Contemporary Guideline Perspectives on Methotrexate and Biologic/Targeted Synthetic Disease-Modifying Antirheumatic...

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is an extra-articular manifestation that affects the patient outcomes. Published guidelines and consensus documents on RA-ILD or systemic autoimmune rheumatic disease/connective tissue disease-associated ILD have updated drug selection for RA-ILD; however, their meanings differ because they were developed using different methodologies for distinct clinical contexts. We compared these documents. Methotrexate (MTX)-associated acute/subacute pneumonitis should be distinguished from its effects on the development or progression of chronic fibrotic RA-ILD. Recent documents no longer consider RA-ILD alone a uniform contraindication for MTX, although severe, newly developed, or progressive ILD and the risk of drug-induced lung injury require reassessment. Abatacept and rituximab are often favored among biologic/targeted synthetic disease-modifying antirheumatic drugs, whereas the use of interleukin-6, Janus kinase, and tumor necrosis factor inhibitors varies. Drug selection should distinguish RA activity control from ILD-directed therapy and be individualized through multidisciplinary discussions considering the RA activity, ILD severity/progression and imaging, pulmonary toxicity, infection risk, and alternatives.