Rheumatoid arthritis Treatment May Increase Shingles Risk


Rheumatoid arthritis (RA) is a chronic disease. It is mainly characterized by inflammation of the synovium (lining) of the joints. It can lead to long-term joint damage, chronic pain, loss of function and disability. Rheumatoid arthritis affects 1.3 million Americans.

Severe arthritis is often treated with anti–TNF-{alpha} agents (anti-tumor necrosis factor) when convention medications fail. There is has been increased use of anti–TNF-{alpha} agents for rheumatoid arthritis patients, as well as patients with other diseases such as ankylosing spondylitis, psoriatic arthritis, and inflammatory bowel disease. Many studies have shown that patients treated with anti–TNF-{alpha} agents are at increased risk of bacterial infections.

A study just published in the Feb 18 issue of the Journal of the American Medical Association looked at whether patients using these drugs are at an increased risk of viral infections, specifically shingles.

Singles (herpes zoster) is a neurocutaneous disease characterized by a painful vesicular dermatomal rash resulting from reactivation of the varicella zoster virus (VZV). It may be complicated by bacterial infection (in the broken skin of the rash) or by postherpetic neuralgia (lingering pain). Older people and anyone who is immunosuppressed (for example, a person taking steroids or a transplant patient) is at increased risk for shingles.

TNF blockers suppress the immune system. Examples of TNF blockers include Humira, Cimzia, Enbrel and Remicade.


To try to answer the question of whether the TNF blockers increased the risk of shingles, Dr Anja Stangfeld and colleagues looked at 5,040 people taking the TNF blockers infliximab (Remicade) or adalimumab (Humira).

There were 86 cases of shingles reported in 82 participants. Thirty-nine cases were deemed related to treatment with one of the two TNF blockers, and 24 were attributed to treatment with conventional medications. That's almost double the risk of developing shingles.

In the cases of shingles observed in the study, 20 percent of episodes were categorized as "severe" and 13 percent required hospitalization.

Dr Strangfeld said "Our recommendations [to physicians and patients] are to advise a careful monitoring of patients under treatment with TNF blockers for early signs and symptoms of herpes zoster."

A vaccine against shingles is available and recommended for people age 60 and over, but it has not been studied in those with rheumatoid arthritis or people taking TNF blockers, the editorial indicated.

Risk of Herpes Zoster in Patients With Rheumatoid Arthritis Treated With Anti–TNF-{alpha} Agents; JAMA. 2009;301(7):737-744; Anja Strangfeld, MD; Joachim Listing, PhD; Peter Herzer, MD; Anke Liebhaber, MD; Karin Rockwitz, MD; Constanze Richter, MD; Angela Zink, PhD

Arthritis Foundation