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HCV and Rheumatic Disease

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The hepatitis C virus—often referred to as HCV—is the leading cause of liver failure and the top reason for needing a liver transplant. Besides hepatitis (liver inflammation), this virus can also cause arthritis (joint inflammation), muscle pain and weakness, and vascular (blood vessel) problems. Arthritis and other inflammatory problems are somewhat common in people with the virus ("HCV positive"). In fact, these problems can appear before you even know you have HCV.

Fast facts

  • It is common for HCV-positive patients to have related rheumatic diseases—problems affecting the muscles, joints and connective tissue.
  • The HCV infection often has no symptoms (what you feel).
  • In the past, HCV spread mainly through tainted blood transfusions. Since 1990, all donated blood has had strict screening. The risk of HCV from a blood transfusion is rare.
  • Most people today acquire HCV through using injectable drugs or through high-risk sex behaviors.
  • Anyone with newly diagnosed arthritis or cryoglobulinemia (a condition marked by abnormal proteins in the blood) should have testing for HCV infection.
  • Some medicines used to treat hepatitis C, such as interferon, can bring on or worsen a related rheumatic disease.

What are HCV-associated rheumatic diseases?

Rheumatic diseases are problems, including pain, in the joints, muscles and connective tissue (the tissue that supports and binds many other parts of the body). HCV-related rheumatic diseases result from infection with HCV. Painful joints and muscles combined with fatigue are usually the first and most common complaints. Less often, joint swelling and inflammation of blood vessels (vasculitis) can occur.

hcv-hands

White fingertips on cold hands are a sign of Raynaud's phenomenon.

What causes HCV-associated rheumatic diseases?

The joint and muscle complications of HCV infection result when the body's immune system fights against the virus. In someone with HCV, the virus constantly multiplies in the blood and liver, and constantly stimulates the immune system. In this setting, a wide variety of rheumatic problems may occur over time. They range from arthritis and "cryoglobulinemia" to kidney failure.

Cryoglobulinemia occurs when certain abnormal proteins in the blood (cryoglobulins) solidify in the cold. It may cause blood vessel problems, mostly during cold weather. This can result in "Raynaud's phenomenon," which causes fingers to whiten in the cold.

Who gets HCV-associated rheumatic diseases?

HCV-related rheumatic disorders can affect HCV-positive people of both sexes and all ages and races.

Risk factors for HCV. The main way HCV spreads today is through intravenous drug abuse using contaminated needles or other tainted drug equipment. HCV can even spread through another type of drug abuse—when persons share instruments to "'snort" cocaine.

Unlike human immunodeficiency virus—also known as HIV or the AIDS virus—unprotected sex with infected partners is a less common cause of getting HCV. Yet, there are reports of HCV spreading in those engaging in high-risk sex behaviors (many sex partners, men who have sex with men). Thus, patients who test positive for HCV should also get a test for HIV. Likewise, those with HIV should have HCV testing.

It is also possible for the baby of an HCV-infected mother to get HCV during birth. This is rare, though.

How are HCV-related diseases diagnosed?

The first hurdle in diagnosing HCV-related disease is the HCV diagnosis itself. Symptoms of HCV infection are often absent, so a doctor must know about the connection between hepatitis C and rheumatic disease in order to know which tests to run.

The HCV diagnosis is made by finding antibodies (immune proteins) against the virus in the blood serum. Then, a second blood test to find the virus in the blood confirms the diagnosis. This blood test lets doctors determine the virus replication, which is how fast the virus is making copies, a sign of how active the virus is. This is useful to know for follow-up visits, when the patient may repeat the test.

Once the HCV diagnosis is confirmed, diagnosing HCV-related disease is fairly straightforward

How are HCV-related diseases treated?

All patients with HCV infection need to see a liver specialist (a hepatologist or a gastroenterologist). This doctor will assess how severe the liver damage is and whether to screen for liver cancer. The doctor also will decide whether the patient can start HCV therapy. Some patients who have other infections, mental health issues, or drug or alcohol problems may not be ready to start treatment right away.

Combination treatment. Most often, HCV treatment combines interferon with antiviral medicines such as ribavirin. Antiviral treatment can improve control of liver damage caused by the virus. Unfortunately, it also can cause or worsen HCV symptoms, including joint and muscle complaints.

Recently, newer drugs known as "protease inhibitors" were approved for use along with the standard HCV medicines. These add-on medicines— boceprevir and telaprevir—directly target the virus and in some cases can shorten the length of treatment. The cure rates with these drugs are higher than without.

With proper use of HCV medicines, up to 75% of patients completing treatment can be cured of HCV. The downside is that the treatment is long and has many side effects. Yet, successful treatment of HCV often results in excellent control, or even cure, of rheumatic problems.

Treatment of joint problems. Better control of HCV joint problems also is possible through drugs used to treat other forms of arthritis. However, some of these drugs can have their own toxic effects on the liver or can worsen the viral infection. Therefore, rheumatologists and liver doctors should work together to treat these patients.

Anti-tumor necrosis factor (commonly called "anti-TNF") drugs have improved the treatment of rheumatoid arthritis. Their use in HCV-positive patients with this type of arthritis appears to be safe. There seems to be no harm to the liver or increase in viral replication. Another rheumatoid arthritis drug, rituximab (MabThera, Rituxan), also is being tested in patients with HCV.

Prevention

Better screening of blood transfusions has greatly reduced the spread of HCV in this way. It is now an extremely rare cause of new infections. Thus, there should be little worry of contracting HCV from a blood transfusion. The Center for Disease Control and Prevention now recommends that all Americans born between 1945 and 1965 be tested for HCV.

If you have risk factors for HCV (see "Who gets HIV-related rheumatic diseases?"), reducing them can help prevent the spread of the virus.

Given the advances in therapy, there is a need for more widespread screening for HCV. If you are at risk for HCV, ask your doctor about testing.

hcv-docs

The best approach to care is when health care providers from different medical specialties work as a team.

Living with HCV-associated diseases

HCV-related joint and muscle problems can cause discomfort and make it harder to do daily activities. Thus, it is important to see a rheumatologist, who is an expert in detecting and treating problems of the joints and muscles. Because treatment is complex, make sure there is contact between your doctor in charge of treating liver disease and your doctors who treat the non-liver symptoms of HCV.

Also, make sure you get long-term follow-up care. This is vital, since the liver disease can become worse, leading to liver failure or liver cancer.

Support groups also provide helpful support and coping suggestions. You can find other tips in the fact sheet, "Living Well With a Rheumatic Disease."

Points to remember

  • Almost any muscle and joint problem can result from HCV infection, even in those who do not have hepatitis.
  • HCV-related rheumatic disease may occur before HCV infection is found. Most patients with HCV are unaware they have it.
  • Treatments of these rheumatic problems do exist. New drugs have improved treatment.
  • The best approach to care is "multidisciplinary," in which health care providers from different medical specialties work as a team to take care of the patient.

To find a rheumatologist

For a list of rheumatologists in your area, click here.

Learn more about rheumatologists and rheumatology health professionals.

For more information

The American College of Rheumatology has compiled this list to give you a starting point for your own additional research. The ACR does not endorse or maintain these web sites, and is not responsible for any information or claims provided on them. It is always best to talk with your rheumatologist for more information and before making any decisions about your care.

National Institutes of Health MedlinePlus
www.nlm.nih.gov/medlineplus/hepatitisc.html

Updated February 2013

Written by Leonard H. Calabrese, DO, and reviewed by the American College of Rheumatology Communications and Marketing Committee.

This patient fact sheet is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2013 American College of Rheumatology