Shingles risk in rheumatoid arthritis independent of biologics
By Lynda Williams, Senior medwireNews Reporter
11 March 2013
JAMA 2013; 309: 887–895

medwireNews: Choosing between biologic and nonbiologic treatment pathways does not alter the risk for shingles in patients with rheumatoid arthritis (RA) and other autoimmune conditions, suggest results from a large cohort study published in JAMA.

The findings showed no significant difference in the risk for herpes zoster in 33,324 patients initiating anti-tumor necrosis factor (anti-TNF) therapy and 25,742 patients beginning treatment with nonbiologic disease-modifying antirheumatic drugs (DMARDs) between 1998 and 2007.

Adjusted rates of herpes zoster were highest among the 36,212 patients with RA, at a comparable 12.1 and 12.7 cases per 1000 patient-years for treatment with anti-TNF agents and DMARDs, respectively.

The corresponding rates were 11.3 and 9.4 for the 10,717 patients with inflammatory bowel disease and 4.4 and 6.9 for the 12,137 patients with psoriatic arthritis, psoriasis, or ankylosing spondylitis, respectively, again with no significant differences detected.

However, patients of any diagnosis with a baseline corticosteroid dose of 10 mg/day or higher had a significantly greater risk for herpes zoster than those not using steroids, with a hazard ratio (HR) of 2.13.

Further analysis of the RA patient cohort confirmed that patients given anti-TNF agents had no increased risk for herpes zoster than DMARD-treated patients, and this remained true when comparing patients using infliximab with those given etanercept or adalimumab. Across all treatment indications, the HR for herpes zoster with anti-TNF therapy was a nonsignificant 1.09 compared with DMARD therapy.

While vaccination is currently contraindicated during anti-TNF therapy due to safety concerns about use of a live vaccine, the team notes that hospitalization for herpes zoster in their study was no more likely in anti-TNF agent users than DMARD-treated patients (6.0 vs 5.5%). In addition, studies of small groups of anti-TNF agent users have suggested that vaccination can be given without spread of varicella or zoster.

"The high herpes zoster rates observed within our study support the widespread vaccination of all patients with RA in this age group," comment Kevin Winthrop (Oregon Health and Science University, Portland, USA) and co-authors.

They continue: "Given these findings, the potential importance of this vaccine within the RA setting and the difficulty in vaccinating patients given the widespread use of anti-TNF therapy, we believe that a trial to evaluate the safety of this live virus vaccine among current anti-TNF users is warranted".

Free full text abstract

Friendly links


Follow me on Twitter