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Drug-induced lung disease in rheumatoid arthritis

Fiona R Lake, MD, FRACP
Section Editors
Talmadge E King, Jr, MD
Eric L Matteson, MD, MPH
Deputy Editor
Helen Hollingsworth, MD


Drug-induced pulmonary disease is an important consideration in the differential diagnosis of patients with rheumatoid arthritis (RA) who present with respiratory symptoms [1]. Knowledge of the types of lung toxicity that are associated with the individual agents used to treat RA, the patterns of lung disease that are associated with RA (unrelated to medication), and the spectrum of potential comorbid disease processes will help in the diagnosis and management of drug-induced lung disease.

A review of drug-induced lung disease in patients with RA will be presented here. Other aspects of pulmonary disease associated with rheumatoid arthritis are discussed separately. (See "Overview of lung disease associated with rheumatoid arthritis" and "Interstitial lung disease in rheumatoid arthritis" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis".)


A number of drugs used to treat RA can induce alveolar inflammation, interstitial inflammation, and/or interstitial fibrosis (Pneumotox.com), although the exact pathogenesis of the toxicity is unknown [2,3]. The risk and type of lung toxicity varies among the different agents. (See 'Features of individual agents' below.)

In addition to direct lung toxicity, virtually all of the disease modifying antirheumatic drugs (DMARDs) have immunosuppressive effects that increase the risk of bacterial and opportunistic lung infection [4-6]. As an example, in an observational study of 16,788 patients with RA, patients taking prednisone had a higher risk of hospitalization due to pneumonia than patients not taking glucocorticoids (hazard ratio 1.7, 95% CI 1.5-2.0) [7]. The effect was dose dependent. Although methotrexate and tumor necrosis factor (TNF) antagonists were not associated with an increased risk of pneumonia in this study, they have been associated with pneumonia in other studies [8-16]. (See "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections".)


The net effect of the disease modifying antirheumatic drugs (DMARDs) on the incidence of drug-induced lung disease in patients with RA is uncertain. Medication side effects may become more common as the clinical use of DMARDs and biological agents such as tumor necrosis factor (TNF) blockers increases [17-20].

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Literature review current through: Nov 2017. | This topic last updated: Jun 17, 2016.
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