Author Insights: No Apparent Increase in Shingles Risk for Patients With Rheumatoid Arthritis Who Take Certain Immunosuppressants

Kevin L. Winthrop, MD, MPH, of Oregon Health & Science University in Portland, and colleagues found that patients with rheumatoid arthritis who began taking a certain class of powerful immunosuppressant medications did not appear to have an increased risk of developing shingles. (Image: George Petricek, Casey Eye Institute, Oregon Health & Science University)

Kevin L. Winthrop, MD, MPH, of Oregon Health & Science University in Portland, and colleagues found that patients with rheumatoid arthritis who began taking a certain class of powerful immunosuppressant medications did not appear to have an increased risk of developing shingles. (Image: George Petricek, Casey Eye Institute, Oregon Health & Science University)

Concern that a front-line class of immunosuppressant drugs used to treat rheumatoid arthritis might increase a patient’s risk of developing herpes zoster (shingles) appears to be unfounded, according to research appearing today in JAMA.

Shingles, caused by a reactivation of the herpes zoster virus in individuals who previously had chickenpox (caused by the same virus), is characterized by a painful rash and can also cause depression and long-term disability. The condition tends to develop in elderly individuals or those who are immunosuppressed. Patients with rheumatoid arthritis, a disease that involves dysregulation of the immune system, are up to 3 times more likely to develop shingles than people without the disease.

Although anti–tumor necrosis factor (anti-TNF) therapy is considered the treatment of first choice for patients first diagnosed with moderate to severe rheumatoid arthritis, the medications’ powerful immunosuppressant effects prompted concerns about whether their use would increase the risk for shingles in such patients.

But the JAMA researchers found no increased shingles risk for patients with rheumatoid arthritis and other inflammatory diseases (inflammatory bowel disease, psoriasis, psoriatic arthritis, or ankylosing spondylitis) who started using an anti-TNF drug compared with those who began taking nonbiologic disease-modifying antirheumatic drugs. The findings are based on retrospective analysis of 59 066 new users of these medications between 1998 and 2007.

Lead author Kevin L. Winthrop, MD, MPH, of Oregon Health & Science University in Portland, discusses his team’s findings:

news@JAMA: Why did you do this study of anti-TNF therapy?

Dr Winthrop: This class of drugs is widely used in rheumatoid arthritis and for other autoimmune diseases and is known to increase the risk of certain opportunistic infections like tuberculosis, and herpes zoster is a pretty common infection, especially in those with rheumatoid arthritis and other autoimmune diseases. Several studies previously, using different methodologies, came up with conflicting results, with some saying the therapy did increase risk and others saying it didn’t. So we tried to take a formal look at this, using a large cohort that allowed us to do a large study.

news@JAMA: What did you find?

Dr Winthrop: We found that patients starting a new anti-TNF drug didn’t have a higher risk of shingles than those starting other disease-modifying medications. It’s reassuring that it didn’t increase risk. We also found that patients who had herpes zoster before were also able to start these therapies without increasing risk. These findings should be comforting to both patients and physicians.

news@JAMA: You also looked at a synthetic corticosteroid immunosuppressant, prednisone, and its effect on shingles risk in these patients. What were the results?

Dr Winthrop: Prednisone doubled the risk of herpes zoster, and this finding is another nail in the coffin for using that drug. If you can get people off prednisone, you can do them quite a bit of good for risk reduction of infections.

news@JAMA: A live vaccine to prevent herpes zoster is approved in the United States for individuals aged 50 years or older. Should this vaccine be given to patients with rheumatoid arthritis?

Dr Winthrop: While most patients with rheumatoid arthritis are eligible for the vaccine due to their age, those taking an anti-TNF drug don’t get it because the vaccine is contraindicated due to a concern that if you get the vaccine, you’d get the disease. But we’ve published an earlier study showing that certain people who got the vaccine while on the drug didn’t have any adverse events.



Categories: Immunologic Disorders, Pain, Rheumatoid Arthritis, Uncategorized