An international study published this year showed a high degree of variability in disease assessment and clinical practice between rheumatologists and pulmonologists, the 2 specialties involved in the care of patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD).1
Authors of the study found that not only were the practices between the specialties different, but the knowledge and beliefs about RA-ILD substantially differed between providers, indicating the need for more education “to optimize clinical decision making in the risk assessment, screening and treatment of RA-ILD.”1
The study published in Rheumatology (Oxford) included composite responses from 2 separate electronic surveys sent to pulmonologists and rheumatologists from 6 continents. Of the 616 responses, 354 (57%) were from pulmonologists and 262 (43%) were from rheumatologists. Demographic and practice data from all respondents were also collected.1
An area in which there was differing views between rheumatologists and pulmonologists was the prevalence of ILD in RA. While more than 50% in each group accurately chose “10% or greater” as the prevalence, rheumatologists underestimated the prevalence of RA-ILD by choosing “2%” at 4 times the rate of that of pulmonologists (27% vs 6.5%, respectively). Study authors explained that this may have been because of the lower likelihood that rheumatologists see patients with RA-ILD.1
“If rheumatologists are not screening for ILD in RA as a part of their routine practice, they are unlikely to diagnose patients with mild ILD. Pulmonologists are not seeing many patients with RA who do not have ILD and may be more likely to refer to the prevalence in some published literature rather than their own experience as a result,” Laura C. Cappelli, MD, a rheumatologist at Johns Hopkins Arthritis Center in Baltimore, MD, told us in an interview.
Awareness of Risk Factors
From the survey, pulmonologists and rheumatologists had varied knowledge regarding known risk factors of RA-ILD.1
The male sex, smoking, and older age have all been associated with higher risks for RA-ILD; some studies have even reported a 4-fold increased risk for those older than 65 years.1 Severity of RA-ILD has been linked to the presence of anticyclic citrullinated peptide (CCP) titers.3
Survey findings showed that a greater percentage of rheumatologists compared with pulmonologists believed that high-titer rheumatoid factor (RF)/anti-CCP antibodies and smoking were risk factors for ILD. A total of 20% of pulmonologists in the study did not identify smoking as a risk factor for RA-ILD; 50% and 30% of rheumatologists did not identify male sex and older age, respectively, as risk factors for ILD in RA.1
“These differences are at least partially explained by the patients we see,” said the lead author of the study, Joshua J. Solomon, MD, a pulmonologist at National Jewish Health in Denver, Colorado. “Rheumatologists see a lot of younger female patients with RA and we (pulmonologists) see older male patients with ILD, likely skewing our perception of who is getting the disease.”
A coauthor on the study, Paul Dellaripa, MD, a rheumatologist at Brigham and Women’s Hospital in Boston, Massachusetts, added his perspective to Dr Solomon’s views. He noted, “Lung health has not been a priority in the care of patients [with RA], and thus, understanding what to look for and ask (ie, screening) has not been advocated through consensus guidelines — but I do believe that will happen soon.”
Screening and Referral Practices
Approximately 90% of rheumatologists in the study reported screening for respiratory symptoms and smoking in patients with RA; however, these providers reported referral to a pulmonologist in only 33% and 25% cases, where a high-risk patient had respiratory symptoms or had abnormal results on a chest exam, respectively.
To provide a possible explanation for this, Dr Cappelli said, “It could suggest that for mild ILD, rheumatologists are comfortable managing and monitoring patients themselves. Another explanation is that rheumatologists are underdiagnosing RA-ILD, and thus, not referring patients frequently to pulmonary specialists.”
Bryant R. England, MD, PhD, of the Medicine & Research Service at the VA Nebraska-Western Iowa Health Care System and the Division of Rheumatology & Immunology at the University of Nebraska Medical Center in Omaha, Nebraska, agreed that many rheumatologists may feel comfortable initiating the workup for ILD in patients with RA and determine the necessity of referral to a pulmonologist, based on the results of this evaluation. “This emphasizes the need to ensure the workup for RA-ILD being ordered by rheumatologists is optimal,” he said.
Dr Dellaripa noted there is a distinct subset of pulmonologists “who are really interested in this area of lung disease, but at the end of the day the rheumatologist sees these patients the most and must be the one who reaches out and creates relationships with pulmonary colleagues to assess, prognosticate, and treat these very challenging [cases].”
On the other hand, Dr Solomon reported being surprised by this finding and felt that most pulmonologists were unaware of the low referral rates. “We need to foster our relationship with our colleagues in rheumatology and work together to identify this high-risk population and screen as indicated.”
With regard to treatment decisions, academic pulmonologists vs those in private practice were found to be more likely to believe in the efficacy of rituximab; however, this belief reduced with greater years of experience. Academic pulmonologists were also more likely to avoid using methotrexate in patients with RA-ILD.
Dr Solomon suggested that targeted education for selected groups will help to close these gaps, “but the best way to address this across the board is to conduct high-quality studies in these patients to answer important questions about effective and ineffective medications and develop consensus guidelines.”
Dr Dellaripa pointed out that methotrexate has only recently been cleared as a cause for ILD in RA, from data from high-quality studies.
Unmet Needs in RA-ILD
Study authors noted, “More education is needed regarding our understanding of RA-ILD including prevalence, risk factors, screening, and management.” While educational efforts are clearly needed, the biggest obstacle to optimal treatment has been the lack of guidelines to standardize practices across specialties.1
“There is no standard or guideline that instructs providers on which patients [with RA] to screen for ILD, how to screen them, and how often to repeat screening,” Dr England said.
“It would be helpful to have standardized recommendations about how to screen for ILD at RA diagnosis and how to monitor patients with RA over time, potentially from rheumatology societies,” Dr Capelli added. “Prospective studies in this area showing benefit would be the most helpful to convince rheumatologists to adopt particular practices.”
- Solomon JJ, Swigris JJ, Kreuter M, et al. The attitudes and practices of physicians caring for patients with rheumatoid arthritis-interstitial lung disease: an international survey. Rheumatology (Oxford). Published online July 14, 2021. doi:10.1093/rheumatology/keab552
- Assayag D, Lee JS, King TE Jr. Rheumatoid arthritis associated interstitial lung disease: a review. Medicina (B Aires). 2014;74(2):158-165.
- Munoz-Rocha AD, Guarneros-Ponce M, Gamez-Nava J, et al. Anti-cyclic citrullinated peptide antibodies and severity of interstitial lung disease in women with rheumatoid arthritis. J Immuno Res. 2015;2015:151646. doi:10.1155/2015/151626