Moderate-To-Severe RA Patients and Herpes Zoster | Arthritis Information

 

Moderate-To-Severe RA Patients at Higher Risk for Herpes Zoster

NEW YORK (Reuters Health) May 25 - Patients being treated for moderate-to-severe rheumatoid arthritis (RA) are more likely to develop herpes zoster than are patients treated for mild RA.

This finding stems from a study of more than 20,000 RA patients in the Veterans Affairs healthcare system, reported in the May 15th issue of Clinical Infectious Diseases.

Using the VA's national administrative databases, Dr. Jay R. McDonald from St. Louis Veterans Affairs Medical Center, St. Louis, Missouri, and colleagues found an overall incidence in the RA cohort of 9.96 herpes zoster episodes per 1000 patient-years.

The incidence of zoster was significantly higher among patients who received "Group 2" (e.g., methotrexate, leflunomide, azathioprine, cyclophosphamide, cyclosporine, or anakinra) or "Group 3" (etanercept, infliximab, or adalimumab) medications for treatment of moderate or severe disease, respectively, than among patients treated for mild disease (e.g., with hydroxychloroquine, sulfasalazine, auranofin, injectable gold, or penicillamine).

Among the TNF antagonists, infliximab was associated with a higher risk of herpes zoster than were etanercept and adalimumab.

Other independent risk factors for herpes zoster were older age, prednisone use, malignancy, chronic lung disease, renal failure, and liver disease, the researchers note.

"We are currently looking at risk factors for zoster recurrence and the impact of different doses of oral steroids on zoster risk," Dr. McDonald said.

"There are a lot of patients who take immunosuppressive medications for rheumatic diseases, obstructive lung disease, and autoimmune conditions who are at risk for zoster, but to whom the current varicella zoster virus vaccine recommendations do not apply," Dr. McDonald explained. "Because the vaccine is a live attenuated virus, it may not be safe to vaccinate them while they are receiving immunosuppression, but they may benefit from the vaccine if it is administered prior to planned immunosuppression."

"It is not known how far in advance of immunosuppression the vaccine would have to be given in order to minimize risk, but this should be investigated in prospective clinical studies," Dr. McDonald added. "I wouldn't advocate a particular vaccination strategy until such studies have been carried out."

In a related editorial, Dr. Jeffrey I. Cohen from the National Institutes of Health in Bethesda, Marylan, writes, "A clinical trial should be considered for vaccinating patients with rheumatoid arthritis who are less than 60 years old and who will soon be receiving TNF-alpha inhibitors or high doses of prednisone, azathioprine, or methotrexate, to determine if the vaccine reduces the incidence of zoster in these patients."

Clin Infect Dis 2009;48:1364-1371,1372-1374.

  Such a painful thing to go through.   I wish we could get the vaccine!  I look forward to hearing more research on this... I've had problems with these since I was a young kid, not just since being on immune suppresants. The sun always makes them worse and I've had some so painful I couldn't even stand near a draft or drink unless I had a straw. Forget about food. Horrible! Luckily I haven't had any trouble in about a year. (knocking on wood) [QUOTE=waddie]  I wish we could get the vaccine!  [/QUOTE]

Absolutely. Shingles, and the aftermath, post-herpatic neuralgia, can be horrendous.

I have has herpes simplex, sometimes know as 'sold sores' around my mouth and know how painful they can be it is only too easy to imagine the pain associated with those itching, burning blisters must cause as they incubate and then blossom along a nerve path.

My PCP has prescribed anti-viral medication for herpes simplex and given me explicit instructions on how to take the medication if I suspect herpes zoster.

Thanks, Lynn, for bring this forward for our edification.




Man oh man, I do not want shingles again! 2 times are enough and in the same nerve path. It's painful and takes so long to recover. I have post-herpatic neuralgia there now. I too wish we could take the vaccine.I think we can get the vaccine, but docs are a little hesitant to give it to people under the age of 60 because it can wear off over time.  This is what I was told by my PCP.  I've had shingles once and don't want them again.  It was nearly a year ago and my scalp still has periods of numbness and tingling.  I think that is also why my facial swelling comes and goes.  Not from the high dose pred but from PHN.   I also get outbreaks of cold sores every now and again.  I'm having one now because I've had this viral respiratory thing going on for about a week now and am pretty worn down from that so out pops the old cold sores!  Good thing I keep tubes of Zovirax on hand for when they show up. Did any of you that have had shingles have really bad scars from it? The scars I have are horrible, thank goodness none of them are on my face or arms. I thought I knew pain from having RA for all these years but I would happily take RA over shingles any day.

Hi Lovie, long time no see. Hope you and your family are well.

edited by me to tell bob I love your avatar! I've always loved Beaker!auntlisa2009-05-28 19:52:41 [QUOTE=bob_h76]I think we can get the vaccine, but docs are a little hesitant to give it to people under the age of 60 because it can wear off over time.  This is what I was told by my PCP. [/QUOTE]

Hi Bob, my PCP and my RD sited the following from CCD, when I requested immunization:
[quote=CDC]Because the risk of morbidity and mortality from herpes zoster is heightened in immunocompromised persons, eligible patients who are scheduled to begin immunosuppressive therapy should be immunized at least 14 days (preferably a month, according to some experts) before such therapy is initiated. Otherwise, immunization is contraindicated in immunocompromised persons.[/quote]

We discussed at length the pros and cons of discontinuing immunosuppressive drugs for 90 days, vaccinating, and then waiting four or five weeks to begin RA treatment. In the finally analysis, we collectively decided to continue RA combo therapy and keep a supply of Acyclovir tablets on hand. Monotherpy does not seem to raise the same concerns as combo therapy, or at least that is what my RD indicated.

From the same CDC handout, [quote]The zoster vaccine is licensed for use only in persons 60 years and older. It is safe for those who are receiving blood products. Persons who already have been vaccinated against varicella-zoster virus should not be re-immunized; however, the ACIP stated that concern regarding unintentional re-immunization in persons 40 years and older was slight because varicella vaccination did not begin in the United States until 1995. The ACIP also noted that there is no need to question older patients about a history of chickenpox or to conduct serological testing for varicella immunity before administering the vaccine. Persons who have had an episode of herpes zoster in the past can receive the vaccine, but it should not be used to treat acute herpes zoster or PHN or be used as prophylaxis against PHN. In the absence of contraindications and precautions related to health status, persons with chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease, or other chronic conditions can receive the vaccine.

Persons on immunosuppressive therapy, including high-dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks. Zoster vaccination should be deferred for at least 1 month after discontinuation of such therapy . Short-term corticosteroid therapy (<14 days); low-to-moderate dose (<20 mg/day of prednisone or equivalent); topical (e.g., nasal, skin, inhaled); intra-articular, bursal, or tendon injections; or long-term alternate-day treatment with low to moderate doses of short-acting systemic corticosteroids are not considered to be sufficiently immunosuppressive to cause concerns for vaccine safety. Persons receiving this dose or schedule can receive zoster vaccine. Therapy with low-doses of methotrexate (<0.4 mg/Kg/week), azathioprine (<3.0 mg/Kg/day), or 6-mercaptopurine (<1.5 mg/Kg/day) for treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease, and other conditions are also not considered sufficiently immunosuppressive to create vaccine safety concerns and are not contraindications for administration of zoster vaccine.[/quote]

Although not identical to the pamphlet I have, similar information can be found online at the CDC website. Edited to add this link http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm

From what your doctor told you and what mine told me, it seems to be another case of having to put trust in our individual doctors and take their advice.

Cheers, Shug


Spelunker2009-05-28 22:45:20
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