Background Managing patients with rheumatoid arthritis (RA) and concomitant hepatitis B virus (HBV) or hepatitis C virus (HCV) infections represents a major challenge in modern rheumatology.Due to a high risk of HBV, HCV infection reactivation and potential hepatotoxity the use of disease-modifying antirheumatic drugs (DMARDs) and corticosteroids is limited in such patients. Since biologic agents have been increasingly employed in patients with chronic inflammatory rheumatic diseases, their efficacy and safety need to be further investigated in patients with chronic HBV and HCV infection.
Objectives To assess the safety and efficacy of TNF-alfa inhibitors (TNFi) in RA patients with concomitant chronic HBV and HCV infection.
Methods From 2012 to 2015 we have been observing 10 RA patients (5 male, 5 female, mean age 45,4 years) with chronic HBV (6 patients) and HCV (4 patients) infection who were undergoing therapy with TNFi. Mean duration of the disease before initiating biologic agents was 8 years, mean follow-up period was 18,2 months. Criteria for starting biologics included high disease activity score (DAS28 - 6,7) with little response to non-biologic DMARDs (methotrexate, leflunomide, sulfasalazine) and/or low-dose corticosteroids (4–8 mg/day); intolerance of DMARDs or contraindications to them. 2 patients with RA and chronic HBV infection were given a preventive treatment with ribavirin and a concomitant treatment with alfa-inetrferon. One patient with RA and chronic HCV infection recieved an antiviral preventive treatment with alfa-interferone. Hepatitis activity was monitored with viral load and liver function tests, RA activity was monitored with ESR, CRP, pain assessment with visual analogue scale (VAS) and disease activity score in 28 joints (DAS28). All tests were performed every 3 months during the first year and every 6 months beyond the first year of study. Patients were given standard doses of TNFi – adalimumab (2 patients with hepatitis C), etanercept (8 patients with hepatitis B, 2 patients with hepatitis C).
Results Disease activity reduction was observed in all patients: mean pain VAS score decreased from 80 to 26.5 mm (p<0,001), mean ESR decreased from 32,8 to 12,5 mm/h, mean CRP level decreased from 4.2 to 0.3 mg/dl (p<0,001), mean DAS28 decreased from 6.25 to 3.36 (p<0,001). No viral load or liver enzymes increase was observed in our study. One patient with chronic hepatitis B and one patient with chronic hepatitis C had leukopenia on while being on etanercept and concomitant or preventive alfa-interferon therapy, which was successfully reversed with Leucostim
Conclusions After 3 years of study TNF-alfa inhibitors (adalimumab and etanercept) appear to be effective and quite safe in patients with RA and concomitant chronic HBV and HCV infection. During the mean follow-up period of 18.2 months no viral load increase or signs of hepatitis virus reactivation have been noted. Althigh, TNFi-based treatment requires regular monitoring of HBV and HCV activity using PCR test.
Disclosure of Interest None declared