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Systemic sclerosis ILD — SCE Rheumatology MCQ

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HardConnective tissue diseasesSystemic sclerosis ILDSCE Rheumatology

A 48-year-old woman with diffuse cutaneous systemic sclerosis has received mycophenolate mofetil 1.5 g twice daily for 12 months, with confirmed adherence and acceptable tolerability. Exertional dyspnoea has progressed, FVC has fallen from 76% to 63% predicted, and repeat HRCT demonstrates extension of fibrotic NSIP. Infection and pulmonary hypertension have been excluded. The respiratory-rheumatology multidisciplinary team plans to add a biologic for progressive systemic sclerosis-associated interstitial lung disease. Which is the most appropriate agent?

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Correct answer: C — Rituximab

Rituximab is the appropriate listed biologic. This patient has unequivocally progressive systemic sclerosis-associated ILD despite an adequate course of mycophenolate, with symptomatic, physiological and radiological deterioration. The 2024 BSR systemic sclerosis guideline includes rituximab among treatment options for SSc-ILD and supports escalation with rituximab in progressive disease despite mycophenolate, in a specialist multidisciplinary setting. Tocilizumab and nintedanib may also have roles in selected patients, but neither is offered; nintedanib is an antifibrotic rather than a biologic. Adalimumab, belimumab, mepolizumab and anakinra do not have an established guideline-supported role in this SSc-ILD phenotype.

Reference: British Society for Rheumatology. Guideline for the management of systemic sclerosis in people of all ages, 2024; systemic sclerosis-associated interstitial lung disease treatment recommendations. https://www.rheumatology.org.uk/guidelines