ACR Releases Guideline for Managing ILD in Patients With Rheumatic Disease

Lucy Hicks

August 29, 2023

The American College of Rheumatology (ACR) has released a summary of upcoming guidelines on screening, monitoring, and treatment for interstitial lung disease (ILD) in patients with systemic autoimmune rheumatic disease.

The recommendations apply to adults with rheumatic diseases at greater risk for ILD: rheumatoid arthritis (RA), systemic sclerosis (SSc), mixed connective tissue disease (MCTD), Sjögren's disease (SjD), and idiopathic inflammatory myopathies (IIM).

"Interstitial lung disease is a major cause of morbidity and mortality across several systemic autoimmune rheumatic diseases," Sindhu R. Johnson, MD, PhD, lead author of the new guidelines and director of the Clinical Epidemiology and Health Care Research program at the University of Toronto, Ontario, Canada, said in an ACR press release. "Guidance was needed for which tests to use for screening and monitoring this particular disease."

The two documents are summaries of part of a larger manuscript currently awaiting peer review, according to the ACR, and the final guidelines are anticipated to be published by early 2024.

The recommendations were developed using "the best available evidence and consensus across a range of expert opinions and incorporated patient values and preferences," according to the press release.

Highlights of recommendations for screening and monitoring ILD are:

  • Providers can screen patients at higher risk for ILD with pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) of the chest.

  • PFTs, chest HRCT, and ambulatory desaturation testing are conditionally recommended for monitoring ILD progression.

  • It is conditionally recommended that providers do not use 6-minute walk test distance, chest radiography, or bronchoscopy for screening or monitoring disease.

  • It is suggested that patients with IIM-ILD and SSc-ILD receive PFTs for monitoring every 3-6 months during the first year, then less frequently once stable.

  • It is suggested that patients with RA-ILD, SjD-ILD, and MCTD-ILD receive PFTs every 3-12 months for the first year, then less frequently once stable.

Suggestions on how often to screen for ILD were not present in the summary documents, but will be made available in the larger manuscript, said Elana Bernstein, MD, director of the Columbia University Medical Center/New York-Presbyterian Hospital Scleroderma Program in New York City. She is co-first author of the guidelines.

Dr Elana Bernstein

Nearly all recommendations are conditional, primarily because the certainty of evidence behind many of these recommendations is low or very low, she told Medscape Medical News. More clinical data on ILD in patients with rheumatic disease would help strengthen evidence, she said, particularly for best practices in frequency of testing. "We need more research on how often patients should be screened for ILD and how often they should be monitored for ILD progression," she said. "That would enable us to provide recommendations, rather than just suggestions."

Highlights of recommendations for ILD treatment are:

  • The guidelines strongly recommend against using glucocorticoids for first-line ILD treatment in patients with SSc-ILD.

  • Short-term glucocorticoids are conditionally recommended as a first-line ILD treatment for patients with systemic autoimmune rheumatic disease–related ILD (SARD-ILD), excluding SSc-ILD.

  • Mycophenolate, azathioprine, rituximab, and cyclophosphamide are all potential first-line ILD treatment options for patients with SARD-ILD.

  • It is conditionally recommended that patients with SARD-ILD do not receive leflunomide, methotrexate, tumor necrosis factor inhibitors, or abatacept as first-line ILD treatment.

  • If SARD-ILD progresses despite first-line therapy; mycophenolate, rituximab, cyclophosphamide, and nintedanib are potential secondary treatment options.

  • If RA-ILD progresses following initial therapy, pirfenidone is a treatment option.

  • The guidelines conditionally recommend against pirfenidone as a secondary treatment option for SARD-ILD other than RA-ILD.

These summary guidelines appear "comprehensive," but there has yet to be information published on the basis of these recommendations, Elizabeth Volkmann, MD, told Medscape Medical News.

Dr Elizabeth Volkmann

"It's important to understand that we don't know whether most of these recommendations were just driven by expert opinion versus actual evidence from randomized, controlled clinical trials," said Volkmann, who codirects the Connective Tissue Disease–Related Interstitial Lung Disease (CTD-ILD) Program at the University of California, Los Angeles. She was not involved with creating the guidelines.

She expects that many of the recommendations for first- and second-line ILD treatment options were based on expert opinion, as there have been no randomized clinical trials looking at that specific topic, she said. For example, nintedanib is conditionally recommended as a first-line treatment option for SSc-ILD, but as a second-line treatment for SjD-ILD, IIM-ILD, and MCTD-ILD. "There's no literature to support one or the other — whether nintedanib is first-line or second-line [treatment]," she added.

The decision to publish the summary recommendations online prior to peer review is unusual, she said, as these recommendations could be altered during that process; however, Bernstein noted that was not likely.

By releasing the summary guideline now, the ACR can "get the needed information to clinicians earlier as the manuscript goes through its remaining stages and is finalized," an ACR representative explained.

Prior to the expected publication of these guidelines in early 2024, Volkmann noted that the American Thoracic Society will be publishing guidelines on the treatment of SSc-ILD in the American Journal of Respiratory and Critical Care Medicine in September.

Bernstein reports grants/contracts with the US Department of Defense, the Scleroderma Research Foundation, the National Institutes of Health, Eicos, Boehringer Ingelheim, Kadmon, and Pfizer. Volkmann has received consulting and speaking fees from Boehringer Ingelheim and GSK and institutional support for performing studies on systemic sclerosis for Kadmon, Boehringer Ingelheim, Horizon, and Prometheus. 

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