From the Guidelines
Hydroxychloroquine is the safest disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA) patients with hepatitis, as it has minimal hepatotoxicity. For patients with viral hepatitis (B or C) who need RA treatment, hydroxychloroquine is generally the first choice due to its favorable hepatic safety profile 1. Other options with relatively lower hepatotoxicity include sulfasalazine and the biologic DMARDs such as TNF inhibitors (etanercept, adalimumab), though these require more careful monitoring.
- Methotrexate, leflunomide, and tofacitinib carry higher risks of liver injury and should be used cautiously, if at all, in patients with pre-existing liver disease.
- When treating RA in hepatitis patients, regular liver function monitoring is essential regardless of which DMARD is chosen.
- The safety profile of hydroxychloroquine stems from its metabolism, which occurs primarily through dealkylation in the liver without producing hepatotoxic metabolites, making it uniquely suitable for patients with compromised liver function. According to the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis, methotrexate is conditionally recommended over alternative DMARDs for DMARD-naive patients with nonalcoholic fatty liver disease, normal liver enzymes and liver function tests, and no evidence of advanced liver fibrosis who have moderate-to-high disease activity 1. However, for patients with hepatitis, hydroxychloroquine remains the safest option due to its minimal hepatotoxicity.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
DMARDs for RA Safe in Hepatitis
- There are no direct studies comparing the hepatotoxicity of different DMARDs in patients with rheumatoid arthritis (RA) and hepatitis.
- However, some studies suggest that hydroxychloroquine (HCQ) may be a safer option for patients with RA and hepatitis due to its relatively low hepatotoxicity profile 2, 3.
Least Hepatotoxic DMARD
- Hydroxychloroquine (HCQ) is considered to be one of the least hepatotoxic DMARDs, with a low risk of liver damage 2, 3.
- Methotrexate (MTX) and sulfasalazine (SSZ) are also commonly used DMARDs, but their hepatotoxicity profiles are not as well-established as HCQ 4, 5.
- Combination therapy with MTX and HCQ may be effective for patients with RA, but its hepatotoxicity profile is not well-established 4, 6.
Efficacy and Safety of DMARDs
- HCQ has been shown to be effective in reducing disease activity and improving quality of life in patients with RA, with a relatively low risk of adverse effects 2, 6, 3.
- MTX and SSZ are also effective DMARDs, but their safety profiles may be less favorable than HCQ, particularly in patients with hepatitis 4, 5.
- The choice of DMARD should be individualized based on the patient's specific needs and medical history, including the presence of hepatitis 4, 5, 2, 6, 3.