From the Journals

Thiopurines linked to zoster in IBD patients

View on the News

Vaccination should be part of caring for IBD patients

Patients with inflammatory bowel disease are thought to have altered immune regulation, which may increase the risk of systemic complications including infections like herpes zoster. Many of the prior studies assessing the risk of herpes zoster in IBD patients were done before the advent of biologics and excluded older patients, thereby limiting their utility. This study by Khan et al. aimed to better estimate the incidence and risk factors for development of herpes zoster and to determine the effect of immunosuppressant use on this risk. In two large, retrospective cohort studies they found that, compared with patients without IBD, patients with IBD had a significantly increased risk of developing herpes zoster. Furthermore, this risk was higher in those with recent or cumulative steroid use and in those treated with thiopurines (as monotherapy or in combination with anti-TNF agents). Interestingly, exposure to TNF antagonists alone was not associated with an increased risk of herpes zoster infection.

Dr. Richa Shukla

This study helps to better clarify the risk of important infections such as herpes zoster in patients with IBD; perhaps more importantly, it informs readers that the risk is increased even in those not on immunosuppressants. These findings should urge practitioners to pay close attention to health maintenance recommendations when caring for IBD patients, specifically appropriate immunizations. With the advent of an inactivated vaccine option against zoster, the benefits of vaccinating patients may be invaluable while risks are minimal and widespread vaccination should be considered.

Richa Shukla, MD, assistant professor, section of gastroenterology and hepatology, Baylor College of Medicine, Houston.


 

FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

For patients with inflammatory bowel disease (IBD), thiopurine exposure was associated with a significantly increased risk of herpes zoster, compared with 5-aminosalicylic acid (5-ASA) monotherapy, according to the results of two large retrospective cohort studies.

Herpes zoster Joloei/Thinkstock

Herpes zoster

In the multivariable analysis, thiopurine monotherapy was linked to about a 47% increase in the risk of herpes zoster, compared with 5-ASA monotherapy (adjusted hazard ratio, 1.47; 95% confidence interval, 1.31-1.65; P less than .001). Combination therapy with thiopurines and tumor necrosis factor antagonists conferred about a 65% increase in zoster risk (aHR, 1.65; 95% CI, 1.22-2.23; P = .001). However, tumor necrosis factor–antagonist monotherapy did not appear to significantly increase the risk of zoster when compared with 5-ASA monotherapy, reported Nabeel Khan, MD, of the University of Pennsylvania in Philadelphia, and his associates.

“Compared to [patients without] IBD, ulcerative colitis (UC) and Crohn’s disease (CD) each were associated with significantly increased risk of herpes zoster infection,” the researchers wrote online in Clinical Gastroenterology and Hepatology. “With the approval of a new and potentially safer vaccine for herpes zoster, the effects of immunization of patients with IBD should be investigated.”

Past studies have linked IBD with a 1.2- to 1.8-fold increase in the risk of zoster, but these studies date to the prebiologic era or excluded patients who were in their midsixties or older, the researchers wrote. “Additionally, these prior studies have not assessed the validity of the codes used to identify herpes zoster and also did not account for the impact of vaccination,” they added. “They also did not take into consideration the severity of the disease or degree of steroid exposure.”

Therefore, the researchers conducted two retrospective cohort studies of patients in the United States Department of Veterans Affairs between 2000 and 2016. The first cohort study compared the incidence of herpes zoster among patients with IBD who received 5-ASA alone with matched patients without IBD. The second cohort study measured the incidence of herpes zoster in patients with IBD who received various medications and combination regimen. “The VA has a predominantly older population, which makes it an ideal cohort to study herpes zoster incidence in a high-risk population,” the investigators noted. “Unlike insurance databases, the VA database can be validated internally and vaccination records are documented.”

After adjusting for age, race, sex, geographic region, disease flare, corticosteroid use, and baseline comorbidities, the estimated hazard of developing herpes zoster was 1.81 (95% confidence interval, 1.56-2.11) among patients with ulcerative colitis and 1.56 (95% CI, 1.28-1.91) among patients with Crohn’s disease, as compared with patients without IBD. Regardless of their age or the medications they were receiving, patients with IBD had a higher incidence of zoster than the oldest group of patients without IBD (older than 60 years), regardless of age or medication. “The highest risk of herpes zoster was observed in patients with IBD who were less than 60 years of age and on combination therapy,” the investigators wrote. “Patients with IBD younger than 50 years who were on combination therapy had higher risk of herpes zoster, compared with patients with IBD older than 60 years of age who were not on immunosuppressive therapy.” Based on the findings, they recommended studying the efficacy of widespread use of the new herpes zoster vaccine in patients with IBD.

Pfizer provided unrestricted research funding but was not otherwise involved in the study. One coinvestigator disclosed ties to Pfizer and several other pharmaceutical companies. The remaining investigators reported having no conflicts of interest.

SOURCE: Khan N et al. Clin Gastroenterol Hepatol. 2018 Jan 5. doi: 10.1016/j.cgh.2017.12.052.

Recommended Reading

Blood test outreach, navigation could close colorectal cancer screening gap
MDedge Internal Medicine
Aspirin cuts risk of ovarian and liver cancer
MDedge Internal Medicine
Novel score predicts esophageal varices in patients with cirrhosis prior to EGD
MDedge Internal Medicine
Etrasimod improves clinical, endoscopic outcomes in patients with UC
MDedge Internal Medicine
Longer withdrawal time in right colon increases adenoma detection rate
MDedge Internal Medicine
HCV adapts to HIV coinfection
MDedge Internal Medicine
Endocuff decreases withdrawal time but not detection rate during colonoscopy
MDedge Internal Medicine
Child-Pugh class does not affect HE recurrence in patients taking rifaximin
MDedge Internal Medicine
Length of stay, complications predict readmission for cirrhosis patients
MDedge Internal Medicine
Primary care holds key to curbing early-onset colorectal cancer
MDedge Internal Medicine