Treatment of rheumatic diseases in patients with HCV and HIV infection
Introduction
A wide variety of rheumatic diseases has been documented in the presence of hepatitis C virus (HCV) infection and in human immunodeficiency virus (HIV) infection, that includes inflammatory arthritis, reactive arthritis, myositis, vasculitis, psoriasis vulgaris as well as pustular psoriasis [1]. Dealing with this cohort of patients raises a challenge for physicians. In fact, the treatment of autoimmune disorders need immunosuppressant agents and/or corticosteroids, but physicians refrain from using them in patients also affected by concomitant viral infection, because excessive immunosuppression favours viral replication and facilitates the progression of the underlying viral disease. So, it is necessary a safe and efficacious therapy able both to control the evolution of the autoimmune disorder and not influence the viral infection outcome.
In the present review we will focus our attention on the possible role of cyclosporine A (CsA), anti-Tumour Necrosis Factor (TNF) alpha agents and even the combination of both for the treatment of this particular group of patients.
Section snippets
CsA and HCV
CsA is an immunosuppressant agent widely used to treat autoimmune disorders and organ transplanted patients. Evidences in literature demonstrated that CsA also exerts an inhibitory effect on HCV replication both in vivo and in vitro, through inhibition of cyclophilin B and not by the inhibition on calcineurin, which is responsible of the immunosuppressive effect [2].
Although this therapy may be suitable, however literature data on this topic are very few [3], [4], [5]. To confirm CsA safety and
CsA and HIV
Theoretically, drugs that inhibit programmed cell death could be used to inhibit the increased apoptotic decay of lymphocyte populations in HIV infection. The concept that immunopathologic processes cause immunosuppression provides a further rationale for the use of agents such as CsA early in HIV infection to reduce cytotoxic CD8+ T cell-mediated destruction of HIV infected target cells [8].
In addition, many cyclophilin A inhibitors, such as CsA, can inhibit HIV-1 replication in vitro.
Biological therapies and infections
As to the possible role of some biological agents for the treatment of patients affected by autoimmune diseases and concomitant chronic viral infection, our attention will be focused on anti-TNF-alpha agents.
Conclusions
CsA seems safe in HCV and HIV infected patients and may contribute to reduce the viral load.
In addition, anti-TNF alpha agents are safe and probably useful in the treatment of autoimmune disorders in chronically infected HCV and HIV patients.
The combination therapy with TNF alpha blockers and CsA in HCV and HIV infected patients may be a good alternative option for the treatment of autoimmune disorders when anti-TNF alpha agents are indicated.
Take home messages
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CsA exerts an inhibitory effect on HCV and HIV replication
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it is not rare to encounter in clinical practice patients with autoimmune disorders also affected by HCV and/or HIV infection.
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CsA can be safely used in this cohort of patients
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anti-TNF alpha agents can be used in patients with autoimmune disorders and concomitant HCV/HIV chronic infections with very limited risks of worsening the viral outcome
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Combination therapy with TNF alpha blockers and CsA may be a good alternative option for the
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