Mehta, Puja;
Redhead, Gabrielle;
Nair, Arjun;
Sparks, Jeffrey A;
Porter, Joanna C;
(2022)
Can we finally exonerate methotrexate as a factor in causing or exacerbating fibrotic interstitial lung disease in patients with rheumatoid arthritis?
Clinical Rheumatology
, 41
pp. 2925-2928.
10.1007/s10067-022-06245-5.
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Abstract
Methotrexate (MTX) is the recommended first-line disease-modifying antirheumatic drug (DMARD) for most patients with rheumatoid arthritis (RA) [1, 2], either alone or in combination with biological therapy to reduce biologic-associated immunogenicity and improve drug survival. Clinically apparent interstitial lung disease (ILD) occurs in 7–10% of patients with RA and 33–61% have subclinical ILD [3,4,5]. These estimates vary depending on thresholds for investigation, diagnostic methodology and definition of controls. ILD in patients with RA is poorly understood despite being recognised as prevalent, with considerable impact on prognosis, survival and therapeutic approach. Median survival after RA-associated ILD (RA-ILD) diagnosis is only 3–7 years, which is markedly reduced compared with RA patients without ILD and the general population [3, 6, 7]. Growing evidence suggests that RA disease control is of paramount importance, as increased systemic disease activity is associated with increased mortality in patients with RA-ILD [8], therefore making the decision whether to continue or stop an effective drug (MTX) even more important. Discussions continue amongst Rheumatologists, Pulmonologists and Radiologists as to whether MTX is culpable in causing or worsening fibrotic ILD (fILD), despite accumulating evidence to assuage concerns. Here, we describe the current clinical challenge, propose suggestions to guide clinical decision-making within the current state of evidence and discuss future directions to address unresolved questions.
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