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Suhail - Tough questions, looking for good answers, but I only have tough answers:
1. LEF is not safer than MTX. This review (and many others) state that if MTX is working, the presence or concern of RA-ILD is not a good reason to stop or change MTX (no matter what pulmonary yells about). Your choice is not supported by available evidence
2. See the EULAR 2025 ILD guidelines, that state Tocilizumab is indicated for PSS-ILD. While it seems like a good option, it has not been studied, nor is there an indication for TCZ in RA-ILD https://rheumnow.com/podcast/ild-guidelines
https://rheumnow.com/therapeutic-update/ild-treatment-and-guidelines
These patients are really hard to manage. I often will call or email one of the ILD experts, or authors of either the ACR or EULAR ILD guidelines for advice on what to do. Thanks for looking at this and considering the options!1 JC