While the past decade has seen great advances in the understanding and treatment of rheumatoid arthritis, there are still segments of the rheumatoid arthritis population that have not been able to even try many newer treatments due to the presence of other illnesses. Such patients must deal with more than one potentially life-shortening illness, and the realization that they are unable to reap the benefits of available treatments.
One such illness that can impact the therapeutic management of a rheumatoid arthritis patient is hepatitis C. Infection with the hepatitis C virus represents a growing problem throughout the world: It is estimated that 170 million people are infected with hepatitis C; in the United States, the number is about 3 million.
It has been estimated that there are about 40,000 rheumatoid arthritis patients with chronic hepatitis C infection.
The transmission and risk for acquiring hepatitis C is mainly through exposure to contaminated blood, but can occur through high-risk sexual activity, tattoos or body piercing and shared personal items, to name a few. Most patients with hepatitis C infection do not have outward signs of the disease; the majority of those who do complain of anything, complain of fatigue. Treatment of chronic hepatitis C involves pegylated interferon with ribavirin.
There are several ways hepatitis C can affect a rheumatologist's ability to diagnose rheumatoid arthritis:
1) many patients with hepatitis C have a falsely positive rheumatoid factor
2) patients with hepatitis C can suffer joint pain and swelling, looking very much like rheumatoid arthritis patients
3) hepatitis C patients do have lower levels of anti-CCP antibodies compared to the rheumatoid arthritis patient.
It is difficult to answer the question regarding the safest treatment for rheumatoid arthritis patients who also are infected with hepatitis C. But I do believe that it is reasonable to avoid drugs which have the high potential for liver toxicity, such as methotrexate and Arava. And there are published recommendations to avoid even the less-liver toxic drugs, such as Plaquenil and sulfasalazine.
Interestingly, the tumor necrosis factor inhibiting drugs appear to be safe, and the data is growing on their safety in hepatitis C patients who also suffer from rheumatoid arthritis: There seems to be no obvious influence on the underlying hepatitis C infection when these biologic agents are used. Of greater interest is the fact that there was a study published which found that Enbrel in combination with interferon and ribavirin was safe and effective for the treatment of hepatitis C! Currently, there is an ongoing clinical trial examining the safety and usefulness of Remicade for the treatment of hepatitis C. In fact, the American College of Rheumatology has recommended that the tumor necrosis factor inhibiting drugs (Enbrel, Remicade and Humira) can be used in patients with chronic hepatitis C without causing worsening of liver function.
It is important that patients and rheumatologists be aware that hepatitis C is a relatively common chronic viral infection, affecting the diagnosis and treatment of rheumatoid arthritis. And while the tumor necrosis factor inhibiting agents appear to be safe and effective in rheumatoid arthritis patients with hepatitis C, definitive studies still are underway. In the meantime, rheumatologists must work closely with liver specialists to monitor patients with hepatitis C, all the while being as aggressive as possible in treating the potentially disabling disease, rheumatoid arthritis.