Background TNF blockers have demonstrated their efficacy in inflammatory rheumatic diseases (IRD) and are now widely used. A moderate but indubitable increase in bacterial infectious events is known in patients treated with these drugs but little is known about the potential risk of reactivation of herpes zoster infections.
Objectives To assess the risk of herpes zoster infections in patients with IRD treated with TNF blockers based on available reported data in the literature.
Methods A systematic literature search was performed to January 2011, in Medline, Embase, Cochrane library and abstracts from ACR and EULAR congresses 2006-2010. Studies were included for meta-analysis if they reported the respective incidences of herpes infections in anti-TNF and conventional DMARDs-treated patients. The Mantel-Haenszel method was used to provide a pooled odds-ratio (OR) estimate and a 95% confidence interval (CI) in anti-TNF versus conventional DMARDs. Statistical heterogeneity was assessed on the basis of the Q test (Chi2), using a significance level of 0.05. Incidence of severe herpetic infections (multidermatomal lesions, requiring hospitalization or intravenous treatment) was extracted and reported when available.
Results The literature search identified 655 articles and 134 congress abstracts, and the additional manual search considered 11 national registries and 2 articles. Finally, 22 articles and 28 abstracts met selection criteria and were included in the study. Among these, 3 articles (1,2,3) and 2 abstracts (4,5) allowed a meta-analysis to estimate the relative risk of herpes infections, with a total follow up of 124,966 patient-years (PY) (74,198 PY in biologics group and 50,768 PY in conventional DMARDs group). Based on these 5 registries, the pooled OR was 1.75 [95%CI 1.50–2.04] without significant heterogeneity (I2=52%, p=0.08). Proportions of severe herpes infections, reported in the US and German populations were respectively 4.9% and 20.9% (1,2). In the British registry, the respective rates were 6% and 0.02% with biologics and conventional DMARDs.
Conclusions This meta-analysis of registries shows a significant increased risk of herpes zoster infections up to 75% in patients with IRD treated with TNF blockers. These data raise the issue of a systematic prophylactic treatment in patients with a known history of herpetic infections, or vaccination in naïve patients.
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BSRBR: Galloway et al, Abstract 421. ACR 2010.
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Disclosure of Interest None Declared
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