• Rheumatoid Arthritis
• Lower Respiratory Infections
• Chronic Obstructive Pulmonary Disease

• Rheumatoid Arthritis
• Lower Respiratory Infections
• Chronic Obstructive Pulmonary Disease
• Rheumatology

Long-term use of oral glucocorticosteroids should be avoided in patients with rheumatoid arthritis (RA) who have concomitant interstitial lung disease (ILD), according to the findings of a British initiative.

Presenting author Clive Kelly, MD, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, United Kingdom, explained that respiratory diseases, including pulmonary fibrosis and infection, are a leading cause of mortality in patients with RA, second only to cardiovascular disease [Young A et al. Rheumatology (Oxford) 2007].

ILD has been long been recognized as a complication of RA; ILD previously was associated with a high (40%) postmortem incidence, and this was confirmed in approximately 25% of patients using high-resolution computed tomography (HRCT) in the 1990s. Today, the clinical prevalence of ILD in RA is thought to be about 5%, with an estimated lifetime risk of 7.7% and estimated mean survival of just 2.6 years after diagnosis [Bongartz T et al. Arthritis Rheum 2010].

The British Rheumatoid Interstitial Lung (BRILL) Network is comprised of 16 UK centers that have contributed retrospective data to a central database of 260 proven cases of RA-ILD that occurred over a 25-year period since 1987. These data were used to examine trends in mortality and the effects of treatments on survival of patients with RA-ILD compared with a control group of RA patients without lung disease.

For RA-ILD patients in the database, ILD was diagnosed at a median age of 64 years, at a median of 9 years' RA duration and 4 years' ILD duration. RA was present before ILD in most cases (83%), with ILD seen first or occurring concurrently with RA in 10% and 7% of patients, respectively. The most common ILD subtype on HRCT was usual interstitial pneumonia (UIP; 65% of cases), which carries a worse prognosis in RA patients. Seropositive disease was more common in RA patients with ILD than in those without ILD.

Data from the BRILL Network showed that all-cause mortality was significantly higher for patients who had used oral steroids than for those who had not (p=0.0002). Respiratory mortality was also significantly increased in oral steroid versus nonsteroid users (p=0.0002; Table 1).

Survival of patients with RA-ILD was shown to be improved in recent years (Table 2), but the effects of oral steroid use appear to have reduced this in some patients, Dr. Kelly observed.

Patients with RA-ILD were more likely to have used steroids than were RA controls (59% vs 14%; p=0.01). Patients with RA-ILD were also more liked to have UIP (p=0.02). The excess of this ILD subtype may account for some of the increased mortality.

Conversely, the BRILL Network has recently reported that certain immunosuppressants and biologic therapies appear to carry a survival benefit.

Since all these data are retrospective, however, 2 prospective therapeutic trials are planned. The first will recruit RA patients with progressive ILD and compare the use of mycophenolate mofetil and azathioprine, allowing for the use of oral steroids. The second will recruit patients with active RA and ILD and compare the potential survival advantage of using rituximab over anti–tumor necrosis factor-a therapies.

Concluding, Dr. Kelly observed that patients with RA and concomitant ILD have increased mortality compared with controls and that more than half of these patients have been treated with oral steroids. This large, retrospective, multicenter study suggests that the long-term use of oral steroids should be reconsidered when possible in RA patients who also have ILD.

• © 2014 MD Conference Express®