CLEVELAND — As the national population of patients who are HIV-positive continues to age, rheumatologists will be increasingly called on to manage routine care for crystal disease, osteoarthritis, soft tissue rheumatism and other conditions, according to Leonard Calabrese, DO, of the Cleveland Clinic.
“HIV is an infection that is in descendancy,” Calabrese told attendees at the Biologic Therapies Summit. “There are rare inflammatory complications that need aggressive therapy. Secondly, the HIV population is aging, and they will have a lot of rheumatic problems — they have osteoarthritis, [polymyalgia rheumatica], gout and other conditions. They also have drug-drug interactions that are very important and hopefully are going away. There are also some new complications, such as the presence of osteoporosis, which has been a problem.”
Although a study published in 2017 in Arthritis Care & Research demonstrated that a patient with HIV can be safely and effectively treated with a TNF-alpha inhibitor under current HIV practices — including aggressive CART, controlling the virus with a good CD4 cell response — in monotherapy, other drug-drug interaction problems are “formidable,” according to Calabrese.
As the national population of patients who are HIV-positive continues to age, rheumatologists will be increasingly called on to manage routine care for crystal disease, osteoarthritis, soft tissue rheumatism and other conditions, according to Calabrese.
“There are now more than 35 drugs used to treat HIV in different combinations,” he said. “If you are a patient on HIV medications and you need to use anything from glucocorticoids to antimetabolites, call the pharmacist. It is absolutely imperative, because some of the drug-drug interactions are profound.”
Generally, drugs that treat HIV carry the same cautionary notes as those for patients who are not infected with HIV, with several caveats, Calabrese said. For example, patients who are treated with ritonavir or cobicistat should avoid glucocorticoids.
There are several pharmacologic boosters, such as ritonavir and cobicistat, that can increase the area under the curve for glucocorticoids by 400%, Calabrese added. Further, he recommended caution in using methotrexate in patients with HIV as several HIV drugs — including cobicistat, darunavir, lopinavir, ritonavir and saquinavir — may increase the serum concentration and absorption of methotrexate, as well as decrease elimination and enhance distribution.
“A recent AIDS clinical trials group that just looked at methotrexate as a potential anti-cardiovascular disease progression agent showed significant toxicity, with lymphopenia and loss of CD4 cells,” Calabrese said. “That jives with our clinical observations made over several decades. So, when we need to use aggressive therapy for things, particularly inflammatory arthritis, which is still occasionally seen, we use TNF monotherapy.”
Lastly, Calabrese stressed that nearly every patient aged 15 to 65 years should be screened for HIV, even if they are not at great risk for contracting the virus, in line with U.S. Preventive Services Task Force recommendations.
“If you find yourself screening someone for hepatitis C or hepatitis B, and they are between the ages of 15 and 65, the guidelines are that you ask if they have ever been tested for HIV, and if they haven’t, you include that in the mix as well,” he said. “It would be good medicine and good monitoring.” – by Jason Laday
Calabrese L. Chronic viral disease (HIV, HCV, HBV) and the rheumatologist. Presented at: Biologic Therapies Summit VIII; May 16-17, 2019; Cleveland, Ohio.
Disclosure: Calabrese reports consulting fees from AbbVie, Bristol-Myers Squibb, Genentech/Roche, GlaxoSmithKline, Horizon, Janssen, Novartis, Pfizer, Regeneron, Sanofi Aventis and UCB, as well as teaching and speaking fees from AbbVie, Bristol-Myers Squibb, Crescendo, Genentech/Roche, Janssen and Novartis.