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Lowering the risk of shingles in rheumatoid arthritis patients

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Patients with rheumatoid arthritis have a higher risk of developing shingles than other adults, but new research shows how that risk could be lowered.

In the first of two studies conducted by Dr Kevin Winthrop of the Oregon Health and Science University and his colleagues, the live varicella-zoster vaccine — which is given to protect against shingles — was found to elicit a robust immune response in patients when administered several weeks prior to the start of treatment with the arthritis drug tofacitinib.

The findings are encouraging because tofacitinib and certain other disease-modifying antirheumatic drugs are thought to further increase the risk of developing shingles in this patient group.

The researchers noted, however, that the vaccine should only be given to patients who have had chickenpox in the past because shingles arises when the chickenpox virus that remains dormant in the body is reactivated. Arthritis drugs that suppress the immune system put patients at an elevated risk of disseminated varicella infection following vaccination.

In the second study, the researchers investigated whether concomitant use of what’s known as conventional synthetic disease-modifying antirheumatic drugs (csDMARDs, such as methotrexate and chloroquine) or corticosteroids contribute to the increased risk of shingles linked to tofacitinib.

They found that shingles rates were lowest for patients taking tofacitinib without csDMARDs or corticosteroids, and highest for those taking tofacitinib with csDMARDs and corticosteroids.

The investigators noted that in phase III clinical studies, similar efficacy has been observed with tofacitinib regardless of whether it is administered as monotherapy or in combination with csDMARDs and/or corticosteroids. As a result, they recommended the use of tofacitinib alone for the treatment of rheumatoid arthritis to help reduce the risk of shingles in vaccinated patients, provided that the patient’s arthritis remains controlled on the drug.

“If you want to lower shingles risk for rheumatoid arthritis patients, there are two strategies: one is vaccinating them and the other is getting them off steroids and methotrexate if you can,” Dr Winthrop concluded.

The findings of both studies have been published in Arthritis & Rheumatology, an official journal of the American College of Rheumatology.