Management of Inflammatory Arthritis in Patients With Comorbid HIV Infection

PsA in patients infected with HIV is associated with more severe, erosive, and deforming arthropathy that may be resistant to treatment. Further, psoriatic skin lesions tend to be more persistent and severe in these patients. New-onset PsA in patients with HIV typically presents as an abrupt, lower extremity ,asymmetric poly- or oligoarthritis with rapid development of erosions and progression to other joints over time.  

Adizie and colleagues highlight the usual self-limiting nature of HIV associated rheumatic diseases allows for non-steroidal anti-inflammatory drugs to be the first line treatment. Further, evidence for the safety of disease modifying antirheumatic drugs (DMARDs) in HIV patients is limited mostly to case series. Likewise, treatment with highly active antiretroviral medication is associated with clinical improvement in SpA.

The authors’ literature review included case series studies that evaluated the treatment of HIV-associated inflammatory arthritis with common antirheumatic medications.  Historically there has been limited information on the safety of immunosuppressive drug use for the treatment of rheumatic disease in patients with HIV. 

Methotrexate, initially deemed as contraindicated in patients with HIV due to concerns over opportunistic infection, has now been used in patients with comorbid RA or PsA and HIV when CD4 counts exceed 100/mm³ with close monitoring.

Sulfasalazine, mycophenolate, and azathioprine have been used to treat SpA without subsequent adverse effects on HIV infection control.  Short courses of steroid treatment, including prednisolone, were also found to be safe. 

Biologic DMARDs including etanercept, adalimumab and infliximab have also been used to treat RA, PsA, and undifferentiated SpA in patients infected with HIV with good safety profile.  Their use was closely monitored and eligible patients carefully selected, using HIV viral load and CD4 counts. 

“Current evidence suggests strong immunosuppressants such as anti-TNF treatment can be used in HIV patients if restricted to those patients with a CD4 count over 200 cells/mL and a viral load of under 60,000 copies/mL at initiation of therapy. Cell counts need to be monitored closely however and they need screening for latent TB,” Dr Adizie said in an email interview with Rheumatology Advisor. 

“Registries for prospective follow up of HIV positive patients with arthropathies are urgently needed to shed light on clinical features and natural history of these conditions, and to develop treatment guidelines,” the review authors recommended.¹

Reference

1.       Adizie T, Moots RJ, Hodkinson B, French N, Adebajo AO. Inflammatory arthritis in HIV positive patients: A practical guide. BMC Infect Dis. 2016;16(1):100.