Therapy Insight: The Changing Spectrum of Rheumatic Disease in HIV Infection

Rashmi M. Maganti; John D. Reveille; Frances M. Williams

Disclosures

Nat Clin Pract Rheumatol. 2008;4(8):428-438. 

In This Article

Treatment of Rheumatic Disease Coexistent With HIV Infection

The treatment of rheumatic diseases is broadly similar in HIV-positive and HIV-negative individuals. Most HIV-positive patients with rheumatic diseases do well with conventional anti-inflammatory therapy, but some might require cytotoxic therapy. The major caveats are potential drug interactions (e.g. between statins and protease inhibitors) and advanced immunosuppression (CD4+ T-cell count of less than 200/mm3).

Indomethacin directly inhibits HIV-1 replication.[45] Sulfasalazine is an effective treatment for HIV-associated arthritis and has been shown to improve CD4+ T-cell counts.[46] Hydroxychloroquine inhibits replication of HIV-1 in vitro.[47] Short-term prednisone use is safe even in advanced HIV infection.[48,49]

The experience with biologic agents, especially anti-TNF drugs, is growing. A study that investigated the effects of etanercept treatment in HIV-infected patients without rheumatic diseases also suggested that anti-TNF therapy is safe in such patients.[50] Several case reports that described the successful use of etanercept to treat RA[51] and reactive or psoriatic arthritis,[52] and of infliximab to treat reactive arthritis,[53] psoriasis[54] and Crohn's disease[55] in the setting of HIV infection attest to the safety and efficacy of these agents. In addition, rituximab has been used to treat patients with HIV-associated lymphomas, and one case report has described the use of rituximab to treat refractory immune thrombocytopenia in a HIV-infected patient.[56] Currently, however, there are no reports of rituximab therapy in HIV-associated rheumatic disease.

Whether or not TNF blockade is beneficial, detrimental or has any effect on the course and outcome of HIV and/or AIDS remains to be elucidated. However, the available literature indicates that anti-TNF agents do not worsen the morbidity or mortality of HIV-infected people. Ultimately, physicians must remain vigilant for the appearance of infections known to be associated with anti-TNF therapy (tuberculosis, histoplasmosis, coccidiomycosis, etc.).

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