How to treat a patient with RA and HCV?

[Guest guest]

Question

A 45-year-old woman with active rheumatoid arthritis has been on

methotrexate and prednisone. Her serum aminotransferases are increased

and she is hepatitis C virus (HCV)-antibody positive. Results of serum

HCV RNA are pending. How would you recommend I manage this patient?

Zaigham Abbas, MD

Response

from M. DiBisceglie, MD, 03/20/01

My approach would be to first establish whether the patient does have

HCV infection. I agree with the suggestion to check for serum HCV RNA

positivity. Assuming that this patient is seropositive, the next step

would be to determine the severity of liver injury. Again, assuming that

the patient has no physical signs of cirrhosis or liver failure, this

would require liver biopsy. The biopsy should be examined by an

experienced liver pathologist for evidence of methotrexate toxicity.

Methotrexate hepatotoxicity is a rare and dose-dependent side effect of

long-term therapy and is typically not associated with increased serum

aminotransferases.

The most likely finding is that the biopsy has features of chronic

hepatitis C without methotrexate toxicity. In this case, the need for

continuing methotrexate should be determined clinically, weighing the

possible benefit against the possible toxicity (ie, worsening of liver

disease). If the hepatitis is at all severe on liver biopsy, it may be

advisable to find an alternative therapy for this patient's rheumatoid

arthritis. If possible, the corticosteroids should also be stopped. If,

however, the liver injury is not severe, or the patient has no

alternative to methotrexate, then it may be in her best interests to

continue this therapy.

The role for antiviral therapy (interferon with or without ribavirin) in

this case is not clear. The effect of interferon is somewhat lessened by

concomitant administration of steroids. Also, there is some concern

about the risk of rheumatoid arthritis flaring up with the use of

interferon.

Finally, it is worth mentioning that patients with hepatitis C and

cryoglobulinemia are sometimes mistakenly diagnosed as having rheumatoid

disease. These patients often have arthralgias, sometimes even mild

arthritis, and they are seropositive for rheumatoid factor because of

the presence of cryoglobulinemia. Treatment with interferon and

ribavirin is appropriate therapy for patients with hepatitis C and

cryoglobulinemia.

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This news article was posted on 03/22/2002

http://janis7hepc.com/side_effects.htm

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