For Patients with Inflammatory Bowel Disease, A Warning About Herpes Zoster
—Regardless of whether they’re on immunosuppressive therapy, individuals suffering from inflammatory bowel disease have a greater risk for herpes zoster. Now, a new study says, these patients are also at higher risk for complications from HZ.
For individuals with inflammatory bowel disease (IBD), there are a host of therapies that can help them achieve higher rates of clinical remission, including thiopurines, anti-tumor necrosis factor (TNF)-alpha inhibitors, Janus kinase (JAK) inhibitors, and corticosteroids.
But as any clinician knows, with the good sometimes comes the bad. These therapies, while highly effective in many patients, can increase risk of infections, including herpes zoster (HZ). The investigators of a new study, citing a recent analysis, note that JAK inhibitors—particularly at higher doses—exhibited the highest risk for HZ infection.1,2
Complications from HZ are more likely in those who are immunosuppressed, including patients with IBD. Post-herpetic neuralgia (PHN), which can lead to chronic neuropathic pain, is the most common of these complications. Others include disseminated HZ, as well as neurological and/or ophthalmic complications.
Evaluating the risk of serious infections
Given the fact that current data on the frequency of HZ-related complications in patients with IBD are lacking, investigators from the University of Wisconsin-Madison and the Mayo Clinic designed a retrospective cohort study to evaluate whether HZ complications are more common in patients with IBD.1
Patients with IBD (n=4756) were identified from a large medical and pharmacy administrative claims database and matched 1:1 with non-IBD controls based on age, sex, and index year, defined as the year that HZ was diagnosed. The analysis included data covering more than 15 years, from January 1, 2007, through April 1, 2022. Complications of HZ identified up to 90 days after the index date were included in the analysis.
The study used a composite primary outcome for any HZ complication; secondary outcomes included risk factors for complications, such as PHN. Among patients with and without IBD, 94.3% and 93.5%, respectively, were not immunized for HZ with either the ZVL (live attenuated varicella zoster) vaccine or the RZV (recombinant herpes zoster) series.
Who’s experiencing complications?
The investigators determined that there was a greater risk of complications of HZ in those with IBD versus controls: 738 patients (15.5%) versus 595 controls (12.5%); P<.0001. HZ-related hospitalization, PHN (the most common complication; n=286 [6.0%]), neurological complications, and disseminated zoster were all more common in those with IBD versus controls.
The most frequent complication of HZ in the non-IBD cohort was ophthalmic complications (n=238 [5.0%]). There was an absolute risk difference of 3.0% between the IBD and non-IBD groups, and the number needed to harm was 33.
Patients with IBD who went on to develop complications of HZ tended to be older (60.9 versus 53.4 years; P<.0001) and had higher Charlson Comorbidity Index scores (1.86 versus 1.18; P<.0001) than IBD patients who did not have any HZ complications. When analyzing IBD patients with a higher comorbidity score using logistic regression analysis, there was an increased risk of an HZ-related complication in those over 50 years of age, and among those on anti-TNF therapy or who were taking corticosteroids.
Limitations and conclusions
The retrospective nature of the study was among the limitations of the analysis. Others included a limited ability to assess the association of non-TNF biologics and JAK inhibitors with HZ complications due to the small sample sizes. Similarly, low RZV immunization rates made it hard to determine the protective effect of vaccination against HZ complications. The study did not include disease activity measures, although prednisone use—a possible proxy for flares—was associated with increased HZ complications. Finally, among the IBD cohort, higher comorbidity scores may have contributed to their greater risk of complications.
Still, the study blazed a new clinical trail, according to the authors. “Ours is the first study showing that patients with IBD are at increased risk for complications of HZ,” says lead investigator Freddy Caldera, DO, PhD, of the Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine and Public Health, University of Wisconsin-Madison. He stressed that clinicians should recommend vaccination for patients with IBD. To encourage this, he pointed to the need for “studies evaluating the effectiveness of vaccines in preventing these complications.”
As for the current analysis, the authors view it as “. . . a call to action for gastroenterologists in addressing the elevated risk of HZ complications in patients with IBD. By leveraging the risk factors and medication associations identified in our study, and the proven benefits of vaccination in other studies, gastroenterologists can optimize patient care and contribute to reducing the burden of HZ-related complications.”1
Published:
References
.jpg)
