Background/Purpose: Lung involvement is common in patients with Rheumatoid Arthritis (RA), including interstitial lung disease (ILD), pleural disease and small airway disease. There are no full reports in the literature analyzing the influence of Rituximab (RTX) in patients with RA with pre-existing lung disease, although it is a rising question in daily clinical practice. We aim to evaluate the safety and efficacy of RTX in our cohort of RA patients with pre-existing lung involvement.

Methods: Retrospective observational study of the RA cohort treated with RTX at University College Hospital, identifying patients treated with RTX with any lung involvement. Data were collected on type of lung disease, mortality, respiratory infections and stabilization/progression of symptoms.

Results: 264 patients with RA have received RTX in our unit between 1998 and 2012. A total of 38 patients (14%) had lung involvement, 24 of them (63%) were female, mean age was 64 years (range 37-79), mean disease duration was 19 years (range 3-42), mean number of RTX cycles was 4 (range 1-10), total follow up duration was 146.7 patient years (median 2.5 years, range 0.5-13.5). 19 of them (50%) had ILD: 3 usual interstitial pneumonitis (UIP), 5 nonspecific interstitial pneumonitis (NSIP, 2 of those had an overlap antisyntetase syndrome), 4 organizing pneumonia (OP) and 7 undetermined ILD. 15 patients (40%) had bronchiectasis. The remaining 4 patients had diagnosis of chronic obstructive pulmonary disease (COPD), small airway disease, pleural effusion requiring decortication and pleural plaques. 6 of the above patients had concomitant COPD.

Lung disease has remained clinically and radiologically stable in most patients. One patient with severe UIP before RTX showed slow lung progression over 4 years of follow up, and Mycophenolate mofetil is being considered. The 2 patients with antisynthetase syndrome have stable NSIP but on combination therapy (1 azathioprine, 1 mycophenolate mofetil). 25 patients (66%) reported respiratory infections but in only 6 of these patients was an increased frequency of infections after starting rituximab treatment noted. 2 of these 6 patients had low serum immunoglobulins (1 IgG only, 1 IgG and IgM). 2 patients had serious infections requiring hospitalization.

There were 2 deaths, both in patients with bronchiectasis and multiple comorbidities, none directly related to rituximab treatment. 

Conclusion: RTX seems to be a relatively safe therapy in the cohort of RA patients with lung involvement. There is no definite evidence for improvement in lung involvement in RA patients treated with rituximab, but nor there is data suggesting that RTX can lead to a progression of lung symptoms. Only one patient with severe UIP before RTX showed lung progression after 4 years of follow up.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/safety-and-efficacy-of-rituximab-in-patients-with-rheumatoid-arthritis-and-lung-involvement/