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Risk for Herpes Zoster with Anti–TNF- Agents

Herpes zoster may occur more often and more severely in patients receiving monoclonal antibody treatment.

Dermatologists use anti–TNF- agents to treat a number of skin conditions, but one serious complication related to their use is an apparent increase in the incidence of several kinds of infections, most notably tuberculosis. The monoclonal antibodies adalimumab and infliximab seem to confer a higher TB risk than the receptor fusion protein etanercept. Scattered studies have also shown an increased incidence of herpes zoster (HZ), an issue addressed by this prospective study based on data from a German registry of 5040 patients treated for rheumatoid arthritis.

The researchers compared the frequency of HZ among those receiving anti–TNF- agents and those receiving other medications and examined a subgroup of patients who switched from one treatment group to another. They found a significantly increased incidence of HZ in recipients of the monoclonal antibodies but not in etanercept recipients. The HZ was clinically severe in 20% and often involved a multidermatomal distribution (whether contiguous or noncontiguous is unclear), ophthalmic involvement, and the necessity of hospitalization. Postherpetic neuralgia, however, was quite uncommon.

Comment: Patients with rheumatoid arthritis have an inherently greater risk than the general population for herpes zoster. Accordingly, the incidence of HZ in this study may not be directly applicable to receipt of anti–TNF- agents for cutaneous disorders. Nevertheless, dermatologists should be aware that HZ may occur with increased frequency in those receiving monoclonal antibodies and may be more severe than usual. In addition to multidermatomal and ophthalmic involvement, HZ may occur in atypical locations, such as the lower legs (Joint Bone Spine 2008; 75:540). The markedly low incidence of postherpetic neuralgia is curious and may represent inadequate reporting.

Inoculation with HZ vaccine decreases the risk for and severity of HZ in immunocompetent adults 60 and older, but its efficacy in immunocompromised hosts is uncertain. Moreover, because it is a live virus preparation, it could cause clinically significant infection in patients receiving TNF- antagonists. The authors make a reasonable but unproven suggestion that patients receive HZ vaccination at least 3 weeks before beginning treatment with anti–TNF- agents or after treatment has been discontinued for at least five half-lives.

— Jan V. Hirschmann, MD

Published in Journal Watch Dermatology February 27, 2009

Citation(s):

Strangfeld A et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti–TNF- agents. JAMA 2009 Feb 18; 301:737.

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