Abstract
The incidence of herpes zoster in psoriasis patients is higher than in the general population. However, the association between herpes zoster risk and different systemic therapies, especially biologic agents, remains controversial. This study investigated the association between herpes zoster risk and several systemic antipsoriasis therapies. This prospective open cohort study was conducted using retrospectively collected data from the Taiwan National Health Insurance Research Database. We included 92,374 patients with newly diagnosed psoriasis between January 1, 2001, and December 31, 2013. The exposure of interest was the “on-treatment” effect of systemic antipsoriasis therapies documented by each person-quarter. The outcome was the occurrence of newly diagnosed herpes zoster. During a mean follow-up of 6.8 years, 4834 (5.2%) patients were diagnosed with herpes zoster after the index date. Among the systemic antipsoriasis therapies, etanercept (hazard ratio [HR] 4.78, 95% confidence interval [CI] 1.51–15.17), adalimumab (HR 5.52, 95% CI 1.72–17.71), and methotrexate plus azathioprine (HR 4.17, 95% CI 1.78–9.82) were significantly associated with an increased risk of herpes zoster. By contrast, phototherapy (HR 0.76, 95% CI 0.60–0.96) and acitretin (HR 0.39, 95% CI 0.24–0.64) were associated with a reduced risk of herpes zoster. Overall, this study identified an association of both etanercept and adalimumab with an increased risk of herpes zoster among psoriasis patients. Acitretin and phototherapy were associated with a reduced risk.
Highlights
The incidence of herpes zoster in psoriasis patients is higher than in the general population
We observed that treatment with etanercept, adalimumab, and MTX plus AZA were significantly associated with higher risk of Herpes zoster (HZ)
Variable Age Female sex, n (%) Urbanization level of patient’s residence, n (%) Low Moderate High Very High Comorbidity, n (%) Diabetes mellitus Hypertension Dyslipidemia Chronic kidney disease Gouty arthritis Psoriasis arthritis Charlson Comorbidity Index score Medication of primary interest, n (%) PUVA or UVB Cyclosporine Oral retinoids (Acitretin) Tacrolimus Hydroxyurea Mycophenolate mofetil Azathioprine Methotrexate without any biological agents Etanercept without methotrexate Adalimumab without methotrexate Ustekinumab without methotrexate Methotrexate with any biological agents Steroid use at diagnosis of psoriasis Never user < 5 mg/day ≥ 5 mg/day Statin
Summary
The incidence of herpes zoster in psoriasis patients is higher than in the general population. This study investigated the association between herpes zoster risk and several systemic antipsoriasis therapies. Among the systemic antipsoriasis therapies, etanercept (hazard ratio [HR] 4.78, 95% confidence interval [CI] 1.51–15.17), adalimumab (HR 5.52, 95% CI 1.72–17.71), and methotrexate plus azathioprine (HR 4.17, 95% CI 1.78–9.82) were significantly associated with an increased risk of herpes zoster. This study identified an association of both etanercept and adalimumab with an increased risk of herpes zoster among psoriasis patients. Research has yet to identify a significantly different risk of HZ between psoriasis patients treated with biologic agents and those receiving other systemic therapies; the suppression of T cell–mediated immunity leads to the reasonable inference that biologic agents may be associated with an increased risk of HZ7,8. To determine the risk of HZ in psoriasis patients receiving various medications, we conducted a nationwide population-based cohort study
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