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Rheumatoid Arthritis and Interstitial Lung Disease: Doc, I get short of breath easily.

An interesting thing about rheumatoid arthritis (RA) is that it is not just a joint disease. Some patients may develop lung involvement.

Lung involvement in RA is also an inflammatory process that generally occurs if joint disease is active.

Say, your RA is active, as defined by painful, swollen, and stiff joints, the most important goal your rheumatologist will have with you is to control those symptoms with DMARDs. If you develop at anytime new onset of persistent shortness of breath (medical jargon: dyspnea) and/or dry cough without a preceding illness like a viral infection, which would typically cause a runny nose and sore throat, then inform your rheumatologist.

Common is common. So infections, COPD, emphysema, and heart failure are the first things to exclude as the potential cause of dyspnea. Most people are likewise treated symptomatically with inhalers, antibiotics, oral prednisone, and/or diuretics. Chest X-ray could show “possible pneumonia”.

You should definitely inform your rheumatologist at this point and hold your DMARD if you have an infection.

If you feel better after whatever treatment you’ve received then great. Unlesss you were treated with a prednisone taper, which would also be treatment for lung inflammation. Hence, it can be missed.

Common is common also applies to rheumatology but that means you need to inform your rheumatologist if you develop new persistent symptoms, such as dyspnea.

If you didn’t improve with those treatments, then a CAT scan (CT) of your chest should be done. This will show if you have interstitial lung disease (ILD) or inflammation of the lung. It’ll also show if you have scar tissue (fibrosis). A pulmonary function test (PFT) and echocardiogram are also necessary tests that should be done. The PFT will show evidence of damage in your lung oxygenation, which could explain your dyspnea. The echocardiogram would show if you have heart failure.

A CT scan is like a bag of sand; you see it and know it’s heavy. The PFT tells you how much it weighs.

What if you do have new onset ILD?

Treatment with immunosuppression would be recommended. Your rheumatologist would likely give you high dose prednisone to quickly turn off the lung inflammation to prevent further damage and likely modify or add to your immunosuppressive regimen.

It is important to treat ILD aggressively so that you do not lose functional capacity due to lung tissue damage that would disrupt oxygenation from scar tissue. Short term steroids will not be pleasant but could allow for better quality of life and improvement in the long term.

What if you already have ILD with fibrosis?

Depending on the severity, you may or may not need to be on oxygen. Pulmonary rehabilitation or physical therapy for the lungs is also very beneficial and is similar to a gym work out for your lungs. The biggest problem with rehab is the cost, so you can train yourself at home or at a gym on a redundant bicycle or elliptical.

The most important thing to do as a RA patient is to inform your rheumatologist if you develop any new persistent symptoms.