Robert Terkeltaub, MD

Disclosures

April 24, 2001

Question

What is appropriate treatment for a patient with rheumatoid arthritis (RA) and active hepatitis C?

Raffaele Improta, MD

Response from Robert Terkeltaub, MD

The first issue is to be certain of each diagnosis. Rheumatoid arthritis can be associated with false-positive hepatitis C virus (HCV) serology (though this was more common with older generation immunoassays). Mixed cryoglobulinemia and vasculitis associated with HCV can cause joint symptoms and clinically inflamed joints (but without destructive arthritis). In addition, HCV infection can be associated with a symmetric inflammatory polyarthritis; many patients in this situation test positive for rheumatoid factor (RF). Sjögren's syndrome also can be associated with HCV. In addition, treatment of HCV with interferon-alfa has been reported to trigger an inflammatory seronegative rheumatoid-like polyarthritis, and possibly promotes the development of classical RA from latent disease in a few individuals.

Hydroxychloroquine and sulfasalazine are a good foundation for treatment in cases where disease-modifying antirheumatic drugs (DMARDs) are indicated for bona fide RA in a patient with active HCV infection. Methotrexate would be contraindicated. There are not enough data at this point to know whether etanercept and leflunomide adversely impact HCV-related liver disease. But I would not be inclined to use either of these drugs for RA in the setting of a chronic infectious disease.

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