Prevalence and correlates of hepatitis C virus-associated inflammatory arthritis in a population-based cohort

Hepatitis C virus infection increases the risk of adverse outcomes following joint arthroplasty: A meta-analysis of observational studies

BACKGROUND

Whether hepatitis C virus (HCV)-positive patients are at risk for increased complications and long hospital stay following total joint arthroplasty (TJA) remains unclear. Therefore we performed a meta-analysis aiming to answer the following question: (1) are there differences in postoperative complications including joint infection and mortality between patients with or without hepatitis C following TJAs? (2) Are patients without HCV be associated with less blood loss, shorter hospital stay, lower readmission rate, higher function scores, lower revision and reoperation rates than patients with HCV?

METHODS

A meta-analysis was conducted to pool data and quantitatively assessing the association between HCV infection and risks for adverse postoperative outcomes. A systematic search of all published studies concerning HCV and TJA was performed in five bibliographic databases, including PubMed, EMBASE, China National Knowledge Infrastructure, Web of Science, and the Cochrane Library databases. Random-effects meta-analysis of odds ratios (OR) was accomplished according to the classification of adverse events, subgroup analyses were performed based on surgery type.

RESULTS

Fifteen eligible observational studies were included with a sample size of 9,788,166 patients. Overall pooled data revealed the increased risk of overall complications, including medical and surgical complications, in HCV-positive patients undergoing TJA compared with than in HCV-negative people (OR 1.57; 95%CI: 1.44-1.71 [p<0.00001]). Joint infections were highly common in HCV-positive patients undergoing lower-extremity TJA (OR 2.06; 95%CI: 1.73-2.47 [p<0.00001]). Furthermore, HCV infections were associated with high rates of reoperations and revisions (OR 1.47; 95%CI: 1.40-1.55 [p<0.00001]).

CONCLUSIONS

Patients with hepatitis C have an increased risk of adverse outcomes post-TJA and a high risk of reoperation and revision that is partially attributed to postoperative complications, particularly joint infections.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Autoantibodies and Rheumatologic Manifestations in Hepatitis C Virus Infection

HCV is a virus that can cause chronic infection which can result in a systemic disease that may include many rheumatologic manifestations such as arthritis, myalgia, sicca syndrome, cryoglobulinemia vasculitis as well as other non-rheumatological disorders (renal failure, onco-haematological malignancies). In this population, the high frequency of rheumatoid factor (45-70%), antinuclear (10-40%) and anticardiolipin (15-20%) antibodies is a B-cell mediated finding sustained by the infection. However, the possibility that a primitive rheumatic pathology may coexist with the HCV infection is not to be excluded thus complicating a differential diagnosis between primitive and HCV-related disorders.

Immune disorders and rheumatologic manifestations of viral hepatitis

Infection with hepatotropic viruses is not limited to the liver and can lead to the development of various immunological disorders (the formation of cryoglobulins, rheumatoid factor, antinuclear antibodies, autoantibodies specific for autoimmune hepatitis and primary biliary cholangitis, and others), which can manifest as glomerulonephritis, arthritis, uveitis, vasculitis (cryoglobulinemic vasculitis, polyarteritis nodosa, Henoch-Schonlein purpura, isolated cutaneous necrotizing vasculitis), and other rheumatologic disorders, and be a trigger for the subsequent development of autoimmune hepatitis and primary biliary cholangitis. A further study of the association between autoimmune liver diseases and hepatotropic virus infection would be useful to assess the results of treatment of these associated diseases with antiviral drugs. The relationship of these immune disorders and their manifestations with hepatotropic viruses is best studied for chronic hepatitis B and C. Only isolated cases of these associations are described for hepatitis A. These links are least studied, and are often controversial for hepatitis E, possibly due to their relatively rare diagnoses. Patients with uveitis, glomerulonephritis, arthritis, vasculitis, autoimmune liver diseases should be tested for biomarkers of viral hepatitis, and if present, these patients should be treated with antiviral drugs.

Rheumatologic manifestations of hepatitis C in the era of direct-acting antiviral agents

Beyond the classic hepatic complications, hepatitis C (HCV) infection is considered as a systemic disease, since extrahepatic manifestations become clinically evident in 40% to 70% of the patients and it can frequently include rheumatic ones. Furthermore, HCV can promote the production of several autoantibodies, thus complicating the differential diagnosis between primitive and HCV-related rheumatic disorders. The recent development of direct-acting antivirals (DAA) against HCV has revolutionized the field, reducing the damage stemming from systemic inflammatory phenomena and persistent immune activation associated with continuous HCV replication. Our review focuses on the main rheumatologic manifestations associated with chronic HCV infection as well as the impact of DAA interferon-free treatments on such extrahepatic clinical involvement.

Impact of hepatitis C treatment on pain intensity, prescription opioid use and arthritis

OBJECTIVE

To assess the impact of direct acting anti-viral (DAA) therapy for hepatitis C virus (HCV) infection on changes in pain intensity and prescription opioid use among Veterans.

METHODS

We conducted a retrospective cohort study of Veterans with HCV who were seen in a rheumatology clinic at least once while receiving DAA therapy between January 1, 2010 and December 31st 2016. Demographic characteristics, HCV status, HCV treatment characteristics, numeric rating scale (NRS) pain scores and opioid prescription data were extracted from the electronic medical record. Pain scores were averaged over 6 months prior to HCV treatment and 6 months after completion of treatment. Prescription opioid dose was converted to a morphine equivalent daily dose (MEDD) and averaged across the two 6-month intervals. Generalized estimating equations were used to model the change in average pain and MEDD from pre- to post-HCV treatment. Effect size was assessed using Cohen's d.

RESULTS

A total of 121 Veterans, 91% male with average age of 59 were included. Average pre-treatment pain was 4.4 (SD 2.4). The average reduction in pain scores was 0.6 points (P = 0.02, Cohen's d = 0.22) after treatment. Among 67 patients prescribed chronic opioid therapy at baseline, average pre-treatment MEDD was 52.4 mg (SD = 62.5 mg) and post-DAA treatment average MEDD was 49.5 mg (SD = 69.3 mg), representing a decrease by 2.9 mg (P < 0.01, Cohen's d = 0.14). Opioid dose reduction was seen in 43/67 patients and 12 patients discontinued opioids entirely.

CONCLUSION

Among US Veterans, subjective pain scores had modest improvement and opioid prescriptions were mildly reduced following treatment with DAA.

Italian consensus recommendations for the management of hepatitis C infection in patients with rheumatoid arthritis

Objectives: The recent introduction of direct-acting antiviral agents (DAAs) which can eliminate Hepatitis C virus (HCV) had revolutionized the treatment of HCV infections also in a complex clinical setting such as the patients with rheumatoid arthritis (RA). HCV elimination is also opportune due to the availability of more efficient immunosuppressive drugs, whose effect on the course of HCV infection is largely unknown.Methods: Consensus process was endorsed by the Italian Society of Rheumatology (SIR) and the Italian Society of Infectious and Tropical Diseases (SIMIT) to review the available evidence and produce practical, hospital-wide recommendations. The consensus panel consisted of 18 infectious diseases consultants, 20 rheumatologists and one clinical epidemiologist, who used the criteria of the Oxford Centre for Evidence-based Medicine to assess the quality of the evidence and the strength of their recommendations.Results: A core-set of statements about management of patients with RA and infection by HCV have been developed to help clinicians in their clinical practice.Conclusions: A screening for HCV should be performed in all RA patients and it is mandatory before starting an immunosuppressive therapy. Finally, a DAA treatment should be considered in all HCV-infected patients.Significance and InnovationsHCV antibodies should be investigated at the time of diagnosis of RA and, in any case, before starting immunosuppressive therapy with disease-modifying antirheumatic drugs (DMARDs).HCV eradication with DAA should be attempted as soon as possible, depending on patient conditions allowing a continuous oral treatment lasting 8-12 weeksConventional and biological DMARDs are allowed in patients with HCV infection, but they should be used cautiously in presence of advanced liver disease.