Figure 3.

Proposed algorithm for pulmonary symptoms in rheumatoid arthritis. In the setting of recent MTX initiation, MTX-pneu is always a concern, especially if the onset of symptoms is acute or sub-acute. In this case, MTX needs to be stopped and usually glucocorticoid therapy and supportive care in an intensive care unit is required. If the onset is more insidious, RA-ILD is a possibility. After ruling out other causes of pulmonary symptoms, management should depend on various factors, including comorbities, age, disease activity, and others. If a patient is diagnosed as having RA-ILD and receives a csDMARD, switching to a bDMARD may be appropriate. If a patient is already on bDMARD therapy, switching therapies may be required. Many authors tend to avoid TNF-inhibitors in this situation, but the evidence is weak. ATC, abatacept; bDMARD, biological disease-modifying antirheumatic drug; csDMARD, conventional synthetic disease-modifying antirheumatic drug; ILD, interstitial lung disease; MTX, methotrexate; MTX-pneu, MTX-pneumonitis; RA, rheumatoid arthritis; RTX, rituximab; TCZ, tocilizumab. *TNF-inhibitors have been reported to be associated with worsening lung function in RA-ILD (weak evidence level).