Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment

Frontiers in Medicine

article

George E. Fragoulis¹  Elena Nikiphorou³  Jörg Larsen⁴  Peter Korsten⁵  Richard Conway⁶ 

[1] First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko General Hospital;Institute of Infection, University of Glasgow, United Kingdom;Department of Inflammation Biology, Faculty of Life Sciences & Medicine, Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, King's College London, United Kingdom;Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen;Department of Nephrology and Rheumatology, University Medical Center Göttingen;Department of Rheumatology, Blackrock Clinic

关键词: rheumatoid arthritis;    interstitial lung disease;    methotrexate;    biologics;    immunosuppressive therapies;   

DOI  :  10.3389/fmed.2019.00238

学科分类：社会科学、人文和艺术（综合）

来源: Frontiers

【 摘 要 】

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.

【 授权许可】

CC BY