American study reveals lung disease can develop silently in the first year of rheumatoid arthritis, particularly in older patients and those with high disease activity
Patients newly diagnosed with rheumatoid arthritis typically focus on managing joint pain, morning stiffness, and selecting appropriate treatment. However, a significant American study has uncovered a hidden threat: as early as the first year of the disease, one in ten patients may be walking around with undetected lung disease that could pose serious health risks.
The research, published in the medical journal The Lancet Rheumatology and conducted across five medical centers in the United States, reveals who faces the highest risk and how the condition can be identified early using simple tools already available in routine clinical practice.
The study tracked patients in the early stages of rheumatoid arthritis—within two years of diagnosis—and discovered a surprising finding: already at the beginning of their journey, 11% showed signs of interstitial lung disease (ILD) on specialized CT scans (HRCT), even though the condition wasn't necessarily causing noticeable symptoms yet.
"Lung involvement is considered one of the most common and also the most lethal complications, to the point of being life-threatening," explains Professor Shai Koyti, Director of the Rheumatology Unit at Meir Medical Center, part of the Clalit health group. "Between 5% and 10% of patients, depending on the study, develop autoimmune lung disease alongside their joint disease."
Rheumatoid arthritis is the most common inflammatory joint disease and represents an autoimmune condition in which the immune system mistakenly attacks the body. According to Professor Koyti, the disease affects approximately 0.5% of the population, primarily women, with an estimated 50,000 patients in Israel. The disease primarily damages joint cartilage—especially in the hands—causing swelling, inflammation, and without timely treatment, can lead to joint destruction, severe deformities, and disability.
"In more severe cases, the disease doesn't limit itself to joints and can involve additional organs, including the eyes, nervous system, skin, and particularly the lungs," Professor Koyti explains. He notes that the risk is especially high among severe patients, including smokers.
However, he emphasizes that the treatment landscape has changed dramatically in recent years: "Since the introduction of biological therapies, we've changed the course of the disease. In the past, people would become disabled, whereas today most lead good, normal lives. It's a 180-degree change." According to him, the lungs remain a challenging and relevant area specifically because lung involvement can still be lethal and requires special attention.
The study included 172 patients who agreed to undergo comprehensive testing: high-resolution chest CT scans, pulmonary function tests, blood tests for disease-related antibodies, medical questionnaires, and complete clinical examinations. Most participants were women (74%), with an average age of 55.3, and two-thirds tested positive for antibodies characteristic of rheumatoid arthritis (RF and CCP).
Data analysis revealed two groups at particularly high risk for lung disease early in rheumatoid arthritis:
Patients with moderate to high disease activity were seven times more likely to have interstitial lung disease detected compared to those in remission or with low activity.
Patients aged 60 and above faced nearly four times the risk compared to younger patients.
To determine whether lung disease could be identified in time, researchers compared several conventional screening methods, including joint guidelines from the American College of Rheumatology and pulmonary specialists, as well as models built from large follow-up studies tracking rheumatoid arthritis patients over time.
The results showed that testing methods vary in effectiveness:
High sensitivity, low specificity: Some methods identify nearly every possible patient and are therefore considered highly sensitive, but lack precision and generate many false positives. For example, the method based on joint ACR-pulmonary specialist guidelines successfully identified every patient with lung disease (100% sensitivity) but could barely distinguish between actual patients and those who appeared suspicious but weren't actually ill—achieving only 11% specificity.
High specificity, low sensitivity: Other methods are much more accurate but may miss patients. For instance, the Paulin criteria—a scoring system based on multiple risk factors to determine who needs testing—almost always correctly identifies when lung disease is absent (97% specificity) but manages to identify only a tiny fraction of patients actually suffering from it, with particularly low sensitivity of just 5%.
An additional finding that may help physicians is how many patients need to be screened to find one case of lung disease. According to the findings, the number is very small: between just 3.6 to 7.7 patients, depending on the screening method used. This means that even simple screening tests can detect the disease early, making it worthwhile to incorporate them from the beginning of rheumatoid arthritis patient monitoring.
ILD is one of the significant complications of rheumatoid arthritis and can develop gradually without the patient feeling almost anything initially. Early detection can greatly impact treatment: it allows for medication adjustments, close monitoring of lung function, and even prevention of dangerous deterioration.
The study's findings clearly indicate that monitoring rheumatoid arthritis patients should include attention to the lungs from the first year, especially in older patients or those with moderate to high disease activity.
Although dealing with early-stage rheumatoid arthritis, one in ten patients already suffers from interstitial lung disease. Researchers emphasize that these patients can be identified in time using simple information already collected during regular rheumatologist visits—such as patient age, disease activity level, blood test results, and physician assessment. Combining this data can flag who needs to proceed to advanced lung testing, such as CT scans.
Professor Koyti summarizes: "The important message is that when a patient comes to a rheumatologist with rheumatoid arthritis, the doctor should already suspect and detect possible signs of lung disease—such as breathing difficulties or coughing. It's possible and even desirable to proactively search for the disease, detect it as early as possible, and consider preventive treatment. This requires additional research, but it's certainly a very important topic."
The research underscores the need for a holistic approach to rheumatoid arthritis management, recognizing that what begins as a joint disease can have serious systemic manifestations. With modern screening tools and heightened clinical awareness, physicians can identify at-risk patients early and intervene before lung disease becomes symptomatic or life-threatening.
For patients newly diagnosed with rheumatoid arthritis, particularly those over 60 or experiencing high disease activity, proactive lung screening may be a critical component of comprehensive care—potentially preventing one of the disease's most serious and deadly complications.
