Rheumatology Advance Access originally published online on June 6, 2007
Rheumatology 2007 46(8):1379; doi:10.1093/rheumatology/kem038
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Adalimumab-associated pulmonary fibrosis – reply
Department of Rheumatology, Southampton University Hospitals NHS Trust, UK
Correspondence to: M. Huggett. E-mail: matthewhuggett{at}doctors.net.uk
SIR, We thought that the response to our case report (by Collins et al.) about a patient with adalimumab-associated pulmonary fibrosis was interesting and raised some important points. The presumption that there was pre-existing interstitial pulmonary fibrosis (IPF) may be correct, however, in the absence of a pre-treatment high resolution CT or lung biopsy, this remains a presumption. Acute pneumonitis associated with methotrexate use tends to occur earlier in treatment than in this patient who had been taking it for 2 yrs. The patient concerned certainly was asymptomatic prior to treatment and deteriorated rapidly within 10 weeks of starting adalimumab. Whether fibrosis was pre-existent or not, there is a temporal relationship in this case between initiation of anti-TNF therapy and rapid deterioration in lung function. This suggests a cause and effect relationship, and certainly does not change the level of concern.
Reduction in gas transfer is a more sensitive test than a chest radiograph in screening for IPF but this test is not specific and generates false negatives. However, in the light of this case and others, there may be a case for gas transfer measurements as part of the screening process.
We believe that above all there is accumulating evidence suggesting increased caution when commencing these drugs. Most importantly, however, there should also be increased awareness and dissemination of information to general medical physicians of the potential side effects that these drugs can cause.
The authors have declared no conflicts of interest.
Accepted 24 January 2007
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