Rheumatoid arthritis

Rheumatologists and respiratory physicians take different approaches to RA-ILD

There are significant variations in how rheumatologists and respiratory physicians approach the diagnosis and management of rheumatoid arthritis interstitial lung disease (RA-ILD), a large international study has revealed.

The survey, which included over 600 responses from six continents, revealed differences between the two specialties in attitudes towards risk factors for the disease, its prevalence, and diagnostic approaches, and highlighted the need for better education on detection and treatment to help improve outcomes.

While more than half of respondents in each group estimated the prevalence of ILD in RA to be 10% or more, in line with the latest evidence, a much greater proportion of rheumatologists (27%) than respiratory physicians (6.5%) believed it to be just 2%.

Significant variations were seen in knowledge of known ILD-RA risk factors between the specialties. For example, 90% of rheumatologists believed high titre rheumatoid factor (RF)/anti-cyclic citrullinated protein (anti-CCP) antibodies to be a risk factor, compared to 62% of respiratory physicians. Whereas just 88% versus 79%, respectively, thought smoking was a risk.

Almost half of rheumatologists failed to identify male sex as risk factor for ILD-RA (versus 36% for pulmonologists), while 31% (versus 26%) did not identify older age as one.

However, the data showed consensus on many of the treatment options for the condition, particularly on prednisone, mycophenolate and rituximab, where the responses between specialties were “surprisingly similar” the authors noted.

There was no statistical difference in the perception of methotrexate (MTX) as a risk for RA-ILD between rheumatologists and pulmonologists (18% versus 25%), however,  60% reported avoiding it in patients with the condition. The authors highlight that the perception that MTX may cause or worsen ILD is important, “as such beliefs could have the effect of denying or underutilising one of the most effective medications in RA”.

The research also revealed that “rheumatologists in particular did not consider a significant number of high-risk asymptomatic patients as candidates for screening, and infrequently referred both high-risk asymptomatic and symptomatic patients to a respiratory physician.

Lead researcher Dr Joshua Solomon from the Department of Medicine, at the National Jewish Health in Denver told the limbic that the most important finding of the study  was the “strikingly wide variability amongst providers in the knowledge of RA-ILD’s impact on patients and its diagnosis and management.”

The findings have spurred a renewed call for better education on RA-ILD, to help reduce variability in disease understanding and practice, particularly given the lack of consensus guidelines relating to the pulmonary manifestations of RA.

“Various groups are working on guidelines but are limited by a lack of evidence,” Dr Solomon told the limbic. “In spite of the prevalence of disease and its impact on patients, there are no published randomized placebo-controlled treatment trials focused on RA-ILD and we have yet to really understand both the prevalence of disease and its natural history. We have a lot of work to do.”

The research also indicates a greater need for “closer cooperation between rheumatologists and pulmonologists in a multidisciplinary approach to both enhance accuracy of diagnosis and assist with treatment strategies,” the researchers noted in the paper published in Rheumatology.

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