Subacute Care Forum

Use of Prednisone for Rheumatoid Arthritis in an HIV-Positive Patient

Following an initial hospitalization for infection with human immunodeficiency virus and osteomyelitis, the patient whose case is presented in the box below was admitted to the subacute care unit for further administration of iv antibiotics and patient education for home therapy. During the stay, her drug therapy was reviewed, with particular attention to the wisdom of continuing prednisone for rheumatoid arthritis in an immunocompromised patient with HIV infection and osteomyelitis.

Clinical Course and Treatment of RA

ED has stage II arthritis. She is in pain a large portion of the day but still can perform activities of daily living. Her fingers display some slight ulnar deviation and enlarged PIP joints, with decreased extension and flexion but functional motion. She has significantly decreased range of motion in her left elbow.

RA is characterized by chronic inflammation of the synovial tissue lining the joint capsule. This results in proliferation of the synovial tissue (pannus). The proliferating tissue eventually invades the cartilage and bone surrounding it and destroys the joint. The inflammation of RA involves polymorphonuclear neutrophils, macrophages, and lymphocytes, which release prostaglandins, cytotoxins, free oxygen radicals, and hydroxyl radicals and thereby damage tissue. An autoimmune component also may be involved in the disease process.¹

RA is usually treated in a stepwise fashion, beginning with nondrug therapy such as rest and range of motion exercises. High-dose aspirin or nonsteroidal anti-inflammatory agents are the first drug therapies used to treat RA. If adequate control of pain and inflammation cannot be achieved with NSAIDs alone, a slow-acting antirheumatic drug is added. SAARDs include gold salts, hydroxychloroquine, and methotrexate. If SAARDs do not achieve the desired effect, other agents such as sulfasalazine, penicillamine, azathioprine, or cyclophosphamide are used.¹

Corticosteroids-prednisone and prednisolone-are used in RA therapy for acute flare-ups, to bridge therapy while waiting for an SAARD or alternate agent to take effect, or in refractory cases. ED, who has been on low-dose prednisone since 1993, did not respond to other treatments.

Prednisone relieves the symptoms of RA through its anti-inflammatory and immunosuppressive properties.¹ Prednisone's immunosuppressive properties raise the question of its place in therapy for individuals who are HIV positive. Will immunosuppression make these individuals' disease progress faster or make them more susceptible to opportunistic infections?

Use of Prednisone in HIV-Positive Patients

No studies evaluate the use of prednisone to treat pre-existing RA in an HIV-positive patient, and few studies evaluate the use of prednisone to treat AIDS-related complications. In a 1991 study, prednisone produced clinical improvement without significantly changing total lymphocyte counts. In this study, six hemophiliac, HIV-positive boys aged 10 to 18 years were given prednisone 1 mg/kg/day for two weeks (maximum 40 mg), 1 mg/kg/every other day for six weeks, and 0.5 mg/kg/day for four weeks. IgG concentrations were reduced in all patients during the trial, but these concentrations returned to normal after therapy was discontinued.² A 1990 study reported that a patient had no further opportunistic infections after one year on continued prednisone therapy for HIV wasting syndrome.³

Low-Dose Prednisone Reasonable

While the available data are sparse, we recommended that ED be restarted on low-dose prednisone to control her RA symptoms once her osteomyelitis was resolved and antibiotic therapy completed.

Leslie Philips, Doctor of Pharmacy Candidate
College of Pharmacy
University of Arizona
Tucson, AZ 85721

References

1. Schuna AA, Coulter L, Lee SS. Rheumatoid arthritis and the seronegative spondlyloarthropathies. In: DiPiro JT, Talbert RL, Hayes PE, Yee GC, Matzke GR, Posey LM, eds. Pharmacotherapy: a pathophysiologic approach. 2nd ed. Norwalk, CT: Appleton & Longe, 1993: 1313-26.

2. Saulsbury FT et al. Effects of prednisone on human immunodeficiency virus infection. South Med J 1991; 84:431-5.

3. Simpson DM et al. Human immunodeficiency virus wasting syndrome may represent a treatable myopathy. Neurology 1990; 40: 535-8.

Case Presentation: Prednisone for RA in HIV-Positive Patient

CC: Osteomyelitis secondary to a septic joint.

HPI: ED is a 37-year-old white woman newly diagnosed with HIV infection and osteomyelitis. She has a history of rheumatoid arthritis diagnosed when she was 19 and intermittent history of drug abuse since that time. The patient states that she has had numerous medications for her RA, but the only agent that has really helped her is prednisone 5 mg daily. Her current problems include RA, osteomyelitis secondary to a septic joint, cellulitis on the right foot and hip secondary to rheumatoid vascular disease, HIV infection, and intravenous drug abuse.

PMH: She has a family history of RA through her grandmother. ED smokes two packs of cigarettes per day.

PR: Current medications include codeine 30 mg q 4-6 h prn pain, vitamin C 1000 mg b.i.d., vitamin B12 100 µg q.d. for anemia, folate 1 mg q.d. for anemia, multivitamin 1 q.d., cefazolin 1 g. i.v. q 8 h x 38 d for osteomyelitis/cellulitis, naproxen 500 mg b.i.d. for inflammation, Colace 100 mg q.d., and MOM q. h.s. p.r.n. constipation.

SH: Intravenous drug abuse.

ROS: Not available.

PE: Not available.

Labs: Her pertinent labs from hospitalization are as follows: hemoglobin 9.9g/dL, hematocrit 29.8%, white blood cell count 4,200/mL3, mean cell volume 101 fL, mean cell hematocrit 33.6% [AUTHOR: PLS. CHECK MEANING OF ABBREVIATION AND UNITS], total iron-binding capacity 177 mg/dL, ferritin 78 ng/mL, folate 2.6 ng/mL, B12 326 pg/mL, % lymphocytes 43, no. lymphocytes 1806, % CD4 cells 36, no. CD4 cells 650/mL3, % CD8 cells 40, no. CD8 cells 722/mL3, CD4/CD8 ratio 0.9.

Other: None.

Abbreviations used: CC = chief complaint, HPI = history of present illness, PMH = past medical history, PR = pharmacist review, SH = social history, ROS = review of systems, PE = physical examination, Labs = laboratory values.