RA in Patient With History of AIDS and Active Synovitis
RA in Patient With History of AIDS and Active Synovitis
The patient is a 44-year-old man with AIDS (diagnosed 10 years ago) on multiple anti-HIV drugs. His viral load is stable. He has rheumatoid arthritis (RA) with active synovitis despite treatment with 10 mg of prednisone, 1.5 g of sulfasalazine, and hydroxychloroquine 200 mg twice daily. Labs: Hb 10.5; ESR 68; anti-CCP-positive. X-ray of hands showed multiple erosions. Where do I go from here? Methotrexate? Anti-TNF? The remedy may be worse than the disease.
Mohammed Mughni
The question raised is always a tough one, and as suggested in the question, the "remedy may be worse than the disease" when one considers immunomodulatory therapies in patients who are immunocompromised for another reason, such as HIV infection. Although it is an important area, there is a lack of data that address this, specifically in terms of controlled clinical trials. Certainly there are anecdotes addressing the use of methotrexate, leflunomide, and even TNF inhibitors in patients with HIV. Of course, the health of the patient is paramount. Due to concerns of the potential immunosuppressive effects of these agents, many would probably try therapies perhaps less likely to induce immune suppression. In this case, sulfasalazine and hydroxychloroquine were tried, but apparently the patient did not respond. If possible, it might be interesting to try gold, preferably as an intramuscular preparation if it is available. Gold is known to affect some elements of the immune system, but it does not seem to cause immunosuppression. Minocycline can also be considered as an alternative therapy because there are pretty good data supporting its use, particularly in early RA.
The patient is a 44-year-old man with AIDS (diagnosed 10 years ago) on multiple anti-HIV drugs. His viral load is stable. He has rheumatoid arthritis (RA) with active synovitis despite treatment with 10 mg of prednisone, 1.5 g of sulfasalazine, and hydroxychloroquine 200 mg twice daily. Labs: Hb 10.5; ESR 68; anti-CCP-positive. X-ray of hands showed multiple erosions. Where do I go from here? Methotrexate? Anti-TNF? The remedy may be worse than the disease.
Mohammed Mughni
The question raised is always a tough one, and as suggested in the question, the "remedy may be worse than the disease" when one considers immunomodulatory therapies in patients who are immunocompromised for another reason, such as HIV infection. Although it is an important area, there is a lack of data that address this, specifically in terms of controlled clinical trials. Certainly there are anecdotes addressing the use of methotrexate, leflunomide, and even TNF inhibitors in patients with HIV. Of course, the health of the patient is paramount. Due to concerns of the potential immunosuppressive effects of these agents, many would probably try therapies perhaps less likely to induce immune suppression. In this case, sulfasalazine and hydroxychloroquine were tried, but apparently the patient did not respond. If possible, it might be interesting to try gold, preferably as an intramuscular preparation if it is available. Gold is known to affect some elements of the immune system, but it does not seem to cause immunosuppression. Minocycline can also be considered as an alternative therapy because there are pretty good data supporting its use, particularly in early RA.
