Pulmonary Disorders Induced by Monoclonal Antibodies in Patients with Rheumatologic Autoimmune Diseases

Monoclonal antibodies have emerged as a new class of agents causing drug-related pulmonary involvement in patients with systemic rheumatologic autoimmune diseases. The most frequently associated noninfectious pulmonary diseases are interstitial pneumonia (118 cases reported by August 2010), sarcoid-like disease and vasculitis (40 cases), and 97% of cases are associated with agents blocking tumor necrosis factor (TNF), a cytokine implicated in pulmonary fibrosis, granuloma formation, and maintenance. Drug-induced interstitial pneumonia has a poor prognosis, with an overall mortality rate of around one-third, rising to two-thirds in patients with pre-existing interstitial disease. Sarcoid-like disease has a better prognosis, with resolution or improvement in 90% of cases. Although the evidence comes overwhelmingly from case reports and case series, suggested recommendations for patient management include a detailed pre-therapeutic evaluation, early identification of symptoms suggestive of pulmonary disease, and tailored therapy. Mycobacterial infection should be exhaustively investigated, especially after anti-TNF administration. Large, prospective, postmarketing studies including nonbiological agents as controls may help elucidate the real risk of pulmonary disease in patients with rheumatologic autoimmune diseases receiving monoclonal antibodies. (C) 2011 Elsevier Inc. All rights reserved. The American Journal of Medicine (2011) 124, 386-394