Medication for Rheumatoid Arthritis Raise Risk for Shingles

Arthritis sufferers deal regularly with joint pain and mobility issues, but prescription drugs have offered relief to many, allowing them to continue to have normal, active lives. Like most medications, there are side effects; some worse than others. With one class of medications—TNF blockers—widely used to treat rheumatoid arthritis and other autoimmune diseases, there may be an increase in risk of getting shingles, especially among the elderly and those who are taking steroids.

While the findings, which will appear in the February 18th issue of the Journal of the American Medical Association, might raise awareness of this potential complication among patients and doctors, some of the experts say that it is unlikely to change how the medications are used. Dr. Guy Fiocco, who is the assistant professor of internal medicine at Texas A&M Health Science Center College of Medicine and the director of rheumatology at Scott & White in Temple, said, “We’ve changed people’s lives with use of anti-tumor necrosis factor drugs. People who were housebound are now leading relatively normal lives. This modest increase in risk is not going to stop us prescribing the drug. It may make us more aware.”

However, the increased risk did not reach clinical significance, and Fiocco also added that rheumatoid arthritis itself probably increases the risk of shingles (herpes zoster), as do steroids, which are taken by many people that suffer from rheumatoid arthritis. Although the link between TNF blockers and bacterial and fungal infections is fairly well-established, associations with the viral infections are not as clear. There have been reports of severe herpes zoster in people that were taking the TNF blockers.

TNF blockers, which can suppress the immune system, are used for many autoimmune disorders such as psoriasis and Crohn’s disease. In September 2008, the U.S. Food and Drug Administration asked the manufacturers of Remicade, Cimiza, Humira, and Enbrel to bolster safety warnings on the risk of developing opportunistic fungal infections. The medications already carried black-box warnings related to other safety issues. This followed an announcement by the FDA that it would begin a review for safety of the drugs, spurred by concerns that the medications also might be associated with cancer.

In the most recent study, researchers from the German Rheumatism Research Center in Berlin looked at approximately 5,040 people that were taking TNF blockers infliximab (Remicade), adalimumab (Humira), the fusion protein etanercept (Enbrel), or the monotherapeutic drug anakinra (Kineret). The lead author of the study, Dr. Anja Stranglfield from the epidemiology unit at the research center in Berlin said that although it is generally considered a TNF blocker, Enbrel was not put in that category for the study because it works with a slightly different mechanism than Humira and Remicade. “The target that is blocked (TNF) is the same, but it is reached with different molecular mechanisms of action.”

Out of the 86 cases of shingles that were reported in 82 participants, 39 of them were deemed related to treatment with one of the two TNF blockers, and 24 of the cases were attributed to treatment with other controversial medications. The study found that the people that were taking Humira or Remicade had almost doubled the risk of developing shingles. According to an editorial that accompanied the study, the risk was about the same as that seen in general populations that are over the age of 80. The people that participated in the study were, on average, in their early 50s.

Also, according to this editorial, the cases of the shingles that were observed in the study seemed to be worse than those that are usually seen in the general population, with 20 percent of the cases categorized as “severe” and 13 percent requiring hospitalization.

There is a vaccine that is available to fight against shingles and it is recommended for people who are aged 60 and older, but it has not yet been studied in those that have rheumatoid arthritis or the people who are taking TNF blockers.