Cordeiro, A.

Fonseca, C.

Gonçalves, P.

Santos, M. J.

Silva, J. Canas da

Sousa, S.

Teixeira, L.

Vinagre, F.

English

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ÓRGÃO OFICIAL DA sOCIEDADE PORTUGUEsA DE REUMATOLOGIA159CARTA AO EDITORHepatitis C virus (HCV) infection is a major publichealth problem, with an estimated prevalence of 2-3%of worldwide population1. Because Tumour NecrosisFactor (TNF) seems to have an important role in the im-mune response to HCV infection by inducing apopto-sis of the infected cells, suppression by TNF inhibitorsmay pose a potential threat of excessive viral replicationand worsening of chronic HCV infection2. Althoughprevious reports have shown that treating HCV in fectedpatients with TNFi does not lead to wor sening of he -patocyte lesion/liver disease, in the short-term, guide-lines recommend screening for anti-HCV antibodiesbefore starting a biological agent and making treatmentdecisions only after consulting a gastroenterologist3,4.We report 3 cases of patients with chronic HCV in-fection and advanced liver disease, treated with a TNFi,etanercept (ETN), for a period ranging from 4 monthsto 4 years, without hepatitis C treatment and, in two ofthem, during concomitant therapy with direct-actingantiviral agents (DAA) and continued afterwards.Case 1Male with rheumatoid arthritis (RA) and HCV-com-pensated cirrhosis, Child-Pugh score 5, initiated ETN50mg/week, after maintaining high disease activity withcombination of convencional synthe tic disease modi-fying anti-rheumatic drugs (cDMARD) and systemiccorticoids. He was medicated for almost 4 years withETN 50mg/week without HCV therapy and maintainedstable transaminase levels and viral load (Table I). In2015, he started a 24 week course of sofosbuvir anddaclatasvir with clearance of the virus, sustained 12 and24 weeks after treatment cessation. During these 24weeks of concomitant medication there was a good to -lerance, without adverse events. Three years after HCVtreatment, the patient maintains ETN with good con-trol of RA and the viral load remains negative.Case 2Male with severe polyarticular Psoriatic Arthritis (PsA)and HCV infection at cirrhotic stage, initiated at 2008,treatment with ETN 50mg/week, after failure of cDMARD and PUVA phototherapy. Over 2 years, wi th -out HCV therapy, there was no progression of the li verdisease, maintaining HCV viral load and transa mina seslevels stable (Table I). This patient deceased in 2010,following an ischemic stroke, before DAA becameavaila ble.Case 3Female diagnosed with PsA (peripheral arthritis anddactylitis) and HCV infection in cirrhosis stage (Table I),initiated ETN 50mg/week, after failure and intole ranceto cDMARDs. After 4 months on ETN without hepati-tis C therapy there was no change in transaminase le -vels and the viral load decreased (Table I). In 2015, shewas treated with a 24 week course of sofosbuvir and da-clatasvir with clearance of the virus, persistent at 12and 24 weeks after treatment cessation. As in case1,concomitant medication with ETN, sofosbuvir and da-clatasvir was well tolerated, without adverse events,and the viral load remained negative three years afterthe treatment and under ETN.Although increasing number of clinical reports sup-port the short-term safety and efficacy of TNFi in pa-tients with HCV, some uncertainties remain regardinglong-term safety of these agents5,6. The 3 cases repor ted,with considerable follow-up time, suggests that the riskof HCV reactivation related to ETN remains low evenwithout concomitant antiviral therapy. Nevertheless, astrict collaboration between rheumatologists and gas-troenterologists/hepatologists, allied to clini cal and la -boratory monitoring throughout the treatment periodis advised. The new DAA, highly effective and very welltolerated are, at present date, the standard of care for1. Rheumatology Department, Hospital Garcia de Orta 2. Gastroenterology Department, Hospital Garcia de Orta 3. Rheumatology Department, Hospital Garcia de OrtaRheumatology Research Unit, Instituto de Medicina Molecular –Faculdade de Medicina de LisboaSafety of etanercept in the treatment of rheumatic disease patients with Hepatitis C virus infectionACTA REUMATOL PORT. 2018;43:159-160Teixeira L1, Fonseca C2, Sousa S1, Vinagre F1, Cordeiro A1, Gonçalves P1, Santos MJ3, Canas da Silva J1ÓRGÃO OFICIAL DA sOCIEDADE PORTUGUEsA DE REUMATOLOGIA160Safety of etanercept in the treatment of rheumatic diSeaSe patientS with hepatitiS c viruS infectionHCV patients. Our results also showed a good tole -rance and efficacy when used concomitantly with ETNin patients 1 and 3.CorresponDenCe ToLídia Carina Lopes TeixeiraRheumatology Department, Hospital Garcia de OrtaAlmada, PortugalE-mail: lidialteixeira@gmail.comreferenCes1. Lavanchy D. The global burden of hepatitis C. Liver Int. 2009;29Suppl 1:74-81. doi:10.1111/j.1478-3231.2008.01934.x.2. Fischer R, Baumert T, Blum HE. Hepatitis C virus infection andapoptosis. World J Gastroenterol. 2007;13(36):4865-4872.3. Pompili M, Biolato M, Miele L,Grieco A. Tumor necrosis factor-inhibitors and chronic hepatitis C: A comprehensive literaturereview. World J Gastroenterol. 2013;19(44):7867-7873. doi:10.3748/wjg.v19.i44.7867.4. Fonseca JE, Bernardes M, Canhão H, et al. Portuguese guide-lines for the use of biological agents in rheumatoid arthritis –October 2011 update. Acta Reumatol Port. 2011;36(4):385--388. http://europepmc.org/abstract/MED/22472929.5. Marotte H, Fontanges E, Bailly F, Zoulim F, Trepo C, Miossec P.Etanercept treatment for three months is safe in patients withrheumatological manifestations associated with hepatitis Cvirus. Rheumatology (Oxford). 2007;46(1):97-99. doi:10.1093/rheumatology/kel191.6. Joseph AM. Treatment of rheumatoid arthritis in patients withconcomitant chronic hepatitis C infection. Ther Adv Muscu-loskelet Dis. 2012;4(1):35-40. doi:10.1177/1759720X11424459.Table I. DemographIC anD DIsease CharaCTerIsTICs of paTIenTsPrevious Viral Viral load 3 ExposureRheumatic HCV HCV load at or 6 months Previous time toPatient Sex Age disease genotype therapy baseline* after ETN* csDMARDs anti-TNF**1 Male 49 RA 3 no 5.87 5.18 Cyclosporine 3 years + 9 months2 Male 54 PsA 1b no 5.99 4.8 MTX 2 years3 Female 61 PsA 3 no 6.55 1.66 MTX, Cyclosporine, 4 monthsLEF, SSZRA, Rheumatoid Arthritis, PsA, Psoriatic Arthritis; HCV, hepatitis C virus; DMARDs, disease-modifying anti-rheumatic drugs; MTX,methotrexate, LEF, leflunomide, SSZ, sulfasalazine, ETN, Etanercept. Etanercept was used alone in all patients. Patient 1 met the ACRcriteria for RA. *The values are the log10 copies/ml. **Exposure time to anti-TNF without therapy for Hepatitis C.

Safety of etanercept in the treatment of rheumatic disease patients with Hepatitis C virus infection

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Safety of etanercept in the treatment of rheumatic disease patients with Hepatitis C virus infection

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