These older strategies indicate that rheumatologists should treat patients with HCV and mixed cryoglobulinemia with rituximab. As of 2011, 150 published cases of HCV-mixed cryoglobulinemia treated with rituximab had been published. These studies have not found any evidence of increased risk of liver toxicity, although they have found that HCV viral load may increase in patients treated with rituximab. As of 2012, several studies have suggested that rituximab may be associated with flares of HCV in the context of combined chemotherapy and in the treatment of cryoglobulinemia with advanced liver disease.3,4
HBV & Rheumatic Disease
Global immunization has led to the deceleration of HBV infection. Nevertheless, HBV infects 400 million–500 million individuals worldwide, and there are 1.25 million chronic cases in the U.S. Although HBV is a de-emerging pathogenic cause of rheumatic disease, changes in epidemiology and drug therapy make HBV reactivation a major concern. Extrahepatic complications of HBV include arthralgia, arthritis, arthritis dermatitis, polyarteritis nodosa (PAN), nephropathy and aplastic anemia.
Immunosuppression can lead to HBV reactivation, but unlike with HCV, the major risk of reactivation of HBV is not during, but rather following immunosuppression. Reactivation can then lead to severe and even fatal hepatitis. Researchers have described this phenomenon in patients with rheumatoid arthritis (RA) as well as other conditions that have required a patient who is positive for HBV infection to be treated with conventional or biologic therapy.
Dr. Calabrese proposed what he considered to be a reasonable strategy to treat patients who are positive for HBV infection and also require immunosuppression. He began by stating that rheumatologists should screen all patients from other countries to determine if they are HBV positive. The screening tests should include tests for hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc) and antibody to hepatitis B surface antigen (anti-HBsAb). In addition, all patients who will begin immunosuppressive therapy should be screened first for HBV infection. Any patient who screens positive by serological test should then be tested for the presence of HBV-DNA. Preemptive therapy should be initiated in all HbsAg-positive and HBV-DNA-positive patients. Patients who have an isolated anti-HBc positive test should be carefully monitored. Rheumatologists should refer all patients who are potential candidates for anti-viral therapy to hepatology.
Dr. Calabrese concluded his presentation by saying there is an intimate relationship between human viral infections and rheumatic disease in terms of etiology, comorbidity and complications. The relationship is not simple and is often combinatorial. Rheumatologists must, therefore, stay informed on clinical and basic research in this area in order to improve the diagnosis, management and prevention of disease.
