Developments and Challenges in Treating Rheumatoid Arthritis-Related Interstitial Lung Disease: From Pathogenesis to Treatment Opportunities

Interstitial lung disease (ILD) is the most severe extra-articular manifestation of rheumatoid arthritis (RA), representing one the most frequent causes of death for patients with RA. The treatment of RA-ILD is still debated and challenging for both rheumatologist and pulmonologist. Ideally, it should aim to control the underlying joint disease activity, to prevent ILD, or to reduce the progression of lung damage, in particular fibrotic changes. Disease-modifying antirheumatic drugs (DMARDS) are used in daily practice for the treatment of joint involvement but are not demonstrated to be effective in ILD, although good control of the systemic disease might improve patients' prognosis. However, immunosuppressants, usually suggested for the treatment of ILD related to autoimmune rheumatic diseases, often have low efficacy in regard to inflammatory joint manifestations of RA. Finally, the awareness of potential pulmonary toxicity related to disease-modifying antirheumatic drugs further complicates this scenario. Therefore, a multidisciplinary discussion, including at least a rheumatologist, pulmonologist, pathologist, and thoracic radiologist is generally requested to decide the best therapeutic strategy for an individual patient. In this paper, we will review the current available options for the treatment of RA-ILD, focusing on their possible use according to the current knowledge on pathogenesis and clinical evolution of RA-ILD.