapeutic target to treat heart and lung dysfunction associated with inflammatory arthritis. Arthritic mice on high levels of dietary homocysteine develop cardiac diastolic dysfunction and reduced lung compliance, mirroring two comorbidities in RA. Therapeutic administration of a small molecule FPR2 agonist (BMS986235) to hyper-homocysteine arthritic mice prevented diastolic dysfunction (monitored by echocardiography) and restored lung compliance. These tissue-specific effects were secondary to reduced neutrophil infiltration, modulation of fibroblast activation and phenotype (in the heart) and attenuation of monocyte and macrophage numbers (in the lung). A dual FPR1/2 agonist (compound 43) failed to prevent the reduction in lung compliance of arthritic mice and promoted the accumulation of inflammatory monocytes and pro-fibrotic macrophages in lung parenchyma. This cellular response lies downstream of FPR1-mediated potentiation of CCL2-dependent monocyte chemotaxis and activation. This finding supports the therapeutic development of selective FPR2 agonists to mitigate two impactful comorbidities associated with inflammatory arthritides.

Mortality and medical utilization in rheumatoid arthritis associated interstitial lung disease: A real-world, large-scale retrospective study comparing Janus kinase inhibitors and tumor necrosis factor inhibitors

OBJECTIVE

The study is aimed to investigate the effectiveness of Janus kinase inhibitors (JAKi) on rheumatoid arthritis associated interstitial lung disease (RA-ILD) compared to tumor necrosis inhibitors (TNFi).

METHODS

We applied a retrospective matched cohort analysis using the TriNetX database. The study included patients diagnosed with RA-ILD who received new prescriptions for JAKi or TNFi. The primary outcome was all-cause mortality, and secondary outcomes included medical utilizations. Hazard ratios (HRs) and Cox regression analyses were performed to assess these outcomes.

RESULTS

Among 23,707 RA-ILD patients, 812 were selected for each treatment group (JAKi and TNFi) following propensity score matching. The JAKi group exhibited a higher all-cause mortality risk compared to the TNFi group (HR 1·458, 95 % CI: 1·136-1·870). JAKi group was also associated with a higher risk for hospitalization (HR 1·167, 95 % CI: 1·011-1·348), critical care services (HR 1·854, 95 % CI: 1·414-2·431), and mechanical ventilation (HR 2·609, 95 % CI: 1·718-3·962). Subgroup analysis indicated a heightened mortality risk in JAKi-treated patients aged over 65 years old (HR 1·815, 95 % CI: 1·316-2·503), and those with cardiovascular risk factors (HR 1·636, 95 % CI: 1·197-2·237). Sensitivity analysis yielded results that were not entirely consistent with the primary analysis, except for the subgroup aged over 65, where results remained aligned.

CONCLUSION

This real-world, large-scale cohort study indicated an association of higher mortality and medical utilizations in RA-ILD patients treated with JAKi compared to TNFi, especially among those over 65 years of age. These findings highlight the need for careful assessment when prescribing JAKi or TNFi for patients with RA-ILD.

The use of mechanical ventilation in interstitial lung disease

This review explores the challenges and strategies for managing mechanical ventilation in interstitial lung disease (ILD), particularly during acute exacerbations. It highlights the unique physiological barriers posed by fibrotic, non-compliant lungs, discusses evidence-based approaches to noninvasive and invasive ventilation, and emphasises the importance of balancing life-sustaining treatments with palliative care. This review aims to provide practical insights into optimising respiratory support for ILD patients while aligning treatment goals with patient prognosis and preferences.

Impact of csDMARDs vs. b/tsDMARDs on the Prognosis of Rheumatoid Arthritis-Associated Interstitial Lung Disease: A Multicenter, Retrospective Study

Background/Objectives: Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) significantly affects disease prognosis and patient survival. The impact of conventional synthetic DMARDs (csDMARDs) and biologic/targeted synthetic DMARDs (b/tsDMARDs) on RA-ILD prognoses remains unclear. This study aimed to investigate the effects of csDMARDs and b/tsDMARDs on RA-ILD progression and prognosis based on pulmonary function tests (PFTs), high-resolution computed tomography (HRCT), and symptom changes. Methods: This multicenter, retrospective, observational study included patients with RA-ILD at 13 referral hospitals in South Korea. The participants were categorized into csDMARD-only and b/tsDMARD-exposed groups. RA-ILD prognosis was assessed over a 24-month follow-up period using serial PFTs (the forced vital capacity [FVC] and diffusing capacity of the lungs for carbon monoxide [DLCO]), HRCT findings, and clinical symptom changes. Kaplan-Meier survival analyses and Cox proportional hazards models were used to compare disease progression risk while adjusting for baseline lung function, RA disease activity, and glucocorticoid use. Results: Among 127 eligible patients, 22 (17.3%) were exposed to b/tsDMARDs, predominantly abatacept and tocilizumab. During a mean follow-up of 2.8 years, 65 (51.2%) patients experienced RA-ILD progression. A higher baseline Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR) (adjusted hazard ratio [aHR]: 1.344, 95% confidence interval [CI]: 1.136-1.590, p = 0.001) and initially prescribed prednisone dose (aHR: 1.078, 95% CI: 1.011-1.151, p = 0.023) were significant prognostic factors for ILD progression. No statistically significant difference in progression risk was observed between the csDMARD-only and b/tsDMARD-exposed groups (aHR: 0.937, p = 0.851). Conclusions: The RA-ILD prognosis was more strongly influenced by disease activity, rather than the type of DMARD used. These findings emphasize the importance of maintaining low RA disease activity to improve RA-ILD prognosis.

A review on the epidemiology of rheumatoid arthritis: An update and trends from current literature

Rheumatoid arthritis (RA) is a systemic, chronic autoimmune disease affecting mainly the joints, often with extra articular manifestations. This review provides an update on RA epidemiological trends and management. PubMed and EMBASE were searched from 2014 to 2024 using rheumatoid arthritis as keyword, combined with incidence, prevalence, diagnosis, classification, and management. Emphasis was on papers published in the past 5 years. Globally, the age-standardised prevalence and incidence rate (ASPR and ASIR) of RA increased with varying figures. The ASPR increased by 0.37%, 14.1%, and 6.4% from 1990 to 2019, 2020 and 2017 respectively; and 9% from 1980 to 2019. The ASIR increased by 0.3% and 8.2% from 1990 to 2019 and 2017 respectively; the disability-adjusted life years (DALY) figures increased 0.12% and decreased 0.36% in the same period from different authors. Reduction in ASIR were reported while ASPR varies. Disease modifying anti-rheumatic drugs (DMARDs) remain the cornerstone of treatment.

Alterations in gut microbiota in Rheumatoid arthritis patients with interstitial lung Disease: A Comparative study

BACKGROUND

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is considered one of the most severe complications of rheumatoid arthritis. The etiology of RA-ILD is complex, involving genetic and environmental factors. Recent studies suggest that the gut microbiota, a critical component of the immune system, may influence the pathogenesis of RA and other autoimmune disorders. However, specific data on the gut microbiota in patients with RA-ILD remain limited.

OBJECTIVE

This study aimed to investigate alterations in the gut microbiota of RA-ILD patients and compare these profiles with those of RA patients without ILD and health controls.

METHODS

We included three groups: RA-ILD patients (n = 30), RA patients without ILD (n = 31), and health controls (n = 30). Fresh fecal samples were collected and subjected to 16S rRNA gene sequencing to analyze microbial diversity. Statistical analyses involved α-diversity and β-diversity assessments, principal coordinates analysis (PCoA), and differential abundance testing with LEfSe and PICRUSt2.

RESULTS

Significant differences in gut microbiota composition were observed between RA-ILD patients and the other groups. Notably, g_Prevotella showed differential abundance, particularly in RA-ILD patients. KEGG pathway analysis revealed upregulation in several metabolic pathways in RA-ILD compared to RA and health controls, suggesting a distinct microbial metabolic activity associated with RA-ILD.

CONCLUSION

Our findings indicate that RA-ILD patients have a markedly different gut microbiota profile compared to RA patients without ILD and health controls. The observed microbial alterations may contribute to RA-ILD pathogenesis and could serve as potential biomarkers or therapeutic targets. Further studies are needed to explore these findings' clinical implications and validate the role of gut microbiota in RA-ILD progression.

Clinical Significance of Antinuclear Antibodies in Patients with Rheumatoid Arthritis: From SETOUCHI-RA Registry

Background/Objectives: Rheumatoid arthritis (RA) is a representative systemic autoimmune rheumatic disease (SARD) characterized by synovial inflammation. While antinuclear antibodies (ANAs) positivity in patients with RA varies widely, the relationship between ANA patterns and clinical features remains unclear. This study aimed to evaluate the clinical significance of ANA in patients with RA. Methods: This single-center RA registry study included 814 Japanese patients after excluding those with coexisting SARDs. ANA titers and staining patterns were assessed by indirect immunofluorescence assays on HEp-2 cells. Clinical and laboratory features were analyzed, and logistic regression was used to identify risk factors for pulmonary involvement. Hierarchical clustering and statistical analyses were performed to explore associations between ANA patterns and clinical features. Results: ANA positivity was observed in 41.5% of patients, with the speckled and homogeneous patterns being the most common. ANA-positive patients exhibited significantly higher rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) positivity rates and titers, along with elevated disease activity markers, including Evaluator's Global Assessment and Swollen Joint Count. Nucleolar pattern positivity was independently associated with pulmonary complications, predominantly interstitial lung disease, and higher rates of JAK inhibitor use. Discrete-speckled pattern-positive patients exhibited high ANA titers but lower RF and ACPA levels, reflecting a distinct subset of RA. Conclusions: ANA staining patterns and titers are clinically relevant in RA, with nucleolar and discrete-speckled patterns indicating distinct clinical and pathophysiological profiles. ANA should be interpreted alongside other serological markers and clinical parameters rather than as a standalone tool. Further studies are needed to refine its clinical applicability and integration into RA management.

Lung ultrasound outperforms symptom-based screening to detect interstitial lung disease associated with rheumatoid arthritis

OBJECTIVES

Interstitial lung disease associated with rheumatoid arthritis (RA-ILD) is linked to high mortality. Currently, effective screening tools are lacking. We assessed the role of symptoms and lung ultrasound (LUS) as potential screening tools.

METHODS

116 adult patients with RA presenting to the rheumatology outpatient clinic underwent high-resolution CT (HRCT) scans, pulmonary function tests, LUS (72 zones) and completed a Visual Analogue Scale (VAS) for cough and modified Medical Research Council dyspnoea scale (mMRC). Kruskal-Wallis (KW) tests evaluated the correlation between clinical-radiological HRCT score (no ILD, non-specific abnormalities, subclinical ILD or ILD) and the B-lines on LUS, diffusion capacity (DLCO%pred), forced vital capacity (FVC%pred), VAS Cough and mMRC. Sensitivity and specificity analyses were performed to assess symptom-based questionnaires and the number of B-lines to detect RA-ILD. Area under the receiver operating characteristics (AUROC) for detecting clinical ILD and subclinical ILD were calculated.

RESULTS

In 11.8% of patients, an ILD was detected on HRCT. Additionally, in 5%, a diagnosis of subclinical interstitial lung changes was made. The number of B-lines was most strongly associated with the clinical-radiological score (KW χ²=41.2, p=<0.001). DLCO%pred was also significantly correlated with the clinical-radiological score (KW χ²=27.4, p=<0.001), but FVC%pred, mMRC and VAS cough were not. Cough and dyspnoea only weakly predicted the ILD score in the sensitivity-specificity analyses, while B-lines showed AUROCs>0.9 for predicting subclinical and clinical ILD.

CONCLUSION

LUS is a promising tool for early detection of RA-ILD, outperforming symptom-based questionnaires or the presence of dyspnoea or cough.

Incidence of and predictive factors for lung cancer in patients with rheumatoid arthritis: A retrospective long-term follow-up study

OBJECTIVES

The aim of this study was to determine the incidence and predictive factors of lung cancer in rheumatoid arthritis (RA).

METHODS

We conducted a retrospective follow-up study of patients who were diagnosed with RA at our institution between April 2001 and December 2022. Pulmonary complications were evaluated using high-resolution computed tomography (HRCT) at RA diagnosis. Patients were followed until the diagnosis of lung cancer, diagnosis of other malignancies, death, loss to follow-up, or the end of the study.

RESULTS

Among 771 RA patients, 3.5% were diagnosed with combined pulmonary fibrosis and emphysema (CPFE), 4.9% with interstitial lung disease (ILD) alone, and 6.0% with emphysema alone. During follow-up (mean of 9.3 years), the crude incidence rates of lung cancer per 1000 patient-years were 2.9 in all patients, 47.8 in CPFE patients, 10.5 in ILD patients, 11.9 in emphysema patients, and 0.8 in patients without these complications. Only male patients showed a higher incidence of lung cancer compared with the general population. In multivariable Fine-Gray regression analysis, the presence of HRCT-proven CPFE, ILD, and emphysema, and smoking history were identified as predictive factors for lung cancer in RA patients.

CONCLUSIONS

Close monitoring of lung cancer is needed for RA patients with smoking history and pulmonary complications, especially CPFE.

Mortality and Predictive Factors for Death Following the Diagnosis of Interstitial Lung Disease in Patients with Rheumatoid Arthritis: A Retrospective, Long-Term Follow-Up Study

Objective: The aim of this study was to determine mortality and predictive factors for death in patients with rheumatoid arthritis (RA) diagnosed with and without interstitial lung disease (ILD). Methods: We retrospectively performed a long-term follow-up study of patients diagnosed with RA at our medical center between April 2001 and June 2023. The diagnosis and classification of ILD were made based on pulmonary high-resolution computed tomography (HRCT), taken at RA diagnosis and during follow-up. Results: Among 781 patients with RA, 78 were diagnosed with ILD; all cases except one were subclinical. The most common HRCT pattern was definite usual interstitial pneumonia (UIP) followed by nonspecific interstitial pneumonia (NSIP)/UIP, probable UIP, NSIP, and early UIP. During follow-up (mean of 10.0 years), the crude incidence rate of death (95% confidence interval [CI]) was 7.1 (5.2-10.0) and 1.5 (1.0-1.9) per 100 person-years in RA patients with and without ILD. Poor control of RA activity was associated with increased incidence rates of death. The standardized mortality ratio (95% CI) compared with the general population was 1.32 (1.11-1.53) for all RA patients, 2.09 (1.45-2.73) for RA-ILD patients, and 1.16 (0.95-1.38) for non-ILD RA patients. Lung cancer and respiratory failure were the most common causes of death in RA-ILD patients. The Multivariable Fine-Gray regression analysis revealed that ILD (adjusted hazard ratio [HR] 2.97 [95% CI 1.95-4.53]), advanced age (1.08 per additional year [1.05-1.10]), and low body mass index (3.07 [2.10-4.49]) were strong predictive factors for mortality in RA patients. HRCT patterns did not affect the risk of death in RA-ILD patients. Conclusions: Regardless of HRCT pattern, RA-ILD contributes to the increased mortality risk in patients with RA.

Impact of Sex, Serostatus, and Smoking on Risk for Rheumatoid Arthritis-Associated Interstitial Lung Disease Subtypes

OBJECTIVE

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) includes multiple subtypes with varying histopathology, prognosis, and potential treatments. Limited research has investigated risk factors for different RA-ILD subtypes. Therefore, we examined demographic, serologic, and lifestyle associations with RA-ILD subtypes.

METHODS

We systematically identified RA-ILD cases and RA controls without ILD (RA-noILD) in the Brigham RA Sequential Study and Mass General Brigham Biobank RA cohort. We determined RA-ILD subtype (usual interstitial pneumonia [UIP], nonspecific interstitial pneumonia [NSIP], and other/indeterminate) through chest high-resolution computed tomography imaging pattern. We investigated associations of demographic, lifestyle, and serologic factors with major RA-ILD subtypes using multivariable logistic regression.

RESULTS

Among 3,328 patients with RA, we identified 208 RA-ILD cases and 547 RA-noILD controls. RA-UIP was associated with older age (odds ratio [OR] 1.03 per year, 95% confidence interval [95% CI] 1.01-1.05), male sex (OR 2.15, 95% CI 1.33-3.48), and seropositivity (OR 2.08, 95% CI 1.24-3.48), whereas RA-NSIP was significantly associated only with seropositive status (OR 3.21, 95% CI 1.36-7.56). Nonfibrotic ILDs were significantly associated with smoking (OR 2.81, 95% CI 1.52-5.21). Having three RA-ILD risk factors (male, seropositive, smoking) had an OR of 6.89 (95% CI 2.41-19.7) for RA-UIP compared with having no RA-ILD risk factors.

CONCLUSION

Older age, seropositivity, and male sex were strongly associated with RA-UIP, whereas RA-related autoantibodies were associated with RA-NSIP. These findings suggest RA-ILD sex differences may be driven by RA-UIP and emphasize the importance of further studies to clarify RA-ILD heterogeneity and optimize screening and treatment approaches.

High-titer rheumatologic markers in serum of veterans with severe pulmonary complications 25-30 years after sulfur mustard exposure

Sulfur mustard (SM), known as the "king of toxic agents," continues to pose a potential danger due to its ability to cause widespread damage, including ongoing corrosive effects. We aimed to determine the rheumatologic markers in SM veterans suffering from severe pulmonary manifestations. The serologic markers, including ANA, anti-DNA, rheumatoid factor (RF), and CRP, between SM-exposed veterans (n = 229) with severe problems and not-SM-exposed residents with no pulmonary disease history (n = 63), 25-30 years after SM exposure were compared. Moreover, SM-exposed veterans were divided into subgroups, including bronchiolitis obliterans, chronic bronchitis, and asthma, based on specialists' diagnoses, and all the data were compared among these clinical subgroups. Autoantibodies were assessed by standard indirect immunofluorescence and/or ELISA. The levels of serum hs-CRP were determined using an immunoturbidometry technique in both the patient and control groups. Statistical analysis was performed using SPSS software. Patients had significantly elevated ANA (P = 0.000), anti-DNA (P = 0.024), RF (P = 0.000), and CRP (P = 0.000) levels compared to the matched control group. These results indicate a possible autoimmune circumstance in this population and suggest the need to follow up the autoimmunity-related markers in all SM-exposed individuals, since they might be a valuable prognostic biomarker for stratifying patients for the future risk of autoimmunity development.

Warrick score in rheumatoid-arthritis interstitial lung disease: a promising tool for assessing the extent and progression of lung involvement

BACKGROUND

The clinical manifestations and course of rheumatoid arthritis-associated interstitial lung disease (RA-ILD) exhibits considerable heterogeneity. In this study, we aimed to explore radiographic progression over a defined period, employing the Warrick score as a semi-quantitative measure in early RA-ILD, and to assess the associated risk factors for progression.

METHODS

RA-ILD patients underwent consecutive Warrick scoring based on initial high-resolution computed tomography (HRCT) at diagnosis and the first follow-up. Associations between Warrick scores, pulmonary function tests, and patient characteristics were analyzed. The ROC curve assessed the predictive performance of the Warrick score change rate for ILD progression, while multivariable logistic regression analysis identified risk factors for progression.

RESULTS

Significant correlations were found between Warrick scores and age at RA-ILD diagnosis, age at ILD diagnosis, and baseline DAS28-ESR. For the severity score, correlations were r = 0.359, r = 0.372, and r = 0.298 (p = 0.001, p < 0.001, p = 0.014, respectively); for the extent score, r = 0.364, r = 0.318, and r = 0.255 (p = 0.001, p = 0.005, p = 0.038, respectively); and for the total score, r = 0.376, r = 0.367, and r = 0.280 (p < 0.001, p = 0.001, p = 0.022, respectively). Annual changes in severity, extent, and total Warrick scores showed sensitivities of 91-97% and specificities of 98% for predicting progression over a 5-year follow-up. Cut-off values were 0.0278 for the severity score (AUC 0.954), 0.0227 for extent score (AUC 0.976), and 0.0694 for total score (AUC 0.946). Warrick severity, extent, and total scores increased significantly during follow-up. Age > 50 years (OR 7.7; p = 0.028) and baseline usual interstitial pneumonia (UIP) pattern (OR 3.1, p = 0.041) were identified as risk factors for progression.

CONCLUSIONS

Advanced age and UIP pattern were significant risk factors for progression. Warrick scoring may may help predict progression in RA-ILD, particularly through changes in severity, extent, and total scores. Due to the retrospective design and small sample size, further prospective studies with larger cohorts are needed to confirm these findings and validate Warrick scoring as a reliable marker for RA-ILD progression.

The global prevalence of interstitial lung disease in patients with rheumatoid arthritis: a systematic review and meta-analysis

This study aims to review the literature and estimate the global pooled prevalence of interstitial lung disease among patients with rheumatoid arthritis (RA-ILD). The influence of risk factors like geography, socioeconomic status, smoking and DMARD use will be explored. A systematic review was performed according to the PRISMA and JBI guidelines. Studies published between January 1980 and February 2024 were sourced from 7 electronic databases and screened for eligibility. A random-effects meta-analysis model was used to produce pooled prevalences and the potential between-study heterogeneity was identified using sensitivity, subgroup, meta-regression and correlation analyses. 33 studies were included in this meta-analysis containing 14,281 RA patients. The global pooled prevalence of RA-ILD was 21.38% (CI: 0.1542-0.2886), with a high heterogeneity (I2) of 98%. The prevalence of usual interstitial pneumonia and non-specific interstitial pneumonia among RA patients were 11.01% and 6.86% respectively. Africa had the highest RA-ILD prevalence with an imprecise estimate of 38.15% (95% Confidence Interval [CI]: 2.29-94.2) and Europe had the lowest prevalence of 10.15% (CI: 2.86-30.23). Other risk factors associated with a higher prevalence of RA-ILD included living in low-income countries, smoking and DMARD use. The biggest limitation of this study is the high heterogeneity of results and underrepresentation of Oceania and low-income countries. This study has clarified the global prevalence of RA-ILD. The risk factors identified in this study can aid clinicians in identifying high-risk populations and highlight the need for screening these populations. Smoking cessation should also be encouraged.

Diagnostic Value of Combined Test of Anti-Cyclic Citrullinated Peptide Antibody, AKA Antibody, Carp Antibody, and Rheumatoid Factor for Rheumatoid Arthritis

OBJECTIVE

To analyze the diagnostic value of a combined test of anti-cyclic citrullinated peptide antibody (CCP), anti-keratin antibody (AKA), anti-carbamylated protein antibody (Carp antibody), and rheumatoid factor (RF) in the early diagnosis of rheumatoid arthritis (RA).

METHODS

Sixty cases of RA admitted to our hospital from 2021 to 2022 (observation group) were selected, along with 50 cases of healthy physical examiners (control group). The results of CCP antibody, AKA antibody, Carp antibody, and rheumatoid factor in both groups were analyzed: the concentration of CCP antibody, AKA antibody, Carp antibody, and rheumatoid factor in each group at different levels; the comparison of various testing methods with the "gold standard" test; and the ROC curve analysis of CCP antibody, AKA antibody, Carp antibody, and rheumatoid factor in each group.

RESULTS

The concentrations of CCP antibody, AKA antibody, Carp antibody, and rheumatoid factor were significantly higher in the observation group than in the control group (p < 0.05). Furthermore, there was a significant increase in the concentrations of CCP antibody, AKA antibody, Carp antibody, and rheumatoid factor from the mild to moderate group (p < 0.05), as well as from the moderate to severe group (p < 0.05). Additionally, when comparing the mild and severe groups, there was a significant elevation in the concentrations of CCP antibody, AKA antibody, Carp antibody (p < 0.05), and rheumatoid factor (p < 0.05).

CONCLUSION

Anti-cyclic citrullinated peptide antibody, AKA antibody, Carp antibody, and rheumatoid factor combined tests have high sensitivity and specificity in the diagnosis of RA.

Relationship Between Early and Established Rheumatoid Arthritis Vascular Change of the Dorsalis Pedis Artery Observed with Ultrasound Imaging

BACKGROUND

Despite early treatment of rheumatoid arthritis (RA) being well established to prevent erosive joint damage, studies report persistent moderate to high disease activity. Other pathologies, for example, rheumatoid vasculitis (RV) may contribute symptoms that may not be captured by existing clinical assessment.

OBJECTIVES

To investigate ultrasound-observed changes in the proximal dorsalis pedis artery (DPA) between early (≤ 5 y) and established (>5 y) RA and the RA Disease Activity Index-5 (RADAI-5).

METHODS

Participants with early (n = 20) and established RA (n = 20) were recruited. Five parameters of the DPA were examined with a previously established ultrasound method. Independent t-tests and Cohen d statistics assessed differences and effect size between ultrasound parameters and RADAI-5, and the two groups. Pearson correlation assessed associations between ultrasound parameters and RADAI-5.

RESULTS

Majority of participants (98%) demonstrated arterial wall thickening regardless of disease duration. However, lumen diameter (Cohen's d = 0.972, p = 0.004) and artery diameter (Cohen's d = 0.694, p = 0.034) were decreased in established RA compared to early RA. No strong associations were found between RADAI-5 and ultrasound parameters, except for lumen diameter in early RA demonstrating a fair association to RADAI-5 (r = 0.445). The mean RADAI-5 score indicated moderate to high disease activity with no difference between early and established RA (p = 0.283).

CONCLUSION

Arterial wall thickening of the DPA indicating the precursory changes of RV was observed in most RA participants, with reductions in artery and lumen diameter occurring in established disease. However, the long-standing instrument RADAI-5 may not reflect symptoms and clinical impacts related to vascular changes among people with RA.

New Posttranslational Modification Lactylation Brings New Inspiration for the Treatment of Rheumatoid Arthritis

Lactic acid (LA) is an essential glycolytic metabolite and energy source in the body, which is present in high levels in the synovial fluid of patients with rheumatoid arthritis (RA) and is a reliable indicator for identifying inflammatory arthritis. LA not only acts as an inflammatory amplifier in RA, recent studies have found that novel posttranslational modification (PTM) lactylation mediated by LA may also play a key role in RA. Single-cell sequencing showed that the RA lactylation score of patients with RA was significantly increased, and core lactylation-promoting genes, including NDUFB3, NGLY1, and other genes, were found to be potential biomarkers of RA. More studies have shown that lactylation can regulate genes in various cells, such as fibroblast-like synoviocytes (FLSs) and macrophages, thus playing a special role in the development and occurrence of autoimmune diseases, neurological diseases, and cancer diseases. In this paper, we review the research on lactylation in RA-related cells and mechanisms and bring new insights into the pathogenesis, diagnosis, and treatment of RA.

RS35705950 polymorphism of MUC5B Gene: Association with Rheumatoid Arthritis and Interstitial lung disease in Tunisian Population

INTRODUCTION

Interstitial lung disease (ILD) is the most common extra-articular manifestation in rheumatoid arthritis (RA). Studies have concluded that there is an association between rs35705950 polymorphism of the MUC5B gene and RA-ILD.

AIM

To explore this polymorphism in a cohort of Tunisian patients suffering from RA with or without ILD and stufdy its association to ILD during RA.

METHODS

A case-control study involving 61 patients followed for RA, 26 with ILD and 35 without pulmonary involvement and 62 healthy controls. This was an association study between genetic marker and RA-ILD by genotyping the rs35705950 polymorphism using PCR-RFLP.

RESULTS

No association was found between rs35705950 polymorphism and RA. However, the comparison of RA-ILD patients with controls showed a significant association with the allele frequencies of rs35705950 polymorphism (p=0.008; OR=2.61; CI [1.2-5.66]). Indeed, the minor T allele increased the risk of developing ILD by 2.61 for RA patients compared to the controls. Comparison of allele frequencies in RA-ILD patients and RA patients without ILD showed a significant association between the minor T allele of the studied polymorphism and RA-ILD (p= 0.02; OR= 2.66; CI [1.09-6.5]). In the adjusted model, this risk increased in case of smoking (p=0.025; OR=3,84; CI [1,13-13,08]) and/or female gender (p=0.013; OR = 4,63; CI [1,33-16,17]).

CONCLUSION

Our work has confirmed the role of the polymorphism of MUC5B promoter in the appearance of ILD during RA in Tunisian patients. This variant could be used to early detect preclinical ILD in patients with RA.

Clinical features and risk factors of invasive pulmonary aspergillosis in interstitial lung disease patients

BACKGROUND

The prevalence of invasive pulmonary aspergillosis (IPA) among patients with interstitial lung disease (ILD) is steadily increasing, leading to high mortality. The purpose of this study is to analyze the clinical features and risk factors of IPA in patients with ILD.

METHODS

353 hospitalized ILD patients admitted in Nanjing Drum Tower Hospital from March 2023 and April 2024 were enrolled. The enrolled patients were divided into the IPA group (proven and probable IPA) and non-IPA group, and the clinical characteristics and prognosis were compared between the two groups.

RESULTS

Among 353 patients with ILD, 58 who suffered from IPA were identified. Among them, 2 (3.4%) episodes of proven IPA and 56 (96.6%) of probable IPA were diagnosed. The median age was 68.4 ± 8.6 years, and 35 patients were men. The forms of ILD included idiopathic pulmonary fibrosis (n = 21), interstitial pneumonia with autoimmune features (n = 13), rheumatoid arthritis related interstitial pneumonia (n = 11) and Sjögren's syndrome (n = 4). The clinical features of IPA in ILD were cough (100.0%), dyspnea (93.1%) and fever (55.2%). Chest CT images showed reticulation (87.9%), traction bronchiectasis (84.5%), GGO (77.6%), honeycombing (69.0%), consolidation (44.8%) and pleural effusion (24.1%). The incidence of honeycombing and consolidation were higher in ILD patients with IPA compared to control group (P < 0.05). The main pathogens were A. fumigatus (50.0%) and A. flavus (29.3%). Following the diagnosis of IPA, all patients were treated with antifungal drugs. The overall survival rate after 90 days was 74.1%. Multivariate conditional Logistic regression analysis showed that lymphopenia (OR = 2.745, 95% CI 1.344-5.607) and honeycombing (OR = 2.915, 95% CI 1.429-5.949) were the risk factors of ILD with IPA (P < 0.05).

CONCLUSION

IPA is one of the major complications of ILD and its prognosis is poor. Lymphopenia and honeycombing increased the risk of IPA in ILD patients.

2024 update of the recommendations of the French Society of Rheumatology for the diagnosis and management of patients with rheumatoid arthritis

The French Society of Rheumatology recommendations for managing rheumatoid arthritis (RA) has been updated by a working group of 21 rheumatology experts, 4 young rheumatologists and 2 patient association representatives on the basis of the 2023 version of the European Alliance of Associations for Rheumatology (EULAR) recommendations and systematic literature reviews. Two additional topics were addressed: people at risk of RA development and RA-related interstitial lung disease (RA-ILD). Four general principles and 19 recommendations were issued. The general principles emphasize the importance of a shared decision between the rheumatologist and patient and the need for comprehensive management, both drug and non-drug, for people with RA or at risk of RA development. In terms of diagnosis, the recommendations stress the importance of clinical arthritis and in its absence, the risk factors for progression to RA. In terms of treatment, the recommendations incorporate recent data on the cardiovascular and neoplastic risk profile of Janus kinase inhibitors. With regard to RA-ILD, the recommendations highlight the importance of clinical screening and the need for high-resolution CT scan in the presence of pulmonary symptoms. RA-ILD management requires collaboration between rheumatologists and pulmonologists. The treatment strategy is based on controlling disease activity with methotrexate or targeted therapies (mainly abatacept or rituximab). The prescription for anti-fibrotic treatment should be discussed with a pulmonologist with expertise in RA-ILD.

Rheumatoid arthritis: a review of the key clinical features and ongoing challenges of the disease

Rheumatoid arthritis (RA) is an autoimmune inflammatory condition that primarily affects the joints and periarticular soft tissue. The development of joint swelling is traditionally regarded as the starting point of the disease. Emerging evidence indicates that RA patients often experience a preclinical stage characterized by immunological and inflammatory changes before developing the disease. The review discusses ongoing efforts to predict the transition from this preclinical phase to clinical RA and describes studies aimed at preventing the onset of RA in individuals at risk. Over the past two decades, there have been significant advancements in RA management and outcomes. An increasing number of patients can now achieve disease remission, and in some cases, this remission persists without ongoing treatment, which is effectively a cure. As new therapies and evolving scientific evidence emerge, recommendations for RA management are continuously evolving. Despite these improvements in the management of RA, many patients still do not respond to multiple conventional or more advanced therapies, including biologic and targeted synthetic disease modifying anti-rheumatic drugs, or experience disease flares when treatments are tapered or discontinued. This situation underscores the need for reliable biomarkers to guide therapy more effectively, improve personalized treatment approaches and monitoring strategies (i.e. precision medicine). In conclusion, this review provides a comprehensive overview of RA, covering new research on the 'pre-clinical' phase of the disease, as well as its epidemiology, pathogenesis, clinical manifestations, diagnosis, imaging, and management strategies. It highlights key clinical aspects of RA and addresses ongoing challenges in disease management, particularly in the areas of prevention and treatment.

Bone and Joint-on-Chip Platforms: Construction Strategies and Applications

Organ-on-a-chip, also known as "tissue chip," is an advanced platform based on microfluidic systems for constructing miniature organ models in vitro. They can replicate the complex physiological and pathological responses of human organs. In recent years, the development of bone and joint-on-chip platforms aims to simulate the complex physiological and pathological processes occurring in human bones and joints, including cell-cell interactions, the interplay of various biochemical factors, the effects of mechanical stimuli, and the intricate connections between multiple organs. In the future, bone and joint-on-chip platforms will integrate the advantages of multiple disciplines, bringing more possibilities for exploring disease mechanisms, drug screening, and personalized medicine. This review explores the construction and application of Organ-on-a-chip technology in bone and joint disease research, proposes a modular construction concept, and discusses the new opportunities and future challenges in the construction and application of bone and joint-on-chip platforms.

Proposal of a radiation-free screening protocol for early detection of interstitial lung involvement in seropositive and ACPA-positive rheumatoid arthritis

BACKGROUND

Seropositive rheumatoid arthritis (RA) is associated with significant cardiovascular and pulmonary morbidity. However, screening for early detection of pulmonary involvement especially interstitial lung disease (ILD) is not established in RA.

METHODS

We propose a non-invasive radiation-free approach to screen for interstitial lung involvement (ILI) by means of pulmonary function tests (PFT) and pleuro-pulmonary transthoracic ultrasound (LUS) with additional cardiopulmonary exercise tests (CPET) with ECG, and echocardiography. We included patients with confirmed diagnosis of seropositive RA according to ACR criteria, but without symptoms for or known cardiopulmonary disease. ILD was suspected when significant LUS abnormalities and additional PFT changes were present.

RESULTS

We included 67 consecutive patients (78% female, mean age 61 ± 12 years, 48% active or previous smokers), who fulfilled the inclusion criteria and gave written informed consent. We found 48% of patients with suspected changes in PFT with a diffusion capacity (DLCOc-SB) ≤ 80%, among them 7% with forced vital capacity (FVC) ≤ 80%. In 40% of patients, we found noticeable changes in LUS, 24% with an ILD compatible pattern. In 16% of cases, LUS abnormalities and additional PFT changes were present, and ILI was suspected. Additional findings included obstructive lung disease (n = 11), subpleural consolidation (n = 6) including one confirmed lung cancer, minimal pleural effusion (n = 6), and ischemic cardiac disease (n = 2). None of the patients showed signs of pulmonary vascular involvement.

CONCLUSIONS

ILI was suspected in 16% of cases using a new radiation-free screening protocol in asymptomatic RA patients.

TRIAL REGISTRATION

German Register of Clinical Studies (DRKS00028871).

GZMK Facilitates Experimental Rheumatoid Arthritis Progression by Interacting with CCL5 and Activating the ERK Signaling

Synovial over-proliferation is a key event in the progression of rheumatoid arthritis (RA) disease. Ferroptosis may be essential for maintaining the balance between synovial proliferation and death. This study aimed to investigate the molecular mechanisms mediating the activation and ferroptosis of collagen-induced arthritis (CIA)-synovial fibroblasts (SFs). Differentially expressed genes (DEGs) in the synovial tissues of CIA rats and normal rats were screened through sequencing. The GSE115662 dataset from the GEO database was analyzed and screened for DEGs. The viability, proliferation, migration, invasion, cell cycle, and apoptosis of CIA-SFs were analyzed by cell counting kit-8, 5-ethynyl-2'-deoxyuridine, flow cytometry, transwell migration, and invasion assays. The ferroptosis of CIA-SFs was assessed using matching reagent kits to detect indicators like reactive oxygen species, ferrous iron, malondialdehyde, glutathione, and superoxide dismutase. The interaction between Granzyme K (GZMK) and C-C motif chemokine 5 (CCL5) was determined by coimmunoprecipitation assay. We found abnormal GZMK expression in the GSE115662 database and mRNA sequencing data. GZMK was overexpressed in CIA-SFs, and GZMK promoted cell proliferation, migration, invasion, inflammation, and decreased cell apoptosis and ferroptosis in CIA-SFs. GZMK could interact with CCL5 to activate the ERK signaling. GZMK and CCL5 knockdown improved by reducing arthritis scores, redness and swelling of paws, and pathological changes in joint synovium of CIA rats. CCL5 overexpression reversed the effects of GZMK silencing on CIA-SFs cell proliferation, migration, invasion, apoptosis, and ferroptosis. We confirmed that GZMK accelerated experimental rheumatoid arthritis progression by interacting with CCL5 and activating the ERK signaling.

Biomarkers of rheumatoid arthritis-associated interstitial lung disease: a systematic review and meta-analysis

Background

Interstitial Lung Disease (ILD) represents the most common extra-articular manifestation of Rheumatoid Arthritis (RA) and is a major cause of mortality. This study aims to identify and evaluate biomarkers associated with Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD).

Methods

We searched PubMed, Cochrane Library, EMBASE, and Web of Science databases for studies related to biomarkers of RA-ILD up until October 7, 2023. The Newcastle-Ottawa Scale (NOS) and standards recommended by the Agency for Healthcare Research and Quality (AHRQ) were used for quality assessment, and meta-analysis was conducted using Stata18.0 software.

Results

A total of 98 articles were assessed for quality, 48 of which were included in the meta-analysis. 83 studies were of high quality, and 15 were of moderate quality. The meta-analysis showed significant differences in biomarkers such as C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR), Anti-Cyclic Citrullinated Peptide (anti-CCP) antibody, Rheumatoid Factor (RF), Krebs von den Lungen-6 (KL-6), Surfactant Protein D (SP-D), Carcinoembryonic Antigen (CEA), Carbohydrate Antigen 19-9 (CA19-9), Matrix Metalloproteinase-7 (MMP-7), C-X-C Motif Chemokine Ligand 10 (CXCL-10), and Neutrophil-to-Lymphocyte Ratio (NLR) between RA-ILD patients and RA patients. However, Platelet-to-Lymphocyte Ratio [Platelet-to-Lymphocyte Ratio (PLR)], Cancer Antigen 125 [Cancer Antigen 125 (CA-125)], and Cancer Antigen 153 [Cancer Antigen 153 (CA-153)] did not show significant differences between the two groups. KL-6, MMP-7, and Human Epididymis Protein 4 (HE4) are negatively correlated with lung function, and KL-6 is associated with the prognosis of RA-ILD.

Conclusions

Biomarkers hold promising clinical value for prediction, diagnosis, severity assessment, and prognosis evaluation in RA-ILD. However, these findings need to be validated through multicenter, large-sample, prospective cohort studies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023448372.

Neutrophil extracellular traps as immunofibrotic mediators in RA-ILD; pilot evaluation of the nintedanib therapy

Objective

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a significant pulmonary complication of RA. This study tried to elucidate the mechanisms enhancing inflammation and causing lung injury in RA-ILD, focusing on the role of neutrophil extracellular traps (NETs). The study also investigated the potential benefits of nintedanib in advanced disease.

Methods

Nine RA-ILD patients and nine healthy controls were included in the study. Inflammatory markers in patients' circulation were evaluated with immunoassays. The formation of NETs was examined using a citrullinated histone H3 (CitH3) ELISA and cell immunofluorescence. Inflammatory proteins expressed in neutrophils/NETs were studied with real-time qPCR and NET ELISA. To assess the effect of nintedanib, an intracellular tyrosine kinase inhibitor with antifibrotic properties, in RA-ILD a paired study was conducted in five patients before treatment administration and 16 weeks later.

Results

The soluble terminal complement complex sC5b-9 and the levels of CitH3 were significantly elevated in patients with RA-ILD, compared to healthy controls. In addition, neutrophils isolated from RA-ILD patients released NETs enriched with tissue factor and interleukin-17A. Inflammatory NETs had a dynamic role, increasing the fibrotic potential of human pulmonary fibroblasts (HPFs). On the other hand, nintedanib treatment decreased NETs and sC5b-9 levels in RA-ILD patients.

Conclusion

The findings propose an interplay between circulating NETs and HPFs, establishing the immunofibrotic aspects of RA-ILD. They also support the effectiveness of nintedanib in reducing key pathological processes of the disease. Further research is needed to fully understand these mechanisms and optimize treatment strategies for RA-ILD.

Unique transcriptomic profile of peripheral blood monocytes in rheumatoid arthritis-associated interstitial lung disease

OBJECTIVES

Though interstitial lung disease (ILD) contributes to excess morbidity and mortality in rheumatoid arthritis (RA), RA-ILD pathogenesis remains incompletely defined. As intermediate, non-classical and suppressed CD14+ monocytes are expanded in RA-ILD, this study sought to characterize gene expression profiles of circulating monocytes in RA-ILD.

METHODS

Peripheral blood mononuclear cells were collected from patients with RA without lung disease (N = 5), RA-ILD (N = 5), idiopathic pulmonary fibrosis (IPF; N = 5), and controls without lung and autoimmune disease (N = 4). RNA was extracted from CD14+ isolated monocytes and subjected to transcriptional analysis of 1365 genes. Gene enrichment and pathway analyses were performed.

RESULTS

Unsupervised clustering grouped patients with RA-ILD together with IPF for myeloid innate genes. For fibrosis genes, patients with RA-ILD clustered independent of comparator groups. There were 103, 66, and 64 upregulated and 66, 14, and 25 downregulated genes for RA-ILD, RA, and IPF, vs controls, respectively. For RA-ILD, there was increased expression of genes involved in regulating inflammation and fibrosis (SOCS3, CECAM1, LTB4R2, CLEC7A, IRF7, PHYKPL, GBP5, RAPGEF), epigenetic modification (KDM5D, KMT2D, OGT), and macrophage activation. Top canonical pathways included macrophage differentiation-activation, IL-12, neuroinflammatory, glucocorticoid receptor, and IL-27 signalling.

CONCLUSIONS

Circulating monocytes in RA-ILD patients demonstrate unique gene expression profiles with innate immune gene features more aligned with IPF as opposed to RA in the absence of clinical lung disease with fibrosis gene expression that was distinct from RA and IPF. These studies are important for understanding disease pathogenesis and may provide information for future therapeutic targets in RA-ILD.

Primary Ciliary Dyskinesia Caused by Homozygous DNAAF1 Mutations Resulting from a Consanguineous Marriage: A Case Report from Japan

We present the case of a 58-year-old female patient with primary ciliary dyskinesia (PCD). She was born to parents with a consanguineous marriage. Chest computed tomography conducted at age 41 years indicated no situs inversus, and findings of bronchiectasis were limited to the middle and lingular lobes. Despite long-term macrolide therapy, bronchiectasis exacerbations frequently occurred. PCD was suspected because of the low nasal nitric oxide level (20.7 nL/min). Electron microscopy revealed outer and inner dynein arm defects, and a genetic analysis identified a homozygous single-nucleotide deletion in the DNAAF1 gene. Based on these results, the patient was diagnosed with PCD due to a biallelic DNAAF1 mutation.

Genomic and Serological Rheumatoid Arthritis Biomarkers, MUC5B Promoter Variant, and Interstitial Lung Abnormalities

RATIONALE

Rheumatoid arthritis (RA) has been implicated in interstitial lung disease (ILD) as majority of studies have been comprised of patients with known RA. However, it remains unclear whether an underlying risk for RA in combination with genetic risk for pulmonary fibrosis is associated with radiological markers of early lung injury and fibrosis in broader population samples.

OBJECTIVE

Determine whether genetic and serological biomarkers of RA risk in combination with the MUC5B (rs35705950) risk allele (T) are associated with interstitial lung abnormalities (ILA) on computed tomography (CT) scans.

METHODS

Associations of RA-risk HLA-DRB1 alleles (*04:01, *04:08, *04:05, *04:04, *10:01) and serum RA autoantibodies with ILA in the Multi-Ethnic Study of Atherosclerosis (MESA, n=4,018) and COPDGene (n=5,963) cohorts were modeled using logistic regression and adjusted for age, sex, self-reported race and ethnicity, smoking history, body mass index, and principal components of genetic ancestry.

RESULTS

The prevalence of an RA risk HLA-DRB1 allele was 16.5% and 21.9% in MESA and COPDGene, respectively. ILA was present in 3.9% and 11% in MESA and COPDGene, respectively. An RA risk HLA-DRB1 allele was not significantly associated with ILA in MESA and COPDGene. In MESA, higher serum levels of IgA rheumatoid factor (RF) and anti-cyclic citrullinated peptide were associated with an odds ratio (OR) for ILA of 1.20 (95% CI 1.07-1.35) and 1.19 (95% CI 1.04-1.37), respectively. Among smokers without baseline ILA, per doubling of IgM RF was associated with an OR for ILA 10 years later of 1.25 (95% CI 1.08-1.43). Associations were not significantly different by MUC5B risk allele status.

CONCLUSIONS

RA-related HLA-DRB1 alleles were not associated with ILA, whereas higher serum levels of IgM RF among smokers without baseline ILA were associated with subsequent ILA.

The causal relationship between rheumatoid arthritis and interstitial lung disease in East Asian population: A two-sample Mendelian randomization study

To investigate the causal relationship between rheumatoid arthritis (RA) and interstitial lung disease (ILD) in the East Asian population, we utilized Mendelian randomization (MR). Publicly available summarized data from genome-wide association studies on RA (4199 cases and 208,254 controls), and the data on ILD (1046 cases and 176,974 controls) were obtained from BioBank Japan. Eligible single nucleotide polymorphisms from East Asian populations were obtained from genome-wide association studies as instrumental variables, and 11 RA-related single nucleotide polymorphisms (P < 5 × 10-8) were selected as instrumental variables. MR analysis was performed using inverse variance weighted, MR-Egger regression, weighted median, and MR-PRESSO with RA as the exposure data and ILD as the outcome data. Reliability was evaluated using Cochran Q test, MR-Egger intercept, leave-one-out analysis, and funnel plot. Inverse variance weighted results showed an odds ratio (95% confidence interval) of 1.29 (1.18-1.41), P = 3.99 × 10-8, indicating a positive association between RA and ILD. The reliability evaluation could adopt the fixed-effect model, and the absolute value of the MR-Egger regression intercept was 0.021, P > 0.05, and P value of Global Test in MR-PRESSO was 0.573. The test results of the leave-one-out showed that the results are robust, and the funnel plot indicated that the instrumental variables were not affected by potential factors. In conclusion, this study demonstrates that RA is a risk factor for ILD in the East Asian population.

Clinical utility of lung ultrasound for the detection of interstitial lung disease in patients with rheumatoid arthritis

OBJECTIVE

To establish the diagnostic value of lung ultrasound (LUS) in patients with rheumatoid arthritis (RA) for the detection of interstitial lung disease (ILD).

METHODS

A cross-sectional study was performed. Consecutive patients with RA (American College of Rheumatology/European League Against Rheumatism 2010 criteria) who had a chest high-resolution computed tomography (HRCT) performed within 12 months before inclusion, regardless of symptomatology, were included. Demographic, clinical, laboratory, and pharmacological data were recorded. Each patient underwent a LUS with assessment of B-lines (BL) and pleural irregularities (PI). HRCT was considered the gold standard for the confirmatory diagnosis of ILD. Receiver operating characteristic (ROC) curves were calculated to test the ability of LUS findings (BL and PI) in discriminating patients with ILD.

RESULTS

A total of 104 RA patients were included, of which 21.8% had ILD. Patients with ILD had more BL (median 26 versus 1, p<0.001) and PI (median 16 versus 5, p<0.001) than patients without ILD. The diagnostic accuracy in ROC curves was as follows: area under the curve (AUC) 0.88 and 95% confidence interval (CI) 0.78-0.93 for BL and AUC 0.82 and 95% CI 0.74-0.89 for PI. The best cut-off points for (ILD detection) discriminating the presence of significant interstitial lung abnormalities were 8 BL and 7 PI.

CONCLUSIONS

The presence of 8 BL and/or 7 PI in the LUS showed an adequate cut-off value for discriminating the presence of significant interstitial lung abnormalities, evocative of ILD.

The Therapeutic Efficacy of Abatacept for Rheumatoid Arthritis-Associated Interstitial Lung Disease: Insights from a 12-Month Trial Using Semi-Quantitative Chest High-Resolution Computed Tomography Imaging

Background: Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a major complication of rheumatoid arthritis (RA), but effective treatment remains an unmet need in its management. Our aim was to evaluate the therapeutic efficacy of abatacept for RA-ILD. Methods: This observational retrospective study included patients with RA-ILD treated with abatacept between 2012 and 2021. Indices of RA disease activity and interstitial lung disease (Disease Activity Score in 28 joints using C-reactive Protein [DAS28-CRP], Simplified Disease Activity Index [SDAI], Clinical Disease Activity Index [CDAI], serum Krebs von den Lungen-6 levels, % forced vital capacity [%FVC], and semi-quantified chest high-resolution computed tomography scores) were evaluated before and 1 year after the start of abatacept administration. Results: Overall, 38 patients were included. DAS28-CRP, SDAI, and CDAI were significantly improved (all with p < 0.0001). Total ground-glass opacity scores were decreased in both patients with usual interstitial pneumonia (UIP)-like patterns and with non-UIP-like patterns (p = 0.008 and <0.002, respectively). Total fibrosis scores were also decreased in the UIP-like pattern group (p < 0.042). The %FVC remained stable. Conclusions: Abatacept significantly improves RA disease activity and reduces pulmonary inflammation in patients with RA-ILD.

Therapeutic single-cell landscape: methotrexate exacerbates interstitial lung disease by compromising the stemness of alveolar epithelial cells under systemic inflammation

BACKGROUND

Interstitial lung disease (ILD) poses a serious threat in patients with rheumatoid arthritis (RA). However, the impact of cornerstone drugs, including methotrexate (MTX) and TNF inhibitor, on RA-associated ILD (RA-ILD) remains controversial.

METHODS

Using an SKG mouse model and single-cell transcriptomics, we investigated the effects of MTX and TNF blockade on ILD.

FINDINGS

Our study revealed that MTX exacerbates pulmonary inflammation by promoting immune cell infiltration, Th17 activation, and fibrosis. In contrast, TNF inhibitor ameliorates these features and inhibits ILD progression. Analysis of data from a human RA-ILD cohort revealed that patients with ILD progression had persistently higher systemic inflammation than those without progression, particularly among the subgroup undergoing MTX treatment.

INTERPRETATION

These findings highlight the need for personalized therapeutic approaches in RA-ILD, given the divergent outcomes of MTX and TNF inhibitor.

FUNDING

This work was funded by GENINUS Inc., and the National Research Foundation of Korea, and Seoul National University Hospital.

[Low-dose methotrexate: Indications and side effects, particularly in cases of diffuse interstitial pneumonia]

INTRODUCTION

Methotrexate (MTX) is a folate antagonist used as an immunosuppressant in a number of conditions, including rheumatoid arthritis (RA). Low-dose MTX (MTX-LD) is associated with a risk of haematological, hepatic, gastrointestinal and pulmonary toxicity, which may up until now have limited its use.

STATE OF THE ART

In RA, data from retrospective cohorts have reported a possible excess risk of methotrexate toxicity in cases of underlying interstitial lung disease (ILD). However, recent prospective and retrospective multicentre studies have found no such increased risk, and have reassuringly concluded that MTX-LD can be prescribed in cases of RA-associated ILD (RA-ILD).

PERSPECTIVES AND CONCLUSIONS

Current recommendations are not to delay the introduction of MTX in patients with RA at risk of developing ILD or in the presence of RA-ILD with mild to moderate respiratory impairment.

Distinct mucosal endotypes as initiators and drivers of rheumatoid arthritis

Rheumatoid arthritis (RA) is a potentially devastating autoimmune disease. The great majority of patients with RA are seropositive for anti-citrullinated protein antibodies (ACPAs), rheumatoid factors, or other autoantibodies. The onset of clinically apparent inflammatory arthritis meeting classification criteria (clinical RA) is preceded by ACPA seropositivity for an average of 3-5 years, a period that is designated as 'at-risk' of RA for ACPA-positive individuals who do not display signs of arthritis, or 'pre-RA' for individuals who are known to have progressed to developing clinical RA. Prior studies of individuals at-risk of RA have associated pulmonary mucosal inflammation with local production of ACPAs and rheumatoid factors, leading to development of the 'mucosal origins hypothesis'. Recent work now suggests the presence of multiple distinct mucosal site-specific mechanisms that drive RA evolution. Indicatively, subsets of individuals at-risk of RA and patients with RA harbour a faecal bacterial strain that has exhibited arthritogenic activity in animal models and that favours T helper 17 (TH17) cell responses in patients. Periodontal inflammation and oral microbiota have also been suggested to promote the development of arthritis through breaches in the mucosal barrier. Herein, we argue that mucosal sites and their associated microbial strains can contribute to RA evolution via distinct pathogenic mechanisms, which can be considered causal mucosal endotypes. Future therapies instituted for prevention in the at-risk period, or, perhaps, during clinical RA as therapeutics for active arthritis, will possibly have to address these individual mechanisms as part of precision medicine approaches.

Subcutaneous vs intravenous abatacept in rheumatoid arthritis-interstitial lung disease. National multicentre study of 397 patients

BACKGROUND

Evidence on abatacept (ABA) utility for rheumatoid arthritis (RA) - associated interstitial lung disease (ILD) is growing. Clinical trials have shown equivalence in subcutaneous (SC) and intravenous (IV) administration of ABA for articular manifestations. However, this has not been studied in respiratory outcomes.

OBJECTIVE

To compare the effectiveness of ABA in RA-ILD patients according to the route of administration.

METHODS

National retrospective multicentre study of RA-ILD patients on treatment with ABA. They were divided into 2 groups: a) IV, and b) SC. The following outcomes were analysed from baseline to final follow-up using linear mixed models: a) forced vital capacity (FVC), b) diffusing capacity of the lungs for carbon monoxide (DLCO), c) chest high resolution computed tomography (HRCT), d) dyspnoea, e) RA activity, and f) sparing corticosteroids effect.

RESULTS

A total of 397 patients were included (94 IV-ABA and 303 SC-ABA), median follow-up of 24 [10-48] months. After adjustment for possible confounders, FVC and DLCO remained stable during the first 24 months without differences between IV-ABA and SC-ABA (p = 0.6304 and 0.5337). Improvement/ stability of lung lesions in HRCT was observed in 67 % of patients (75 % IV-ABA, 64 % SC-ABA; p = 0.07). Dyspnoea stabilized/ improved in 84 % of patients (90 % IV-ABA, 82 % SC-ABA; p = 0.09). RA - disease activity improved in both groups. No statistically significant differences regarding any of the variables studied between the two groups were found. ABA was withdrawn in 87 patients (21.9 %), 45 % IV-ABA and 37 % SC-ABA (p = 0.29). ILD worsening and articular inefficacy were the most common reasons for ABA discontinuation.

CONCLUSION

In patients with RA-ILD, ABA seems to be equally effective regardless of the route of administration.

Association between flavonoid intake and rheumatoid arthritis among US adults

Basic research shows that flavonoids have anti-inflammatory effects that influence rheumatoid arthritis (RA) in rats. Investigating potential dietary interventions for RA helps prevent the onset and progression of the disease. Clinical evidence on the association of flavonoid and subclass intake with RA is lacking. Using three survey cycles of 2007-2008, 2009-2010, and 2017-2018 from the National Health and Nutrition Survey and the United States Department of Agriculture's Food and Nutrient Database for Dietary Studies (FNDDS), we analyzed 7,419 American adults (≥20 years old). The values of flavonoid and subclass intake were calculated using FNDDS. The status questions for self-reported RA were from the NHANES codebook. Weighted analyses, revealed that among the 7,419 participants included in this study (mean age of 44.69 years [standard error, 0.40] and 3,584 [48.31%] were female), 408 met the classification criteria for RA. According to the multivariable logistic regression model, compared with the risk of RA in the first quartile (Q1), the risks of RA in the second quartile (Q2), the third quartile (Q3) and the fourth quartile (Q4) were lower (Q2: OR=0.55, 95% CI: 0.38-0.80; Q3: OR=0.66, 95% CI: 0.44-0.97; Q4: OR=0.64, 95% CI: 0.46-0.89; trend: P=.03). The association between total flavonoids and RA remained significant after full consideration of confounding factors. With regard to the subclasses of flavonoids, high flavanones intake was associated with low RA prevalence in Model 3 (Q3: OR= 0.60, 95% CI:0.39-0.92; Q4: OR = 0.56, 95% CI: 0.32-0.99, trend: P=.02), but no such association was found in the other subclasses. Total flavonoids intake protected against RA, and the risk of developing RA decreased significantly with increasing intake of total flavonoids. Total flavonoids and flavanones were significantly associated with reduced RA risk for the American adult population. We highlighted the importance of employing diverse methodologies to assess the health effects of flavonoids.

Identification and Quantification of Precursory Changes of Rheumatoid Vasculitis in the Dorsalis Pedis Artery

OBJECTIVE

Rheumatoid arthritis (RA) is a systemic connective tissue autoimmune disease that can infiltrate arterial walls. The delay in diagnosis and treatment of rheumatoid vasculitis (RV) in patients with RA may lead to irreversible damage to the arterial walls of small-to-medium vessels, which has serious and devastating consequences, most notably lung and cardiac damage. In this work an ultrasound image-based biomarker was developed to detect precursory changes in RV.

METHODS

The ground truth was initiated from a medical diagnosis of RA, with arterial wall thickening of the proximal dorsalis pedis artery (DPA) indicating precursory changes of RV identified with ultrasound scanning. Ultrasound images of the DPA from 49 healthy subjects in the control group and 46 patients in the RA group were obtained. In total, 187 texture features were extracted from the images, followed by principal component analysis and linear discriminant analysis.

RESULTS

The proposed biomarker detected a significant difference between the two groups (p = 5.74 × 10-18) with an area under the receiver operating characteristic curve of 0.85. Ten major textural features contributing most heavily to the biomarker were identified, with these textures being consistent with clinical observations of RV identified in previous studies. Interscan reproducibility was assessed by computing the biomarker twice based on repeated scans of each ankle. High interscan reproducibility was demonstrated by a strong and significant Pearson's coefficient (r = 0.85, p < 0.01) between the two repeated measurements of the proposed biomarker.

CONCLUSION

The proposed biomarker can discriminate image textural differences seen in images acquired from RA patients, demonstrating precursory changes in RV compared with healthy controls. The major discriminative features identified in this study may facilitate the early identification and treatment of RV.

A Systematic Review of the Key Predictors of Progression and Mortality of Rheumatoid Arthritis-Associated Interstitial Lung Disease

BACKGROUND

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is an important extra-articular manifestation of rheumatoid arthritis (RA). Identifying patients at risk of progression and death is crucial for improving RA-ILD management and outcomes. This paper explores current evidence on prognostic factors in RA-ILD.

METHODS

We conducted a systematic literature review to examine the impact of clinical, radiological, and histological factors on lung function decline and the survival of RA-ILD patients. We searched electronic databases, including Medline and EMBASE, from inception to date. The incidence and prognosis of predictors were qualitatively analyzed, and univariate results were combined when feasible. Following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" guidelines, our systematic literature review involved a five-step algorithm. Out of 2217 records, 48 studies were eligible. These studies reported various prognostic factors, including demographic variables, clinical risk factors, serum markers, and preexisting treatments.

RESULTS

Lung function declined over time in 1225 subjects, with significant variability in smoking history and radiological/pathological UIP patterns. Severe lung fibrosis and abnormal pulmonary function tests (PFTs) were key univariate prognostic indicators, while age at initial presentation, RA disease activity, predicted DLCO percentage, and UIP pattern were the most reliable multivariate risk factors for ILD progression. Age, male gender, disease duration, RA activity, acute phase reactants, and specific serum biomarkers (Krebs vin den Lungen 6, surfactant protein D, and interleukin 6) were significantly associated with all-cause mortality.

CONCLUSIONS

RA-ILD is a severe complication of RA characterized by significant prognostic variability. Key prognostic factors include extensive fibrosis observed on imaging, a marked decline in lung function, high RA disease activity, and specific biomarkers. These factors can guide treatment strategies and improve patient outcomes.

Exploring rheumatoid arthritis associated interstitial lung disease a retrospective study from two Saudi tertiary care centers

BACKGROUND

Interstitial lung disease (ILD) is an increasingly recognized complication of rheumatoid arthritis (RA) and is associated with significant morbidity and mortality. Many risk factors for RA-related ILD were reported. The current study aims to explore the features and risk factors of Saudi patients with RA-ILD.

METHODS

This is a multicenter, retrospective, observational study of patients with RA-ILD. Clinical and radiological data from patients with RA-ILD were obtained from electronic medical records, including demographics, clinical characteristics, laboratory tests, pulmonary function tests, ECHO, and HRCT images.

RESULT

Out of 732 patients, 57 had RA-ILD. The mean age at the time of ILD diagnosis was 61.9 (± 12.2) years. RA-ILD diagnosis was significantly less among females (p = 0.008). Patients who ever smoked had significantly more RA-ILD (p < 0.001). Patients with RA-ILD were more likely to present with medical comorbidities, namely diabetes (p < 0.001), hypertension (p < 0.001), ischemic heart disease (p < 0.001), and osteoarthritis (p = 0.030). The multivariate analysis revealed that the age (OR: 1.035, 95% CI: 48.45-52.86, p = 0.0001); gender (OR: 2.581, CI: 1.77-1.86, p = 0.001), DM (OR: 2.498, 95% Cl: 1.65-1.76, P = 0.0001), HTN (OR: 1.975, 95% Cl: 1.61-1.74, P = 0.019), IHD (OR: 6.043, 95% Cl: 1.89-1.93, P = 0.0001) have a significant positive association with RA-ILD. No significant differences were observed between seropositive parameters with or without RA-ILD (p > 0.05). The most common symptoms of RA-ILD were cough (55.6%) and dyspnea (30.2%), and the most common ILD pattern was Non-specific Interstitial Pneumonia (NSIP) (55.6%) followed by Usual Interstitial Pneumonia (UIP) (38.9%). Traction bronchiectasis (75.5%) and glass ground opacities (73.6%) were also observed. The mean FVC and DLCO at baseline were 64.6% and 53.3%, respectively.

CONCLUSION

In this cohort of patients, Saudi RA-ILD patients had a predominant NSIP pattern conversely to what is seen globally. These findings could be explained by the lower rates of smoking in our patient population. Future prospective national studies are needed to confirm the current findings and better evaluate RA-ILD epidemiology and risk factors.

A Systematic Review on Biomarkers: Are There Reliable Molecular Biomarkers in Patients With Rheumatoid Arthritis-Associated Interstitial Lung Disease?

Despite advances in the study of rheumatoid arthritis-associated interstitial lung disease (RA-ILD), the pulmonary manifestation remains an important cause of morbidity and mortality. However, there is a lack of biochemical markers for this manifestation in the literature. Therefore, the objective of this study was to carry out a qualitative systematic review on biochemical markers associated with RA-ILD in the PubMed, Web of Science, Embase, Cochrane Library, and Virtual Health Library (VHL) between January 2015 and July 2024, using the following descriptors: #1 "biomarkers" (MeSH) AND #2 "rheumatoid arthritis" (MeSH) AND #3 "Lung Diseases, Interstitial" (MeSH). Of the 1497 articles found, 27 presented eligibility criteria. The findings were divided into three sessions: "Main biomarkers for RA-ILD," "Other biomarkers for RA-ILD activity," and "Other biomarkers for RA-ILD prognosis." Among the evaluated markers, KL-6, RF, ACPA, ESR, and CRP appear to have prognostic value and association with damage in patients with RA-ILD. The association of some molecules such as sPD-1, sCD25, VCAM-1, MCP-1, and ADMA with tissue damage is intriguing. Longitudinal and randomized studies are imperative to comprehensively delineate the history of RA-ILD and evaluate potential serum biomarkers.

A nomogram model combining computed tomography-based radiomics and Krebs von den Lungen-6 for identifying low-risk rheumatoid arthritis-associated interstitial lung disease

Objectives

Quantitatively assess the severity and predict the mortality of interstitial lung disease (ILD) associated with Rheumatoid arthritis (RA) was a challenge for clinicians. This study aimed to construct a radiomics nomogram based on chest computed tomography (CT) imaging by using the ILD-GAP (gender, age, and pulmonary physiology) index system for clinical management.

Methods

Chest CT images of patients with RA-ILD were retrospectively analyzed and staged using the ILD-GAP index system. The balanced dataset was then divided into training and testing cohorts at a 7:3 ratio. A clinical factor model was created using demographic and serum analysis data, and a radiomics signature was developed from radiomics features extracted from the CT images. Combined with the radiomics signature and independent clinical factors, a nomogram model was established based on the Rad-score and clinical factors. The model capabilities were measured by operating characteristic curves, calibration curves and decision curves analyses.

Results

A total of 177 patients were divided into two groups (Group I, n = 107; Group II, n = 63). Krebs von den Lungen-6, and nineteen radiomics features were used to build the nomogram, which showed favorable calibration and discrimination in the training cohort [AUC, 0.948 (95% CI: 0.910-0.986)] and the testing validation cohort [AUC, 0.923 (95% CI: 0.853-0.993)]. Decision curve analysis demonstrated that the nomogram performed well in terms of clinical usefulness.

Conclusion

The CT-based radiomics nomogram model achieved favorable efficacy in predicting low-risk RA-ILD patients.

Serum YKL-40 and Serum Krebs von den Lungen-6 as Potential Predictive Biomarkers for Rheumatoid Arthritis-Associated Interstitial Lung Disease

BACKGROUND

Interstitial lung disease (ILD) is a common pulmonary manifestation of rheumatoid arthritis (RA) and is associated with a poor prognosis. However, the role of blood biomarkers in RA-associated interstitial lung disease (RA-ILD) is ill-defined. We aim to evaluate the role of YKL-40 and Krebs von den Lungen-6 (KL-6) in the diagnosis and severity evaluation of RA-ILD.

METHODS

45 RA-non-ILD patients and 38 RA-ILD patients were included. The clinical data and the levels of YKL-40 and KL-6 were measured and collected for all patients. The risk factors for RA-ILD were analyzed and their correlation with relevant indicators and predictive value for RA-ILD was explored.

RESULTS

The levels of YKL-40 and KL-6 in RA-ILD patients were higher than RA-non-ILD patients (p < .001). Both YKL-40 and KL-6 were correlated with the incidence of RA-ILD. The predictive power of combined KL-6 and YKL-40 for the presence of ILD was 0.789, with a sensitivity and specificity at 73.7% and 73.3%, respectively. In RA-ILD patients, both YKL-40 and KL-6 were positively correlated with the Scleroderma Lung Study (SLS) I score and negatively correlated with pulmonary function.

CONCLUSIONS

KL-6 and YKL-40 might be a useful biomarker in the diagnosis and severity evaluation of RA-ILD.

Rheumatoid arthritis extra-articular lung disease: new insights on pathogenesis and experimental drugs

INTRODUCTION

Pulmonary involvement is one of the most common extra-articular manifestations of rheumatoid arthritis (RA), a systemic inflammatory disease characterized by joint swelling and tenderness. All lung compartments can be interested in the course of RA, including parenchyma, airways, and, more rarely, pleura and vasculature.

AREAS COVERED

The aim of this paper is to review the main RA lung manifestations, focusing on pathogenesis, clinical and therapeutic issues of RA-related interstitial lung disease (ILD). Despite an increasing number of studies in the last years, pathogenesis of RA-ILD remains largely debated and the treatment of RA patients with lung involvement is still challenging in these patients.

EXPERT OPINION

Management of RA-ILD is largely based on expert-opinion. Due to the broad clinical manifestations, including both joints and pulmonary involvement, multidisciplinary discussion, including rheumatologist and pulmonologist, is essential, not only for diagnosis, but also to evaluate the best therapeutic approach and follow-up. In fact, the coexistence of different lung manifestations may influence the treatment response and safety. The identification of biomarkers and risk-factors for an early identification of RA patients at risk of developing ILD remains a need that still needs to be fulfilled, and that will require further investigation in the next years.

Galangin: A Promising Flavonoid for the Treatment of Rheumatoid Arthritis-Mechanisms, Evidence, and Therapeutic Potential

Rheumatoid Arthritis (RA) is a chronic autoimmune disease characterized by progressive joint inflammation and damage. Oxidative stress plays a critical role in the onset and progression of RA, significantly contributing to the disease's symptoms. The complex nature of RA and the role of oxidative stress make it particularly challenging to treat effectively. This article presents a comprehensive review of RA's development, progression, and the emergence of novel treatments, introducing Galangin (GAL), a natural flavonoid compound sourced from various plants, as a promising candidate. The bioactive properties of GAL, including its anti-inflammatory, antioxidant, and immunomodulatory effects, are discussed in detail. The review elucidates GAL's mechanisms of action, focusing on its interactions with key targets such as inflammatory cytokines (e.g., TNF-α, IL-6), enzymes (e.g., SOD, MMPs), and signaling pathways (e.g., NF-κB, MAPK), which impact inflammatory responses, immune cell activation, and joint damage. The review also addresses the lack of comprehensive understanding of potential treatment options for RA, particularly in relation to the role of GAL as a therapeutic candidate. It highlights the need for further research and clinical studies to ascertain the effectiveness of GAL in RA treatment and to elucidate its mechanisms of action. Overall, this review provides valuable insights into the potential of GAL as a therapeutic option for RA, shedding light on its multifaceted pharmacological properties and mechanisms of action, while suggesting avenues for future research and clinical applications.

The interplay between rheumatic diseases and pulmonary health

Patients with rheumatic diseases (RDs) are prone to a number of comorbidities, particularly those affecting the respiratory system due to inflammatory and autoimmune mechanisms. Rheumatoid arthritis (RA), systemic sclerosis (SSc), and inflammatory idiopathic myopathies (IIMs) often present with progressive interstitial lung disease (ILD). The prevalence of ILD varies among patients with RDs, with 11% in RA, 47% in SSc, and 41% in IIMs. Some diagnostic markers, including KL-6, cytokines TNF-α and IL-6, and autoantibodies (anti-CCP), play a crucial role in assessing and predicting the course of pulmonary involvement in RDs. Lung fibrosis is a progressive disorder in SSc and RA, limiting the effiency of therapeutic interventions. Re-evaluating treatment approaches with disease-modifying anti-rheumatic drugs (DMARDs) is crucial for understanding their impact on the risk of lung affections. Despite initial concerns surrounding methotrexate, recent evidence points to its benefits in RA-associated interstitial lung disease (RA-ILD). Recognizing the intricate relationship between autoimmune RDs and lung affections is crucial for formulating effective treatment strategies. Emphasis is placed on collaborative efforts of rheumatologists and pulmonologists for early diagnosis, comprehensive care, and optimal patient outcomes in RA-ILD.