Evaluation and management of rheumatoid arthritis-associated interstitial lung disease

Interstitial lung disease (ILD) is a significant extra-articular manifestation of rheumatoid arthritis (RA) that is associated with increased mortality risk and has a profound influence on treatment strategies. Early detection using advanced diagnostic tools, such as high-resolution computed tomography (HRCT), is crucial for evaluating RA-ILD and optimising patient outcomes. The traditional classification of RA-ILD into usual interstitial pneumonia and non-specific interstitial pneumonia patterns is challenging because RA-ILD exhibits features distinct from those of idiopathic interstitial pneumonia. Furthermore, the extent of ILD, as assessed using HRCT, has been increasingly recognised as a critical prognostic factor, emphasising its clinical relevance. As RA-ILD represents an organ-specific manifestation of a systemic inflammatory disease, its management should prioritise effective arthritis control. Growing evidence suggests that optimal arthritis control may mitigate the risk of RA-ILD development and progression. RA-ILD has often been diagnosed in advanced stages and managed using glucocorticoids (GCs) and immunosuppressive agents. However, increasing awareness of the toxicity associated with long-term use of GCs has prompted a shift toward the use of molecular-targeted therapies instead. Emerging data support the potential use of methotrexate in patients with RA and early-stage ILD, and the impact of molecular-targeting disease-modifying antirheumatic drugs on RA-ILD. Nintedanib, which has been shown to slow pulmonary function decline, should be considered in the appropriate stages of RA-ILD. As comprehensive follow-up strategies are essential for monitoring disease progression and guiding individualised treatment plans, effective management of RA-ILD requires multidisciplinary collaboration among rheumatologists, pulmonologists, and radiologists with continued research to improve RA-ILD outcomes.