Herpes Zoster Risk and Vaccination Recommendations in Patients With Psoriasis, Psoriatic Arthritis

Risk of stroke after herpes zoster in patients with autoimmune diseases
Risk of stroke after herpes zoster in patients with autoimmune diseases
Investigators assessed the risk for herpes zoster and provided recommendations regarding treatment in patients with psoriasis.

Treatment with tofacitinib systemic corticosteroids and combination therapy in patients with psoriasis (PsO) and/or psoriatic arthritis (PsA) increases the risk for herpes zoster (HZ), according to study results published in the Journal of the American Academy of Dermatology.

Researchers across the Eastern seaboard of the United States  systematically reviewed published literature for studies (randomized controlled trials, cohort studies, case-control studies, systematic reviews, and meta-analyses) of HZ featuring patients with PsO/PsA. Additional studies with data for guselkumab, tildrakizumab, risankizumab, ixekizumab, secukinumab, brodalumab, and apremilast were also included.  A total of 41 studies met the inclusion criteria and were collected for review.

Patients with PsO/PsA had a lower risk for HZ compared with patients with RA in an adjusted analysis (adjusted hazard ratio [aHR], 1.65 [95% CI, 1.57-1.75] to an aHR, 1.91 [95% CI, 1.80-2.03], respectively). Higher rates of HZ were observed in patients with PsO and PsA (13.3 and 15.9/1000 patient-years [PY]) vs healthy controls (8.5/1000 PY) in analyses adjusted for age, sex, and systemic medications. Tofacitinib, systemic corticosteroids, and combination therapy with both biologic (bDMARDS) and conventional synthetic disease-modifying antirheumatic drugs (csDMARDS) were associated with a higher HZ risk. In the tofacitinib group, factors associated with HZ included prior biologic use (HR, 1.72; 95% CI, 1.15-2.59), Asian ethnicity (HR, 2.92; 95% CI, 1.73-4.92), and tofacitinib dose (HR, 1.72; 95% CI, 1.01-2.94).

Recommendations for vaccination include:

●       Live zoster vaccine (Zostavax®)

o   Live zoster vaccine can be given to patients older than 50 who are not on systemic low-level immunosuppression therapy (methotrexate <0.4 mg/kg/d or prednisone <20 mg/d)

o   Live zoster vaccine should not be given to patients on moderate to high levels of csDMARDs, biologic DMARDS (bDMARDs), or targeted synthetic DMARDS (tsDMARDs). Vaccination may be administered if there is an interruption in these medications.

●       Recombinant zoster vaccine

o   Recombinant zoster vaccine is preferred over live zoster vaccine in patients with psoriasis and psoriatic arthritis.

o   Recombinant zoster vaccine should be administered prior to the initiation of systemic therapy when possible. It can be administered safely with concurrent use of csDMARDs, bDMARDs, or tsDMARDs.

o   Recombinant zoster vaccine can be administered in patients age >50 on other systemic therapy based on individualized risk assessment.

o   Recombinant zoster vaccine can be administered in patients older than 50 and younger than 50 on combination systemic therapy, systemic therapy, or tofacitinib because of the increased risk for HZ.

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The researchers wrote that a limitation of the analysis was the inclusion of studies that featured wide heterogeneity.

In conclusion, the researchers stated that “the recombinant zoster vaccine should be administered to all psoriasis and psoriatic arthritis patients >50 years old and to those <50 years old at increased risk,” the investigators wrote.

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Baumrin E, Van Voorhees A, Garg A, Feldman SR, Merola JF. A systematic review of herpes zoster incidence and consensus recommendations on vaccination in adult patients on systemic therapy for psoriasis or psoriatic arthritis: From the Medical Board of the National Psoriasis Foundation [published online March 15, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.03.017