Background/Purpose: Interstitial lung disease (ILD) is a risk factor of pneumonia in RA patients treated with biological DMARDs (bDMARDs) [1-4]. Bronchiectasis (BE) is a well-known risk for severe pneumonia in general population[5]. However, BE is not fully examined as a risk for severe pneumonia during bDMARDs-treatment. We investigated types of respiratory diseases in RA patients before treatment with bDMARDs and correlated them to severe pneumonia during the treatment with special attention to ILD and BE.

Methods: This was a retrospective study. RA patients in Jichi Medical University, who satisfied the American Rheumatism Association 1987 criteria, were examined for their lungs by high-resolution computed tomography (CT) before starting bDMARDs and divided into three groups by a rheumatologist and a pulmonologist: normal, BE and ILD group. The patients with other lung diseases were excluded. The patients who had both BE and ILD were put into a group of the main lesion of the two. The log-rank test was used to compare the survival curves from the three groups for the differences in the probabilities of severe pneumonia requiring hospitalization. Hazard ratios (HR) on the risk of severe pneumonia between two of the three groups were determined by Cox proportional hazard model with covariates.

Results: A total of 494 patients were examined by chest CT before treatment with bDMARDs from 2003 to 2013. There were 348 patients in normal, 30 in BE and 49 in ILD group. Sixty-seven patients with the pulmonary lesions other than BE and ILD were excluded. Fourteen patients developed severe pneumonia which required hospitalization; 2 in normal (0.57%), 4 in BE (13%) and 8 in ILD (16%). Eleven and 3 patients developed bacterial and pneumocystis pneumonia, respectively. The log-rank test showed differences between the groups (p < 0.00001). The pneumonia-free rate of BE was lower than that of normal group (HR 26.79, 95%CI 5.11-196.32). The pneumonia-free rate of ILD was also lower than that of normal group (HR 30.25, 95%CI 7.27-204.54). No difference was shown for the pneumonia-free rates between BE and ILD.

Conclusion: This study suggested that BE in patients with RA is a risk factor of severe pneumonia during the treatment with bDMARDs to the extent comparable to ILD. The frequency of pneumonia in patients with normal lungs is very low.

Reference:

1 Mori S, Yoshitama T, Hidaka T, et al. Comparative risk of hospitalized infection between biological agents in rheumatoid arthritis patients: A multicenter retrospective cohort study in Japan. PLoS One 2017;12(6):e0179179.

2 Zhang Y, Li H, Wu N, Dong X, Zheng Y. Retrospective study of the clinical characteristics and risk factors of rheumatoid arthritis-associated interstitial lung disease. Clin Rheumatol 2017;36(4):817-23.

3 Lake F, Proudman S. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Respir Crit Care Med 2014;35(2):222-38.

4 Tsuchiya Y, Takayanagi N, Sugiura H, et al. Lung diseases directly associated with rheumatoid arthritis and their relationship to outcome. Eur Respir J 2011;37(6):1411-7.

5 Welsh EJ, Evans DJ, Fowler SJ, Spencer S. Interventions for bronchiectasis: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2015(7):Cd010337.

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