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Rheumatoid arthritis-associated interstitial lung disease — ABIM Board MCQ

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HardRheumatology/Allergy/ImmunologyRheumatoid arthritis-associated interstitial lung diseaseABIM Board

A 58-year-old woman with seropositive rheumatoid arthritis on methotrexate has progressive dyspnea. HRCT shows a usual interstitial pneumonia pattern, and serial testing confirms declining FVC and DLCO. Infection and heart failure have been excluded. Which management direction is best?

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Correct answer: A — Use joint pulmonary-rheumatologic treatment guided by ILD progression

The best answer is “Use joint pulmonary-rheumatologic treatment guided by ILD progression”. Rheumatoid arthritis can produce progressive fibrotic ILD, including a UIP pattern. Management requires joint rheumatology-pulmonology assessment of inflammatory activity, fibrosis trajectory, medication toxicity, and comorbidity. Mycophenolate, rituximab, or other immunomodulation may be used, while nintedanib can be considered in progressive pulmonary fibrosis. Methotrexate is not a stand-alone ILD treatment, but an automatic withdrawal decision is also inappropriate without individualized review.

Reference: ACR/CHEST guideline for systemic autoimmune rheumatic disease ILD: https://pubmed.ncbi.nlm.nih.gov/38087426/