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Is incident rheumatoid arthritis interstitial lung disease associated with methotrexate treatment? Results from a multivariate analysis in the ERAS and ERAN inception cohort

Author

Kiely P1,2, Busby AD3, Nikiphorou E4, Sullivan K3, Walsh DA5, Creamer P6, Dixey J7, Young A3. BMJ Open. 2019 May 5;9(5):e028466. doi: 10.1136/bmjopen-2018-028466.

Author Information

1 Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK.

2 Institute of Medical and Biomedical Education, St George's , University of London, London, UK.

3 Center for Health Services and Clinical Research and Post Graduate Medicine, University of Hertfordshire, Hatfield, UK.

4 Department of Academic Rheumatology, King's College, London, UK.

5 Department of Academic Rheumatology, University of Nottingham, Nottingham, UK.

6 Department of Rheumatology, North Bristol NHS Trust, Bristol, UK.

7 Department of Rheumatology, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shrewsbury, UK.

Abstract

OBJECTIVES: 

To assess predictive factors for rheumatoid arthritis interstitial lung disease (RA-ILD) in two early rheumatoid arthritis(RA) inception cohorts with a focus on methotrexate (MTX) exposure.

DESIGN: 

Multicentre prospective early RA inception cohort studies; the early RA study (ERAS) and the early RA network (ERAN).

SETTING: 

Secondary care, ERAS nine centres, ERAN 23 centres in England, Wales and Ireland.

PARTICIPANTS: 

Patients with new diagnosis of RA, n=2701. Standardised data including demographics, drug therapies and clinical outcomes including the presence of RA-ILD were collected at baseline, within 3-6 months, at 12 months and annually thereafter.

PRIMARY AND SECONDARY OUTCOME MEASURES: 

Primary outcome was the association of MTX exposure on RA-ILD diagnosis. Secondary outcomes were the association of demographic, comorbid and RA-specific factors on RA-ILD diagnosis and the association of MTX exposure on time to RA-ILD diagnosis.

RESULTS: 

Of 92 eligible ILD cases, 39 occurred in 1578 (2.5%) MTX exposed and 53 in 1114 (4.8%) non-MTX exposed cases. The primary analysis of RA-ILD cases only developing after any conventional synthetic disease-modifying antirheumatic drug treatment (n=67) showed MTX exposure not to be associated with incident RA-ILD (OR 0.85, 95% CI 0.49 to 1.49, p=0.578) and a non-significant trend for delayed ILD diagnosis (OR 0.54, 95% CI 0.28 to 1.06, p=0.072). In an extended analysis including RA-ILD cases present at RA diagnosis (n=92), MTX exposure was associated with a significantly reduced risk of incident RA-ILD (OR 0.48, 95% CI 0.3 to 0.79, p=0.004) and longer time to ILD diagnosis (OR 0.41, 95% CI 0.23 to 0.75, p=0.004). Other independent baseline associations with incident RA-ILD were higher age of RA onset, ever smoking, male gender, rheumatoid nodules and longer time from first RA symptom to first outpatient visit.

CONCLUSIONS: 

MTX treatment was not associated with an increased risk of RA-ILD diagnosis. On the contrary, evidence suggested that MTX may delay the onset of ILD.