HCV New Drugs

Joint Pain a Major Issue in Chronic HCV Infection
by Diana Swift
Contributing Writer

MEDPAGE TODAY

Smoking increases risk of arthralgias in hepatitis C.

Patient-reported joint pain is prevalent in those with chronic monoinfection with hepatitis C virus (HCV) or monoinfection with immunodeficiency virus (HIV), as well as in patients with HIV/HCV coinfection, according to a study published online in BMC Musculoskeletal Disorders on April 19, 2015. But chronic HCV patients report more arthralgia.

The study, led by Alexis R. Ogdie, MD, a rheumatologist at the University of Pennsylvania in Philadelphia, found that chronically HCV-monoinfected patients more frequently reported arthralgias compared with HIV/HCV-coinfected or HIV-monoinfected persons.

Joint pain was more commonly reported in HCV-monoinfected than HIV/HCV-coinfected (71% versus 56%; P=0.038) and HIV-monoinfected patients (71% versus 50%; P=0.035).

"These results suggest that joint pain remains a major health concern and a determinant of health-related quality of life among these patients," wrote Ogdie and her associates, adding that healthcare providers should address modifiable risk factors for joint pain such as smoking.

HCV is the most common blood-borne infection in the U.S., infecting 4 million persons and having a range of extrahepatic manifestations, including renal, dermatological, neurological, and rheumatological. "While chronic HCV-induced inflammation is generally thought to be a key contributor to these manifestations, the mechanisms by which they occur remain unclear," the researchers wrote.

The cross-sectional study enrolled 202 patients (173 males) and conducted standardized interviews in 79 HIV/HCV-coinfected, 93 HCV-monoinfected, and 30 HIV-monoinfected patients in hepatology and infectious-disease clinics at three U.S. centers. Age and gender distributions were similar across all three groups, while, racially, more than half of participants were black. The Multi-Dimensional Health Assessment Questionnaire (MD-HAQ) evaluated joint pain and associated symptoms, and interviewers collected information on potential risk factors.

Logistic regression determined adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of joint pain associated with risk factors among chronic HCV-infected and HIV-infected patients. Joint pain was reported by more HCV-monoinfected than HIV/HCV-coinfected patients: 71% versus 56% (P=0.038) and by more HIV-monoinfected patients: 71% versus 50% (P=0.035).

In all groups, the fingers, knees, and back were the most frequently cited areas of joint pain. The distribution of painful joints was similar among the groups, although HCV-monoinfected patients more commonly reported finger pain compared with coinfected patients (41% versus 27%, P=0.035) and HIV-monoinfected patients (41% versus 23%, P=0.067).

A previous diagnosis of arthritis and current smoking were risk factors for arthralgias in both infections. In chronic HCV-infected patients, arthritis had an aOR of 4.25 (95% CI 1.84-9.81), and smoking an aOR of 5.02 (95% CI 2.15-11.74). In HIV-infected patients the aOR for arthritis was 5.36 (95% CI 2.01-14.25) and for current smoking 6.07 (95% CI 2.30-16.00).

Smoking has been associated with musculoskeletal pain and the development of, and worse disease activity in rheumatoid arthritis. This is the first study to report on its link to joint pain in chronic HCV. The authors cited the need for further research to determine whether smoking cessation improves arthralgia in chronic HCV patients.

While the etiology of joint pain in chronic HCV remains unclear, the authors noted that immune activation, direct deposition of viral particles in the synovium, and the high prevalence of concomitant mood disorders might be important contributors to the arthralgias commonly reported by chronic HCV-infected patients. More than half of patients reporting joint pain also self-reported depression and anxiety on the MD-HAQ.

The differences in joint pain prevalence among the three groups raise important questions for further study, the authors wrote. "Hypothesized explanations for these findings include differences in unmeasured environmental exposures among the groups or potentially a decrease in local inflammation related to immune dysfunction in HIV infection, resulting in a decreased effect of chronic HCV in the HIV/HCV-coinfected patients." Additionally, HIV-infected patients may be more tolerant of joint discomfort because of the higher priority placed on more serious complications of their disease. With HCV patients reporting a high prevalence of depression, anxiety, and sleep disturbance, depression and anxiety could have contributed to a higher prevalence of joint pain since mood and arthralgia are strongly linked.

Addressing study limitations, the authors noted the cross-sectional design, use of convenience sampling, the inability to perform physical examinations and imaging studies to rule out osteoarthritis, the relatively small sample, and the biasing possibility that patients with joint pain may have been more likely to complete the survey. Additionally, the study was unable to determine the specific etiologies for joint pain. Furthermore, some patients were prescribed analgesic medications and have self-reported joint pain less frequently. Also, because the study evaluated joint pain present within the week before the interview date, some patients with intermittent joint pain may not have been identified in this study.

"Future studies should determine the etiologies and strategies for management of joint pain, including fibromyalgia, in patients with chronic HCV and HIV infection, as well as the mechanisms for modulation of joint symptoms in HIV/HCV-coinfected patients," the authors concluded.

This study was funded by the American College of Rheumatology Research Foundation. The lead author was supported by the American College of Rheumatology Research and the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and another author by the National Institute of Allergy and Infectious Diseases.

The authors declared no competing interests.
Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Last updated 05.03.2015
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