Rheumatoid arthritis (RA) doesn't affect just your joints. It can also damage the tissue surrounding the joints, as well as your eyes, heart, and, most important, lungs.

Lung complications from rheumatoid arthritis can be serious and even cause death.

Don’t wait to protect your lungs and airways if you have rheumatoid arthritis. Research published in the European Respiratory Review shows that damage to the lining of the lung, or the pleura, may occur in up to 70 percent of all people with RA, but only 3 to 5 percent experience symptoms. Almost 10 percent of people living with RA will also develop interstitial lung disease (ILD), or scarring of lung tissue, according to the Arthritis Foundation.

Interstitial Lung Disease: What It Is, How It Relates to RA

Rheumatoid arthritis–associated interstitial lung disease, or RA-ILD, is one of the most serious lung complications for people with rheumatoid arthritis. This illness can be hard to detect but occurs when lung tissue becomes inflamed and eventually scarred. A French study presented as an abstract at the American College of Rheumatology (ACR) annual conference in November 2020 found that the prevalence of subclinical (symptomless) ILD after a mean RA duration of 13 years was 18.2 percent. This shows that the development of ILD with RA is not a rare event.

RA-related lung problems can be fatal. Another study, from Brigham and Women's Hospital, presented at ACR 2020 suggests a strong association of RA-ILD with excess mortality, in particular respiratory and cancer mortality, says lead author Jeffrey A. Sparks, MD, an assistant professor of medicine in the division of rheumatology, inflammation, and immunity at Brigham and Women’s Hospital and Harvard Medical School in Boston.

Risk Factors for Lung Problems With RA

Much is still not known about the connection between RA and ILD, but recent research has identified new risk factors:

Being Male Although more women get RA than men, men are at higher risk than women for developing RA-ILD, according to the Arthritis Foundation. “We need more research to find out why this is so,” says Dr. Sparks. “It could be genetic or that men tend to have a more aggressive severity of RA.”
Long-Term History of Smoking The Brigham and Women’s Hospital Rheumatoid Arthritis Sequential Study (BRASS) presented an abstract at the ACR conference that found that smoking above a threshold of 30 pack-years (for example, one pack per day for 30 years or 2 packs per day for 15 years) was strongly associated with RA-ILD. Sparks was a member of this team.
Genetics In another abstract presented at the conference, a gene variant called the MUC5B promoter variant has been shown to be associated with increased risk of ILD in RA patients. A different ACR 2020 abstract reported, however, that this variant “was not associated with progression of RA-ILD during 10 years of follow-up.” Research isn’t yet at a place where this could be used clinically, but it may be used to help predict risk in the future.
Obesity “We found that obese patients had an over twofold higher risk of future ILD risk,” says Sparks.
Biomarkers Some biomarkers, including antibodies such as ACPA, cytokines/chemokines, and lung epithelial/surfactant markers, have been found to be associated with RA-ILD, according to research presented at ACR 2020.
Age Older age is associated with higher risk of RA-ILD.
Duration of RA Longer duration of RA is associated with higher risk of developing RA-ILD, but patients with early RA can still develop RA-ILD as well.
Higher Disease Activity Patients with active joint disease were at increased risk for developing RA-ILD compared with those with inactive joint diseases, according to a study published in Arthritis Rheumatology in September 2019.

Signs and Symptoms of RA-ILD

RA-ILD may cause breathlessness and dry cough, but in many cases it causes no symptoms at all, making early detection difficult.

Medication and Treatment for RA-ILD

More research is still needed to find effective treatment. According to research published in the journal European Respiratory Review, an analysis of various studies looked at the drug Rituxan (rituximab) for the treatment of RA-ILD, but the results were conflicting and it’s not clear whether it improves or worsens the condition.

Some other drugs, like mycophenolate mofetil, azathioprine (Azasan, Imuran), cyclosporine (Gengraf, Neoral), and cyclophosphamide (Cytoxan), are used to treat RA-ILD. A new class of drugs called antifibrotics (pirfenidone and nintedanib) has been used in people with other types of fibrotic lung diseases, or diseases involving lung scarring or damage. Research is ongoing to determine whether these drugs should be used in patients with RA-ILD.

A Risk for Developing Pulmonary Fibrosis

Inflammation, like the kind caused by RA-ILD, can lead to pulmonary fibrosis, or permanent scarring of the respiratory tissues. This can cause shortness of breath, since healthy air sacs are replaced by scar tissue that may not function properly. Supplemental oxygen can help make breathing easier but will not reverse the damage done by pulmonary fibrosis.

Nodules May Form in the Throat, on Vocal Cords, and in Lungs

Rheumatoid arthritis can also cause nodules to form in the throat and on the vocal cords, causing complications like hoarseness, shortness of breath, and other changes. Nodules can develop in the lungs as well but usually don’t cause symptoms, and patients may never notice them.

Several Other Lung Complications May Occur

People living with rheumatoid arthritis also face a heightened risk of:

Bronchiectasis, or damage to the airways
Bronchiolitis obliterans, or inflammation in small bronchial tubes
Pleural effusion, a buildup of fluid between the lung and chest wall
Pleurisy or pleuritis, or inflammation of the lining of the lung and chest wall
Pulmonary hypertension, high blood pressure in the lungs

Act Now to Preserve Precious Lung Tissue for the Long Term

Don’t wait for experts to understand the “why” behind RA-related lung problems. Get your protective action plan in gear now with these eight tips:

1. Get Early Treatment for RA

“We are still working to understand the natural history of lung involvement in RA and how exactly medication may be involved. At this point, I would encourage early screening for lung involvement for patients with signs and symptoms,” says Sparks. If you have RA and are experiencing shortness of breath, coughing, or other respiratory symptoms, talk to your doctor. These are potentially serious symptoms that warrant prompt attention.”

2. Don’t Smoke, and Avoid Secondhand Smoke

According to the Arthritis Foundation, people with RA who smoke are more apt to develop ILD. To get help with quitting, go to the SmokeFree.gov website.

3. Limit Exposure to Pesticides, Airborne Chemicals, and Air Pollution

There seems to be a tight connection between the lungs and joints in RA, so it's very important to eliminate inhalants, such as pesticides, airborne chemicals, and air pollution, as much as possible. “Most of the research has focused on the detrimental effects of cigarette smoking on both the joints and lungs, but it makes sense that the others are likely unhealthy as well,” says Sparks.

4. Ask Your Doctor About Getting Flu and Pneumonia Vaccines

Have you gotten a flu shot this year? Have you discussed the pheumonia vaccine with your doctor? Preventing infection is better than treating infection, since there may be damage to the lungs. Sparks explains, “The flu and pneumonia vaccines are effective and all patients with RA are strongly advised to receive them, particularly if on immunosuppressive medication, which might make them both more susceptible to infection. If infected, it could become more severe.”

5. Get Your Body Moving!

Exercise for lung health in RA has not been extensively studied yet, but regular exercise provides health benefits for your whole system.

6. Be Aware of Possible RA Drug Risks and Side Effects

Some RA drugs are immunosuppressive and may cause infections in the lungs. “No one really knows for sure how treatment for RA affects the lungs, either positively or negatively. Patients are encouraged to talk with their provider to make sure that the medications are optimal for their joint symptoms and their lung health,” says Sparks.

7. Tell Your Doctor Right Away if You Have Shortness of Breath or Dry Cough

Persistent cough can be caused by any of the lung diseases and conditions mentioned above. If you let it go and it turns out it is due to infection, the infection will get worse.

8. Gather a Good Support System of Friends and Family

“A supportive environment is essential to encourage physical activity, smoking cessation, and helping to lead a full and fulfilling life,” says Sparks.

How Rheumatoid Arthritis Affects the Lungs