Abstract
Janus kinase inhibitors (JAKi) are an exciting option for the treatment of rheumatoid arthritis (RA) but little is known about their safety and tolerability in patients with existing respiratory disorders. The objective was to compare pulmonary safety of JAKi versus rituximab in patients with concurrent interstitial lung disease (ILD) or bronchiectasis. We performed a retrospective electronic patient record review of patients with known ILD or bronchiectasis commencing JAKi or rituximab for the treatment of RA. Patients initiating treatment from January 2016 to February 2020 were included. Respiratory events (hospitalization or death from a respiratory cause) were compared using Kaplan–Meier survival analysis. We analysed patients who received JAKi (n = 28) and rituximab (n = 19) for a mean (SD) of 1.1 (0.62) and 2.14 (1) years respectively. Patients were predominantly female (68%), anti-CCP antibody positive (94%) and non-smoking (89%) with a median (IQR) percentage predicted FVC at baseline of 100% (82–115%) and percentage predicted TLCO of 62% (54.5–68%). Respiratory events occurred in five patients treated with JAKi (18%; 5 hospitalizations, 2 deaths) and in four patients treated with rituximab (21%; 3 hospitalizations, 1 death). Respiratory event rates did not differ between groups (Cox-regression proportional hazard ratio = 1.38, 95% CI 0.36–5.28; p = 0.64). In this retrospective study, JAKi for the treatment of RA with existing ILD or bronchiectasis did not increase the rate of hospitalization or death due to respiratory causes compared to those treated with rituximab. JAK inhibition may provide a relatively safe option for RA in such patients.
Highlights
Therapeutic decision-making in the treatment of rheumatoid arthritis (RA) for patients with concurrent pulmonary disease can be challenging
Demographic and clinical characteristics were similar in both treatment groups (Table 1); those commencing Janus kinase inhibitors (JAKi) had a significantly longer disease duration compared to those starting rituximab (Table 1; Mann–Whitney U test, p = 0.003)
There is an absence of patients with interstitial lung disease and bronchiectasis in randomised controlled trials that examine the effectiveness of JAK inhibitors for the treatment of rheumatoid arthritis
Summary
Therapeutic decision-making in the treatment of rheumatoid arthritis (RA) for patients with concurrent pulmonary disease can be challenging. Fear regarding increased infection risk in bronchiectasis and progression of interstitial lung disease (ILD) secondary to drug administration restricts treatment options. Controversy exists as to whether medications, such as methotrexate, leflunomide and tumour necrosis factor-α inhibitors (TNFi), exacerbate pulmonary disease in patients with concurrent ILD and bronchiectasis [1]. This has led to hesitancy in utilizing these medications systematic review of the evidence is beginning to allay fears [2, 3].
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