What is conventional treatment for arthritis and autoimmune disease in HIV infected patients? Can treatment with anti-tumor necrosis factor (TNF) α therapy be considered?
NSAIDs are generally effective along with physical therapy modalities for mild arthritis. Indomethacin has even been shown to inhibit HIV replication in vitro . Intraarticular and soft tissue corticosteroid injections are especially therapeutic for localized involvement. Low-dose oral corticosteroids (<10 mg/day), sulfasalazine, and methotrexate may be effective agents for moderate/severe arthritis and/or enthesopathy. Hydroxychloroquine may be effective for arthritis as well but should be used cautiously in case of underlying psoriatic arthritis (potential risk for psoriasis flare). The use of other immunosuppressive medications, such as leflunamide, azathioprine, mycophenolate mofetil, cyclosporine, TNFα antagonists, and rituximab, in patients with HIV has been described in the literature. Many experts suggest that these medications may be safely considered in patients who are consistently taking ART, have successful suppression of viral activity, and have CD4+ T-cell counts of >200/μL. Routine screening for comorbid tuberculosis and hepatitis is recommended. Prior to starting any new immunosuppressive medication, it is important to assess for potential drug interactions given the complex pharmacology of ART therapy. Patients must be monitored closely on immunosuppressive therapy since these agents may precipitate fulminant AIDS, Kaposi’s sarcoma, or opportunistic infections.
