Screening for ILD in RA

Patients with rheumatoid arthritis (RA) with risk factors for interstitial lung disease (ILD) or pulmonary symptoms should be evaluated for ILD at baseline RA diagnosis1,2



Up to 30% of RA patients are affected by ILD1,3-6

Risk factors for development of ILD in patients with RA

  • >60 years7

  • Longer disease duration17

  • Higher disease activity1,11,18

  • Decreased functional status1,18

  • Presence of extra-articular manifestations (e.g. rhuematoid nodules)18

  • Elevated ESR15,18


Despite RA-ILD being common in patients in their 40s to 50s, patients aged >60 years are at increased risk of developing ILD5,7

  • For each 10-year age increase, the likelihood of ILD increases by 64%15

RA-ILD is approximately four times more common in men than in women.1,8

Smoking increases the risk of ILD in patients with RA,6,9 but it is important to note that RA-ILD can occur in non-smokers too.19

Positive serologies for either RF or anti-CCP antibody are significant predictors for development of ILD in patients with RA.6,10–14




Early assessment for ILD using baseline PFTs and HRCT is reasonable to identify ILD in RA1

A history of smoking in a patient with RA-ILD should lead to investigation with a chest X-ray and spirometry in the first instance20

Listening for crackles on lung auscultation may be a useful screen for subclinical ILD in patients with RA, inviting comprehensive lung function assessment20,21

Suggested algorithm to identify RA-ILD in patients with RA1
Suggested algorithm to identify RA-ILD in patients with RA

Reprinted from Clinics in Chest Medicine, 40(3), Esposito, Thoracic Manifestations of Rheumatoid Arthritis, 545-560, ©2022, with permission from Elsevier.


Julie has RA-ILD

How can you reach an RA-ILD diagnosis?

Download RA-ILD patient case Opens in new tab
Once you have reached a diagnosis, how should you manage your patients with RA-ILD?
  • CCP, cyclic citrullinated peptide; CT, computed tomography; CTD-ILD, connective tissue disease-associated interstitial lung disease; DLCO, diffusing capacity of the lung for carbon monoxide; ESR, erythrocyte sedimentation rate; HRCT, high-resolution computed tomography; ILD, interstitial lung disease; KL-6, Krebs von den Lungen-6; PFT, pulmonary function test; RA; rheumatoid arthritis; RA-ILD, rheumatoid arthritis-associated interstitial lung disease; RF, rheumatoid factor.

  1. Esposito AJ, Chu SG, Madan R, et al. Thoracic manifestations of rheumatoid arthritis. Clin Chest Med. 2019;40(3):545–560.

  2. Wallace B, Vummidi D, Khanna D. Management of connective tissue diseases associated interstitial lung disease: a review of the published literature. Curr Opin Rheumatol. 2016;28(3):236–245.

  3. Olson AL, Swigris JJ, Sprunger DB, et al. Rheumatoid arthritis-interstitial lung disease associated mortality. Am J Respir Crit Care Med. 2011;183(3):372-378.

  4. Geerts S, Wuyts W, De Langhe E, et al. Connective tissue disease associated interstitial pneumonia: a challenge for both rheumatologists and pulmonologists. Sarcoidosis Vasc Diffuse Lung Dis. 2017;34(4):326–335.

  5. Shaw M, Collins BF, Ho LA, Raghu G. Rheumatoid arthritis-associated lung disease. Eur Respir Rev. 2015;24(135):1–16.

  6. Kelly CA, Saravanan V, Nisar M, et al. Rheumatoid arthritis-related interstitial lung disease: associations, prognostic factors and physiological and radiological characteristics – a large multicentre UK study. Rheumatology (Oxford). 2014;53(9):1676–1682.

  7. Brito Y, Glassberg MK, Ascherman DP. Rheumatoid Arthritis-Associated Interstitial Lung Disease: Current Concepts. Curr Rheumatol Rep. 2017;19:79. doi: 10.1007/s11926-017-0701-5.

  8. Koo SM, Kim SY, Choi SM, et al. Korean guidelines for diagnosis and management of interstitial lung diseases: part 5. Connective tissue disease associated interstitial lung disease. Tuberc Respir Dis (Seoul). 2019;82(4):285–297.

  9. Gochuico BR, Avila NA, Chow CK, et al. Progressive preclinical interstitial lung disease in rheumatoid arthritis. Arch Intern Med. 2008;168(2):159–166.

  10. Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid arthritis. Respir Med. 2012;106(11):1591–1599.

  11. Habib HM, Eisa AA, Arafat WR, et al. Pulmonary involvement in early rheumatoid arthritis patients. Clin Rheumatol. 2011;30:217–221.

  12. Doyle TJ, Patel AS, Hatabu H, et al. Detection of rheumatoid arthritis–interstitial lung disease is enhanced by serum biomarkers. Am J Respir Crit Care Med. 2015;191(12):1403–1412.

  13. Giles JT, Danoff SK, Sokolove J, et al. Association of fine specificity and repertoire expansion of anticitrullinated peptide antibodies with rheumatoid arthritis associated interstitial lung disease. Ann Rheum Dis. 2014;73:1487–1494.

  14. Yin Y, Liang D, Zhao L, et al. Anti-cyclic citrullinated Peptide antibody is associated with interstitial lung disease in patients with rheumatoid arthritis. PLoS One. 2014;9(4):e92449.

  15. Koduri G, Norton S, Young A, et al. Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort. Rheumatology (Oxford). 2010; 49(8):1483–1489.

  16. Avouac J, Cauvet A, Steelandt A, et al. Improving risk-stratification of rheumatoid arthritis patients for interstitial lung disease. PLoS One. 2020;15(5):e0232978. doi:10.1371/journal.pone.0232978.

  17. Ha YJ, Lee YJ, Kang EH. Lung involvements in rheumatic diseases: update on the epidemiology, pathogenesis, clinical features, and treatment. Biomed Res Int. 2018:6930297.

  18. Bongartz T, Nannini C, Medina-Velasquez YF, et al. Incidence and mortality of interstitial lung disease in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2010;62(6):1583–1591.

  19. Ayhan-Ardic FF, Oken O, Yorgancioglu ZR, et al. Pulmonary involvement in lifelong non-smoking patients with rheumatoid arthritis and ankylosing spondylitis without respiratory symptoms. Clin Rheumatol. 2006;24:213–218.

  20. Lake F and Proudman S. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Respir Crit Care Med. 2014;35(2):222–238.

  21. Cottin V and Cordier JF. Subclinical interstitial lung disease: no place for crackles? Am J Respir Crit Care Med. 2012;186(3):289–290.

  22. Iqbal K and Kelly C. Treatment of rheumatoid arthritis-associated interstitial lung disease: a perspective review. Ther Adv Musculoskelet Dis. 2015;7(6):247–267.

  23. Cassone G, Manfredi A, Vacchi C, et al. Treatment of rheumatoid arthritis-associated interstitial lung disease: lights and shadows. J Clin Med. 2020;9(4):1082. doi: 10.3390/jcm9041082.

  24. Ryerson CJ, Cayou C, Topp F, et al. Pulmonary rehabilitation improves long-term outcomes in interstitial lung disease: a prospective cohort study. Respir Med. 2014;108(1):203-210. 

  25. Kreuter M, Bendstrup E, Russell A, et al. Palliative care in interstitial lung disease: living well. Lancet Respir Med. 2017;5(12):968-980. 

  26. Maher TM, Wuyts W. Management of Fibrosing Interstitial Lung Diseases. Adv Ther. 2019;doi:10.1007/s12325-019-00992-9. [Epub ahead of print]. 

  27. Sgalla G, Cerri S, Ferrari R, et al. Mindfulness-based stress reduction in patients with interstitial lung diseases: a pilot, single-centre observational study on safety and efficacy. BMJ Open Respir Res. 2015;2(1):e000065. 

  28. Wijsenbeek M, Cottin V. Spectrum of Fibrotic Lung Diseases. N Engl J Med. 2020;383:958–968.

Resources for patients