CHICAGO—Leonard H. Calabrese, DO, professor of medicine at Cleveland Clinic in Ohio, presented on emerging concepts of viral infections and rheumatic disease at the ACR’s State-of-the-Art Clinical Symposium in April. “We are at a pivotal point in rheumatology in understanding the relationship between viruses and rheumatic disease,” began Dr. Calabrese. “It’s a very exciting time.” Dr. Calabrese then discussed hepatitis C (HCV) and hepatitis B viruses (HBV) and their association with rheumatic disease in more detail.
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Explore This IssueJuly 2017
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HCV & Rheumatic Disease
Dr. Calabrese described HCV as “a deaccelerating infection.” Although there are 200 million individuals worldwide infected with the virus, he believes that, with the advent of direct-acting anti-virals (DAA), it will soon be possible to abolish HCV infections. DAA treatment is associated with cure rates of 95–100%. Treatment protocols can be as brief as six weeks, causing Dr. Calabrese to enthuse, “This is a curable disease—within a few months. … It’s a whole new deal.”
DAAs have not only changed the medical landscape for patients with HCV, but have also led to the question: How quickly does their immune deficit recover? Unfortunately, according to Dr. Calabrese, there appears to be a long delay.
HCV infection increases the risk for several rheumatologic diseases, but patients who are infected with HCV are most at risk for cryoglobulinemic vasculitis, which manifests with palpable purpura, arthralgia and weakness.
A study presented at the 2016 ACR/ARHP Annual Meeting examined the effect of DAAs on HCV cryoglobulinemic vasculitis.1 It included 35 patients who were prescribed sofosbuvir and daclatasvir. The patients achieved 100% sustained virologic response (SVR) and had a 91% complete clinical response at 12 weeks. However, at 12 weeks, only 50% of patients had a complete immunologic response. These findings build on results from previous studies, which also demonstrated either failure to clear cryoglobulinemic vasculitis or a relapse of cryoglobulinemic vasculitis that appeared independent of virologic relapse.
The 2015 ACR screening recommendations for HCV remain unchanged from the 2008 recommendations.2 The guidelines suggest screening those at risk for HCV infection only prior to treatment with methotrexate/leflunomide. Dr. Calabrese counters, however, that HCV as a comorbidity for rheumatic disease now serves as an opportunity to bring HCV-infected patients into a circle of care.
The treatment goal for a patient who is positive for HCV is to first cure the HCV infection and then manage the autoimmune diseases traditionally. Thus, rheumatologists should screen for HCV, and if the patient tests positive, refer them to a good hepatologist for treatment. If the patient does not respond to DAA, then alternative and older treatment strategies apply.