Zusammenfassung
Der Lungenbeteiligung bei der rheumatoiden Arthritis (RA), insbesondere den interstitiellen Lungenerkrankungen (RA-ILD), kommt eine große klinische Bedeutung zu. Schon bei Diagnosestellung und regelmäßig im Verlauf sollte nach Symptomen einer Lungenbeteiligung gefragt und die Lunge klinisch untersucht werden. Vor Einleitung einer medikamentösen Basistherapie ist eine Röntgenaufnahme der Thoraxorgane obligat. Bei klinischen oder radiologischen Auffälligkeiten sollte sich eine weitere Diagnostik mittels Lungenfunktionsprüfung (Bodyplethysmographie mit Diffusionsmessung) und je nach Befund eine Computertomographie des Thorax anschließen. Die Differenzialdiagnose interstitieller Lungenveränderungen bei RA-Patienten ist breit und sollte neben infektiösen Ursachen auch Nebenwirkungen von Basistherapeutika berücksichtigen. Die optimale medikamentöse Therapie einer RA-ILD ist nicht ausreichend untersucht. Der Stellenwert von Methotrexat (MTX) hat sich gewandelt, da entgegen früheren Annahmen zumindest bei milden bis moderaten Verläufen der RA-ILD ein besserer Verlauf unter MTX beobachtet werden konnte. Tumor-Nekrose-Faktor(TNF)-Blocker sollten beim Vorliegen einer klinisch bedeutsamen RA-ILD eher vermieden werden, da z. T. dramatische Verschlechterungen beschrieben worden sind. Favorisiert werden derzeit Abatacept und Rituximab. Ob Januskinase(JAK)-Inhibitoren beim Vorliegen einer RA-ILD bedenkenlos eingesetzt werden können, kann derzeit nicht beantwortet werden. Patienten mit RA-ILD sollten gemeinsam von Pneumologen und Rheumatologen behandelt werden.
Abstract
Pulmonary involvement in patients with rheumatoid arthritis, in particular interstitial lung diseases (RA-ILD) is of great clinical importance. Patients should be asked about symptoms of pulmonary involvement and the lungs should be clinically examined even during the diagnostic procedure and regularly during the course of the disease. Before initiation of a basic pharmacological treatment an X‑ray examination of thoracic organs is obligatory. In cases of conspicuous clinical or radiological findings, extended diagnostic procedures with lung function testing (body plethysmography with diffusion measurement) and high resolution computed tomography (CT) should be performed, depending on the findings. The differential diagnosis of interstitial lung alterations in patients with RA is broad and should consider side effects of the basis medication in addition to infectious causes. The optimal pharmacological treatment of RA-ILD is not sufficiently clarified. The value of methotrexate (MTX) has changed because, in contrast to previous assumptions, a better course could be observed under MTX treatment, at least in mild to moderate courses of RA-ILD. In the case of a clinically relevant RA-ILD, tumor necrosis factor (TNF) blockers should be avoided because a dramatic deterioration of pulmonary function has sometimes been observed. Among biological disease-modifying antirheumatic drugs (DMARD), rituximab and abatacept are currently preferred. The role of Janus kinase (JAK) inhibitors in RA-ILD is currently being discussed but limited data are available. Patients with RA-ILD benefit from a close collaboration between pulmonologists and rheumatologists.
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A. Krause und A. Rubbert-Roth geben an, dass kein Interessenkonflikt besteht.
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Krause, A., Rubbert-Roth, A. Lungenbeteiligung bei rheumatoider Arthritis. Z Rheumatol 78, 228–235 (2019). https://doi.org/10.1007/s00393-019-0611-1
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DOI: https://doi.org/10.1007/s00393-019-0611-1
Schlüsselwörter
- Interstitielle Lungenerkrankung
- Obstruktive Atemwegserkrankung
- Therapie
- Citrullinierung
- Usual interstitial pneumonia