Dr England recaps his presentation on interstitial lung disease among patients with rheumatoid arthritis, including the importance of early detection and how to diagnose this condition.

Bryant England, MD, is associate professor of medicine in the Division of Rheumatology at the University of Nebraska Medical Center and director of its Autoimmune Lung Disease Clinic.

I'm Bryant England, rheumatologist at the University of Nebraska Medical Center in Omaha, Nebraska, and I'm going to talk with you a little bit today about RA-ILD identification based on the talk I gave at ACR Convergence in Washington DC.

So rheumatoid arthritis, what do we know about it? Well, we know that it affects the joints. But the funny thing is, is even though we often think of rheumatoid arthritis as a joint disease, it's not limited to affecting the joints. Rheumatoid arthritis is actually a systemic disease that can affect other organs. And what we're going to talk about today is when rheumatoid arthritis decides it wants to involve the lungs.

Now there's a few different ways that rheumatoid arthritis can affect the lungs, but the one that really worries us as treating providers is rheumatoid arthritis-associated interstitial lung disease or RA-ILD. And what this is, is this is an inflammatory and fibrotic disease that can affect the lungs. Now this happens in about 10 % of people with rheumatoid arthritis, but there's an important caveat. That caveat is only about 10% of people with rheumatoid arthritis will become symptomatic from interstitial lung disease during the disease course. But if we take everybody with rheumatoid arthritis and we have them go lay in a CT scanner and get pictures taken of their lungs, we might find that up to 40% of people with rheumatoid arthritis might have early changes of interstitial lung disease. So that's a pretty remarkably big difference in the number of people that have symptoms compared with the amount of people who have some of these early changes in the lungs.

Now we as a field are still trying to understand at what degree of involvement in the lungs it becomes really important to identify and maybe change how we are treating rheumatoid arthritis if we find interstitial lung disease. But one of the really important things we know right now is there's a big difference between who has symptoms and who we can detect it. So this raises the question of what is the optimal way that we should try and evaluate people with rheumatoid arthritis and detect interstitial lung disease.

The best test to really understand whether the lungs are being involved is with getting a high-resolution CT scan of the chest and pulmonary function tests. So the CT scan is going to give us pictures telling us if we see some evidence of inflammation and fibrosis of the lung. The pulmonary function test—we'll take deep breaths in and out hooked up to you know a measuring system hooked up to a computer and this will tell us how much air we're able to take in take out and how that air is exchanged across our lungs. With those pieces of information, we can usually tell whether or not there's some evidence of interstitial lung disease. If we find that, what we will usually do is involve a pulmonologist in this case. We'll have patients go see a pulmonologist who will assess for any reasons why this person might have interstitial lung disease besides rheumatoid arthritis—any exposures, for instance. Then ideally what we would do is we'd have a rheumatologist, the pulmonologist, and a radiologist who's experienced looking at these images—all get together and discuss what's going on, what findings we see, and make a formal diagnosis of RA interstitial lung disease. That's what's called a multidisciplinary discussion, which is really the gold standard for making the diagnosis.

Now historically, sometimes we do things like take a lung biopsy, but that's pretty infrequent now because of how advanced our imaging is. Now once we identify interstitial lung disease, sometimes that means that we need to make a change in how we're treating this disease. Unfortunately, there aren't very many clinical trials that have been done in rheumatoid arthritis interstitial lung disease, so we don't know exactly the best way to treat it. Usually treatment is a combination of using immunosuppressive medicines and sometimes adjusting which immunosuppressive medicines we use to try and choose a medicine that may have more benefits for the lungs than some of our typical medicines we use in rheumatoid arthritis when there isn't interstitial lung disease.

The other option we have now is adding on medicines that perhaps can slow the progression of fibrosis within the lungs or antifibiotic agents. These have become a new option for us over the last few years. But what's really important is as these treatment changes are being made that it's the patients working with both a rheumatologist and a pulmonologist; that way we can ensure that the whole systemic disease process—in other words both the lungs and the joints—are being adequately treated.

Now there's some exciting things on the horizon in RA interstitial lung disease. One of them is can we improve the way that we identify people early with RA -ILD? Some of the options that we have for doing this would be measuring things like peripheral blood biomarkers, looking for inflammatory or fibrotic mediators, or even genetic predisposition. If people who have these tests, we might be able to send for a PFT testing or a CT scan earlier in the disease course to capture ILD early.

Other things that we have are, you know, informatics tools. So many times patients will go into the healthcare system, they might get a CT scan for another reason. So one reason is the low-dose lung cancer CT screening program. So people who have risk factors for lung cancer might go in and get a chest CT scan until the screen for lung nodules and lung cancer. So what our team has been working on is developing a number of different tools that can evaluate those interactions with the health care system or even read chest CT reports in real time to clue in the referring providers and treating providers that this patient may have early interstitial lung disease. These are all things that we are gonna continue to work on going forward.

Ultimately what we'd really like to do is also start to do clinical trials in RA interstitial lung disease so we can know much more precisely exactly what benefits we can expect from these different medicines for treating both the joints and the lungs, as well as if there are any harms of using some of these medicines. But ultimately our goal is that we can identify people with RA-ILD earlier, that we're able to make a better diagnosis, that we're able to communicate with patients prognostic information of what life might look like 5 or 10 years down the road. And then ultimately that we can choose the right medicine for them to try and slow disease from progressing and ultimately on the rise and we hope to be able to reverse some of this disease eventually.

So thanks for taking time with me to hear a little bit about RA interstitial lung disease.