Lung disease in rheumatoid arthritis

Rheumatoid arthritis (RA) is a prevalent chronic systemic autoimmune inflammatory disease that primarily targets synovial joints and periarticular tissues. In RA, systemic inflammation has been associated with extra-articular manifestations, including pulmonary involvement, which are leading causes of reduced survival. Tobacco smoking is a well-established risk factor for anti-citrullinated protein antibody (ACPA)-positive RA and is also associated with chronic obstructive pulmonary disease, interstitial lung disease (ILD) and lung cancer, the prevalence of which is elevated in people with RA. Pulmonary manifestations such as airway obstructive disease, ILD and bronchiolitis affect a substantial proportion of people with RA. Screening for pulmonary disease, particularly ILD, is gaining emphasis, with high-resolution CT recommended based on risk factors including age, sex, antibody status and smoking. Despite advances in therapies to effectively manage joint inflammation, evidence-based treatments for RA-associated ILD remain limited. Chronic obstructive pulmonary disease and bronchiectasis in RA warrant more recognition owing to their effect on morbidity and mortality, and should be managed in accordance with current international treatment guidelines for these conditions. This Review summarizes the pathophysiology of lung involvement in RA, diagnostic challenges and evolving management strategies aimed at optimizing patient outcomes.