Divergent approaches to rheumatoid arthritis-associated interstitial lung disease: a comparative analysis of international clinical practice guidelines.

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is associated with substantial morbidity and mortality. We compared international and regional clinical practice guidelines to identify agreement, differences, and gaps in RA-ILD care. We conducted a narrative comparative review of five guideline groups: ERS/EULAR, ACR/CHEST, EULAR, PANLAR, and ALAT. Recommendations were assessed across screening, diagnosis, monitoring, and treatment, together with their methodological approaches. Diagnostic recommendations showed the greatest agreement: ILD-focused guidelines emphasized high-resolution computed tomography (HRCT), pulmonary function tests, and multidisciplinary evaluation. Screening recommendations differed: ERS/EULAR and ACR/CHEST favored risk-based assessment, whereas ALAT proposed a broader approach that included lung ultrasound as an adjunct, without replacing HRCT. For established RA-ILD, ACR/CHEST suggested, as implementation guidance, pulmonary function testing every 3-12 months during the first year and HRCT when clinically indicated; ERS/EULAR proposed pulmonary function testing every 3-6 months in the first years and periodic HRCT. Treatment showed the greatest divergence. ACR/CHEST conditionally recommended mycophenolate, rituximab, azathioprine, and cyclophosphamide as first-line ILD therapies, whereas ALAT emphasized integrated control of articular and pulmonary disease, particularly with abatacept or rituximab. EULAR and PANLAR primarily addressed RA treatment and did not provide dedicated RA-ILD algorithms. Antifibrotic treatment was considered mainly in progressive fibrosing disease. Guidelines converge on HRCT-based evaluation but differ in screening, monitoring intervals, and treatment priorities. These differences reflect their scope, methodology, and limited RA-ILD-specific evidence. Prospective comparative studies are needed to inform more consistent care.