How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?

I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD without joints, which makes choosing an agent more difficult. This is my clinical experience but would love some studies citation for RA ILD. I think the lack of screening for RA ILD vs myositis, scleroderma guidelines is the real issue. Certainly, it is less incidence/prevalence of RA ILD but I am surprised when I screen for it how much I find. I do realize for any new pulm s/sx, even a dry cough, new DOE in a RA patient, I am perhaps casting the net...

No data either way. Both will work for joints. If progressive ILD, I would favor ritux, based on the totality of the data (even though the quality is low). The downside of ritux is the response to vaccination we are seeing.

There are published articles indicating that overall RA-ILD is less progressive than IPF, for example. In addition, I fully agree in looking for overlap autoimmune syndromes, especially ruling out myositis disorders. I have seen more than a few patients with such disorders initially presenting or being diagnosed just with “RA”.

This question has been answered already, but I thought I would add a few comments. Both rituximab and abatacept are reasonable options based on current data over TNF inhibitors. The point about rituximab and infections/vaccinations is relevant, especially in light of a recent publication by Zhang et al., PMID 40708472 in Arthritis and Rheumatology, reporting a significant increase in infections in people with RA-ILD vs RA without ILD. Recent data also indicates that 20% of RA-IL patients will progress their ILD on abatacept (and likely other therapies), so patients will need to be followed on a regular basis to determine if a change in therapy is warranted. There is emerging data on the JAKi both in terms of addressing RA-ILD AND preventing...