People with rheumatoid arthritis (RA) have roughly twice the risk of healthy older adults of developing shingles, a virus related to chickenpox that causes pain and a blistering rash.
Most adults have been exposed to varicella zoster virus, which causes chickenpox. This virus is never completely cleared from our bodies, but lies quietly in spinal nerve cells. If it’s reactivated it causes shingles, explains rheumatologist Jeffrey Curtis, MD, professor medicine at the University of Alabama at Birmingham. The reactivated virus is called herpes zoster or shingles.
Shingles often begins as burning, tingling or itching in a limited area on one side of the body. Days or weeks later, fluid-filled blisters appear, often in a single band wrapping around the torso, though shingles also can affect the face and eyes. Pain can be relatively mild, mostly perceived as itching, or quite intense so that even light touch is unbearable.
“As we get older our immune systems are not as effective at protecting us from infection, and this makes it easier for the shingles virus to ‘escape’ and reactivate,” says Dr. Curtis, who notes shingles is most common in people older than 60. “If you have RA, your immune system is already disordered, and then, if you are prescribed medications that further impair your immune defenses, it becomes even more likely the virus will reactivate.”
RA Medications and Shingles Risk
Many medications for RA suppress the immune system and can increase the risk of developing shingles. The clearest association is found with corticosteroids, says Kevin Winthrop, MD, MPH, associate professor of infectious diseases at Oregon Health & Sciences University in Portland.
“Almost every study shows that using prednisone at dosages commonly prescribed for RA [10 mg/day] doubles the risk of developing shingles,” says Dr. Winthrop. “Evidence for other drugs is more mixed.”
A 2015 study published in Arthritis Care & Research used a registry of 28,852 people with RA to look at shingles risk with various drugs, including corticosteroids, conventional disease-modifying anti-rheumatic drugs (DMARDS) and biologics. Results showed only corticosteroid use and aging were linked to an increased risk of shingles.
Dr. Winthrop notes that other studies, particularly those involving tumor necrosis factor (TNF) inhibitors, have found a higher risk of shingles among those taking the medications. Indeed, a 2017 study published in Journal of Rheumatology found that TNF inhibitor use and higher corticosteroids doses were significantly associated with shingles in Japanese patients with RA.
Janus kinase inhibitors, or JAK inhibitors, are the newest class of drugs for RA. “JAK inhibitors have biologic-like properties yet aren’t biologics. While they generally have a safety profile similar to biologics, a unique side effect is that they appear to double the risk of developing shingles,” says Dr. Curtis.
Prompt treatment with antiviral drugs usually resolves pain and rash in a few weeks. Having RA does not appear to increase the virus’ severity — or its complications, says Leonard Calabrese, DO, professor of medicine and vice chair of Rheumatic and Immunologic Diseases at the Cleveland Clinic in Ohio.
“The most important thing for people with shingles is to get treated quickly,” he says. “Extremely prompt treatment [within three days] can decrease severity as well as forestall complications.”
The most common – and feared – complication of shingles is a chronic pain condition called postherpetic neuralgia (PHN), which develops in about 10% to 15% of people who have had shingles.
“This pain can be very severe or mostly felt as unpleasant burning or tingling sensations over the skin. PHN often improves gradually, but can sometimes last for years,” Dr. Calabrese says.
Other potential complications include inflammation of the eye or retina that can cause pain and vision loss, and ear inflammation that can lead to facial weakness on the affected side.
An increased risk of stroke — which is already elevated in people with RA — is another possible complication of shingles. A 2014 study published in Clinical Infectious Diseases, found stroke rates in the month after shingles infection were 1.63 times higher than at other time points.
This risk decreased over following weeks, but remained elevated for about six months. People whose shingles affected their eyes had a three-fold increase in stroke risk 5–12 weeks after their shingles outbreak. Treatment with antiviral medications, however, lowered the risk.
The best way to prevent shingles is to get vaccinated against the virus with Zostavax. The “live” vaccine (meaning it contains living though weakened virus) is approved for people older than 50, but the Centers for Disease Control and Prevention advises against using live vaccines, including for shingles, in people taking biologics.
Author: Emily Delzell for the Arthritis Foundation
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