Ask the Experts - Treating the HCV-positive Patient Who Has Active...
Ask the Experts - Treating the HCV-positive Patient Who Has Active...
A 45-year-old woman with active rheumatoid arthritis has been on methotrexate and prednisone. Her serum aminotransferases are increased and she is hepatitis C virus (HCV)-antibody positive. Results of serum HCV RNA are pending. How would you recommend I manage this patient?
Zaigham Abbas, MD
My approach would be to first establish whether the patient does have HCV infection. I agree with the suggestion to check for serum HCV RNA positivity. Assuming that this patient is seropositive, the next step would be to determine the severity of liver injury. Again, assuming that the patient has no physical signs of cirrhosis or liver failure, this would require liver biopsy. The biopsy should be examined by an experienced liver pathologist for evidence of methotrexate toxicity. Methotrexate hepatotoxicity is a rare and dose-dependent side effect of long-term therapy and is typically not associated with increased serum aminotransferases.
The most likely finding is that the biopsy has features of chronic hepatitis C without methotrexate toxicity. In this case, the need for continuing methotrexate should be determined clinically, weighing the possible benefit against the possible toxicity (ie, worsening of liver disease). If the hepatitis is at all severe on liver biopsy, it may be advisable to find an alternative therapy for this patient's rheumatoid arthritis. If possible, the corticosteroids should also be stopped. If, however, the liver injury is not severe, or the patient has no alternative to methotrexate, then it may be in her best interests to continue this therapy.
The role for antiviral therapy (interferon with or without ribavirin) in this case is not clear. The effect of interferon is somewhat lessened by concomitant administration of steroids. Also, there is some concern about the risk of rheumatoid arthritis flaring up with the use of interferon.
Finally, it is worth mentioning that patients with hepatitis C and cryoglobulinemia are sometimes mistakenly diagnosed as having rheumatoid disease. These patients often have arthralgias, sometimes even mild arthritis, and they are seropositive for rheumatoid factor because of the presence of cryoglobulinemia. Treatment with interferon and ribavirin is appropriate therapy for patients with hepatitis C and cryoglobulinemia.
A 45-year-old woman with active rheumatoid arthritis has been on methotrexate and prednisone. Her serum aminotransferases are increased and she is hepatitis C virus (HCV)-antibody positive. Results of serum HCV RNA are pending. How would you recommend I manage this patient?
Zaigham Abbas, MD
My approach would be to first establish whether the patient does have HCV infection. I agree with the suggestion to check for serum HCV RNA positivity. Assuming that this patient is seropositive, the next step would be to determine the severity of liver injury. Again, assuming that the patient has no physical signs of cirrhosis or liver failure, this would require liver biopsy. The biopsy should be examined by an experienced liver pathologist for evidence of methotrexate toxicity. Methotrexate hepatotoxicity is a rare and dose-dependent side effect of long-term therapy and is typically not associated with increased serum aminotransferases.
The most likely finding is that the biopsy has features of chronic hepatitis C without methotrexate toxicity. In this case, the need for continuing methotrexate should be determined clinically, weighing the possible benefit against the possible toxicity (ie, worsening of liver disease). If the hepatitis is at all severe on liver biopsy, it may be advisable to find an alternative therapy for this patient's rheumatoid arthritis. If possible, the corticosteroids should also be stopped. If, however, the liver injury is not severe, or the patient has no alternative to methotrexate, then it may be in her best interests to continue this therapy.
The role for antiviral therapy (interferon with or without ribavirin) in this case is not clear. The effect of interferon is somewhat lessened by concomitant administration of steroids. Also, there is some concern about the risk of rheumatoid arthritis flaring up with the use of interferon.
Finally, it is worth mentioning that patients with hepatitis C and cryoglobulinemia are sometimes mistakenly diagnosed as having rheumatoid disease. These patients often have arthralgias, sometimes even mild arthritis, and they are seropositive for rheumatoid factor because of the presence of cryoglobulinemia. Treatment with interferon and ribavirin is appropriate therapy for patients with hepatitis C and cryoglobulinemia.
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