Intersection of airways disease and rheumatoid arthritis: Current knowledge, future research
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There is growing attention on the link between airways disease and rheumatoid arthritis.
However, knowledge gaps remain about the underlying pathogenesis, impact and treatment strategies for airways disease — which broadly encompasses asthma, COPD, bronchiectasis and inflammatory bronchiolitis syndromes — in patients with rheumatoid arthritis (RA).
An in-depth review recently published in the Annals of the American Thoracic Society highlighted clinical inquiries and future research required in airways disease involvement in patients with RA.
Healio spoke with Scott M. Matson, MD, pulmonary disease specialist in the division of pulmonary, critical care and sleep medicine at University of Kansas School of Medicine, who co-authored the review with M. Kristen Demourelle, MD, with the division of rheumatology at University of Colorado School of Medicine, and Mario Castro, MD, also with the University of Kansas School of Medicine, to discuss the important take-home messages, challenges, screening, collaboration between pulmonologists and rheumatologists, and future research in the area of airways disease in RA.
Healio: What is the most important message about airways disease in RA?
Matson: Historically, we would think of these as comorbidities, that airways disease and RA have a shared risk factor — smoking — such that, people who smoked were prone to get RA and COPD or asthma. However, recent data show that, even though there’s a shared risk factor, patients who have RA and also have asthma and/or COPD seem to have a worse clinical phenotype of airways disease. There is interesting research and clinical questions about the role that RA and autoimmune inflammation play in the severity of airways disease, and also the potential role that airways disease and inflammation in the lung play in the development of RA.
Healio: Why is there a need to increase awareness among health care professionals who care for patients with RA and airways disease?
Matson: There are two important parts. One, if you don’t recognize that it’s a potential unique clinical phenotype, and you don’t screen for it, then there’s no way to know whether a specific treatment or a specific approach might be needed. Two, for clinicial researchers, it’s important to pique the interest in people who might be thinking about this or working in these fields to say, “How might we be able to approach some of the questions that these hypotheses raise?”
Healio: What are the challenges of airways disease in patients with RA?
Matson: Airways disease can cause many symptoms, including dyspnea or shortness of breath, recurrent pulmonary infections, fatigue, cough and wheezing. When you add these symptoms to a patient who has an inflammatory arthritis, like RA, it’s a two-hit in terms of their functional status. For many, it is painful to walk and do daily activities because of the inflammatory arthritis. Then on top of that, there’s a chance that the RA itself is impacting the airways and making them short of breath with exertion and their functional status can be impacted from two domains. An important question is: Does there need to be a unique approach to treatment that we don’t know about yet? Do we expect that airways disease in patients with RA needs to be treated with more aggressive immune suppression, or does it require the typical approach we take for airways disease with treatments like bronchodilators and inhaled corticosteroids?
Healio: How has knowledge of airways disease in RA changed over time?
Matson: People used to assume that asthma or COPD in a patient with RA were two separate diseases, and that treatment for one likely would not impact the other, and that monitoring the severity of one also likely would not impact the other. In the Annals of the American Thoracic Society review, we highlight that it’s hard to determine which one is the chicken or the egg. At this point, we need to understand how treatment of one impacts the other. So, for a patient who has asthma and RA, for instance, it’s possible that if you can control the RA, the asthma severity might also improve. That’s a novel approach to these two, previously thought to be, disparate diseases. While we don’t know the answer to that, our review brings up the potential that it should be a research question. For the clinician on the ground, that’s all hypothesis, I don’t think there’s any reason that we should change treatment strategies right now; but it does bring up interesting future directions for research.
Healio: What about screening for patients with RA experiencing respiratory symptoms?
Matson: In the review, we propose a screening algorithm to aid clinicians when approaching a patient with RA and undifferentiated respiratory symptoms. It’s important for clinicians who are treating patients with RA to have a way to try to differentiate all the potential things that RA can do to the lungs. The algorithm considers the current modalities we have for screening, including pulmonary function testing with a bronchodilator, laryngoscopy and high-resolution chest CT. We aimed to propose a way to screen for RA-related respiratory manifestations that was thoughtful about when to utilize CT scans. The diagnoses that we put forward in this screening algorithm are at least diagnoses that should require the involvement of a specialized pulmonologist. We can’t say whether treatment for all of the potential manifestations can make a difference, but with this algorithm we aimed to point out diagnoses for which further steps likely should be taken if found in a patient with RA.
Healio: What is be needed for future research involving airways disease in patients with RA?
Matson: I think the way to start to answer some of these questions is a combination of traditional basic science and mechanistic research that explores the role of lung inflammation in the development of RA, which is very difficult to understand in humans and human models because it’s a complex process. Also, it’s important for clinicians and clinical scientists to understand some of the human questions that can only be answered in human studies, such as: In a patient who has both RA and airways disease, how does treatment of one condition affect the severity the other? There are several studies of patients with RA or airways disease, and typically the design of those studies would exclude patients who have both conditions. It might be interesting for clinical investigators who are interested in this question to look at subsets of patients who have both diseases, who’ve been in treatment studies, and to try to understand as a secondary outcome what potential treatment of these conditions has in terms of impacting one or the other.
For more information:
Scott M. Matson, MD, can be reached at smatson@kumc.edu.