Current perspectives on the pharmacotherapeutic management of rheumatoid arthritis-associated lung disease

INTRODUCTION: Pulmonary involvement affects approximately 30-40% of patients with rheumatoid arthritis (RA). Although interstitial lung disease (ILD) has received the greatest attention, non-ILD pulmonary manifestations also contribute substantially to respiratory morbidity. AREAS COVERED: Biologic therapies in RA have improved disease outcomes however, their use in RA-associated lung disease remains challenging due to limited high-quality data. This narrative review summarizes current evidence on the pharmacotherapeutic management of RA-associated lung disease, across its spectrum, focusing on ILD. A literature search was performed in PudmMed/Medline, Scopus and the Directory of Open Access Journals databases up to August 2026. EXPERT OPINION: Early recognition of RA-associated lung disease is crucial, therefore close follow-up and monitoring are mandatory. Pharmacotherapy requires an individualized strategy, rather than the one-size-fits-all. Corticosteroids may be considered in RA-associated ILD (RA-ILD) patients with an inflammatory imaging pattern or non-ILD manifestations (e.g. airway and pleural disease), although prolonged use should generally be avoided. Methotrexate (MTX) can be continued in RA-ILD patients, unless MTX-induced pneumonitis is suspected. Immunomodulatory agents may stabilize lung function, whereas antifibrotics offer the strongest trial-based evidence, especially in individuals with usual interstitial pneumonia or with progressive disease. High-quality prospective studies are needed. Until then, multidisciplinary, personalized approach should be followed.