Liver Management in Rheumatoid Arthritis - RNL2021 Highlight Save

While rheumatoid arthritis (RA) is not known to affect the liver directly, underlying liver disease and treatment-related effects on the liver can often become an obstacle in the management of many RA patients. In his Sunday presentation at RNL2021, Dr. Stanley Cohen detailed many issues liver disease that arise in the course of RA management and ways to overcome them. 

Non-Alcoholic Fatty Liver Disease (NAFL), the most common cause of elevated liver enzymes, can raise concern when using DMARDs with known potential for hepatotoxicity. Infamous for being #3 diagnosis at liver transplant, it may scare away from effective RA therapies. It is useful to know that,  according to the 2020 ACR guidelines, methotrexate is conditionally approved in patient with NAFL given they maintain normal LFTs in the setting of no advanced fibrosis. Non-invasive testing prior to initiation and more frequent LFT monitoring are advised. On the other hand, leflunomide ( another great DMARDs with known potential for hepatotoxicity) comes with the black box warning to avoid in patient with preexisting liver disease or LFT elevation X2 above normal. 

This brings us to another liver related concern in RA – Therapy Induced transaminitis. While many RA therapies can cause such complications, amongst them TNF inhibitors, NSAIDs, JAK inhibitors, that same methotrexate and leflunomide, according to the evidence presented by Dr. Cohen, most of the time the effect is transient and tend to resolve with medication discontinuation. Elastography studies of patients with MTX induced transaminitis report no fibrosis in >80-90% of the cases. 

Now, more on one of the major concerns with biologic use in RA – Hepatitis B and C infection. With 257 million case of chronic hepatitis B worldwide, it is known to be an issues for patients on immunosuppressive therapy. The danger lays in the fact that reactivation can be observed in patient with both “resolved” and chronic hepatitis B infection and can range from asymptomatic to fulminant liver failure and death.

It is comforting to know that HBV reactivation is preventable with appropriate screening and management. It starts with skillful interpretation of hepatitis B serologic panel on each patient who is a candidate for immunosuppressive therapy. If you want to brush up on interpretation of HBV serologies, I strongly recommend reviewing Dr. Cohen's presentation: it is one of the most detailed guides with emphasis on multiple variations of HBV core IgG interpretation. Additional evidence links presence of HBsAb to reduced risk of HBV reactivation, while HBsAg positivity in patient on csDMARDs, anti-CD20 therapy or high dose steroids poses highest risk for increased HBV replication. 

All in all, anti-viral prophylaxis is strongly recommended for patient with high risk for HBV reactivation and should continue for 6-12 months after discontinuation of immunomodulatory therapy.  

So what about hepatitis C? While in the past etanercept was considered the safest option based on small studies results and it was recommended as a preferred Rx for HCV patients by the 2012 ACR guidelines, things have changed now. Nowadays HCV is a curable disease  and with short term direct anti-viral therapies being available it shall not stand In a way of effective RA treatment in patients with preserved liver function.

This lecture video and podcast will be featured on RheumNow in the weeks to come. Look for more exciting updates from this year’s RNL 2021.