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Rheumatology
Research
Risk and severity of herpes zoster in patients with rheumatoid arthritis receiving different immunosuppressive medications: a case–control study in Asia
  1. Tsai-Ling Liao1,2,
  2. Yi-Ming Chen1,2,3,4,
  3. Hung-Jen Liu2,
  4. Der-Yuan Chen2,3,4,5,6
  1. 1Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
  2. 2Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
  3. 3Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taipei, Taiwan
  4. 4Faculty of Medicine, National Yang Ming University, Taipei, Taiwan
  5. 5Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan
  6. 6Institute of Biochemistry, Microbiology and Immunology, Chung Shan Medical University, Taichung, Taiwan
  1. Correspondence to Dr Der-Yuan Chen; dychen{at}vghtc.gov.tw

Abstract

Objective Increasing evidence indicates that the risk of herpes zoster (HZ) is elevated in rheumatoid arthritis (RA). Little is known about the epidemiology of HZ in patients with RA in Asia. The aim of this study was to determine the risk factors and outcomes of HZ among patients with RA.

Design A case–control study.

Setting A medical centre in Asia.

Participants A total of 9025 newly diagnosed and eligible patients with RA (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 714.0) during the period 2001–2014. Among them, 275 (3.05%) were newly diagnosed with HZ (ICD-9-CM code 053.0) after the RA identification. As the control group, patients with RA without HZ were matched for age, gender and RA disease duration at the time of HZ infection with the RA-HZ case group at a ratio of 4:1, and a total of 1100 control subjects were selected.

Outcome measures We estimated ORs using conditional logistic regression to investigate the risk and severity of HZ among patients with RA receiving different immunosuppressive medications.

Results Exposure to corticosteroids (≥10 mg/day adjusted OR (aOR)=2.30, 95% CI 1.25 to 4.22, p=0.01), anti-tumour necrosis factor biologicals (aOR=2.07, 95% CI 1.34 to 3.19, p=0.001) and conventional synthetic disease-modifying anti-rheumatic drugs (methotrexate (aOR=1.98, 95% CI 1.43 to 2.76, p<0.001) and hydroxychloroquine (aOR=1.95, 95% CI 1.39 to 2.73, p<0.001)) was associated with an increased HZ risk in patients with RA. The association between the use of corticosteroids and HZ risk was dose-dependent (ptrend<0.001). Time-to-HZ diagnosis among patients with RA receiving biological medications was significantly shorter than that in patients not receiving biological medications. A higher proportion of severe HZ and ophthalmic involvement was found in patients with RA receiving biologicals.

Conclusions There was an increased risk of HZ in patients with RA taking specific immunosuppressive medication. Biologicals used were associated with severe HZ occurrence. Therefore, it is important to closely monitor and prevent severe HZ complications during specific immunosuppressive therapy.

  • rheumatoid arthritis (RA)
  • herpes zoster (HZ)
  • risk factor
  • outcomes
  • immunosuppressive medications

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2016-014032

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    Footnotes

    • Contributors D-YC conceived of the study, generated the original hypothesis, designed the study, analysed the data, and drafted and revised the manuscript. T-LL designed the study, analysed the data, and drafted and revised the manuscript. Y-MC and H-JL conceived of the study, analysed the data, and drafted and revised the manuscript.

    • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Ethics approval The Institutional Review Board of Taichung Veterans General Hospital.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.