Answered by:
Stuart D. Federman, PharmD, AAHIVP
Gateway Apothecary
Saint Louis, MO

HIV itself causes an inflammatory (swelling) reaction in the body that causes it to be in a state of constant inflammation. Therapy for rheumatoid arthritis can be immunosuppressive, and patients who have low CD4 counts would need to be followed more closely than patients with normal CD4 counts and undetectable HIV RNA levels.

Methotrexate or leflunomide are commonly prescribed medications for rheumatoid arthritis, but they both also can cause liver toxicity. Antiretroviral therapy for HIV can also cause liver toxicity, so providers will need to monitor your liver function to ensure that it’s safe to be on both medications.

Corticosteroids such as prednisone are often used at low doses for patients with rheumatoid arthritis. These medications can cause bone loss when used over the long term. Tenofovir — an HIV medication contained in Viread, Truvada, Atripla, Complera and Stribild — can also lead to bone loss, so your doctor will monitor this closely to prevent bone loss with these medications. When patients are treated for their HIV and have their viral load suppressed, the symptoms of rheumatoid arthritis usually lessen.

There is minimal data with using products like Enbrel or Humira in patients with HIV because these medications can suppress the immune system and lead to infections. Patients who need this medication should be tested for tuberculosis and be virologically suppressed from HIV. Patients should consult with their physician and rheumatologist to make this decision on risk vs. reward of using these medications.

Non-pharmacological treatments are recommended for all patients with rheumatoid arthritis. Rheumatoid arthritis can cause a great deal of pain and stiffness in the joints. While inflamed joints need to be rested, inactivity can lead to a loss of muscle strength and decreased joint stability, which further leads to increased fatigue.

Physical activity has been shown to increase sleep quality, restore joint motion, increase strength and improve weakness. Exercise regimens for patients with rheumatoid arthritis should be designed by a physical therapist and tailored to the patients’ own ability.

Studies have shown that smoking is a risk factor for rheumatoid arthritis and that quitting smoking can improve symptoms of rheumatoid arthritis. Weight loss can also be beneficial in overweight or obese patients who have rheumatoid arthritis by decreasing the pressure placed on the joints, and improve pain and quality of life.

Additional writing by Mason Stewart, student pharmacist at the St. Louis College of Pharmacy.