title: Risk of skin and soft tissue infections (including shingles) in patients exposed to anti-tumour necrosis factor therapy: results from the British Society for Rheumatology Biologics Register.
abstract: BACKGROUND
  Anti-tumour necrosis factor (TNF) therapy is a mainstay of treatment in rheumatoid arthritis (RA). In 2001, BSRBR was established to evaluate the safety of these agents. This paper addresses the safety of anti-TNF therapy in RA with specific reference to serious skin and soft tissue infections (SSSI) and shingles.
  
  
  METHODS
  A cohort of anti-TNF-treated patients was recruited alongside a comparator group with active RA treated with non-biological disease-modifying antirheumatic drugs (nbDMARD). 11 881 anti-TNF and 3673 nbDMARD patients were analysed. Follow-up was by 6-monthly questionnaires to patients and clinicians. Analyses considered SSSI and shingles separately. Incidence rates (IR) were calculated and then compared using survival analyses.
  
  
  RESULTS
  The crude IR for SSSI were: anti-TNF 1.6/100 patient-years (95% CI 1.4 to 1.8); nbDMARD 0.7/100 patient-years (95% CI 0.5 to 1.0) and shingles: anti-TNF 1.6/100 patient-years (95% CI 1.3 to 2.0); nbDMARD 0.8/100 patient-years (95% CI 0.6 to 1.1). Adjusted HR were SSSI 1.4 (95% CI 0.9 to 2.4), shingles 1.8 (95% CI 1.2 to 2.8). For SSSI, no significant differences were seen between anti-TNF agents. For shingles, the lowest risk was observed for adalimumab (adjusted HR vs nbDMARD) 1.5 (95% CI 1.1 to 2.0) and highest for infliximab (HR 2.2; 95% CI 1.4 to 3.4)).
  
  
  CONCLUSIONS
  A significantly increased risk of shingles was observed in the anti-TNF-treated cohort. The risk of SSSI tended towards being greater with anti-TNF treatment but was not statistically significant. As with any observational dataset cause and effect cannot be established with certainty as residual confounding may remain. This finding would support the evaluation of zoster vaccination in this population.
authors.affiliation: Arthritis Research UK Epidemiology Unit, Manchester Academic Health Sciences Centre, Stopford Building, Oxford Road, The University of Manchester, Manchester, M13 9PT, UK.
authors.forename: James B
authors.initials: JB
authors.lastname: Galloway
authors.forename: Louise K
authors.initials: LK
authors.lastname: Mercer
authors.forename: Alison
authors.initials: A
authors.lastname: Moseley
authors.forename: William G
authors.initials: WG
authors.lastname: Dixon
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Ustianowski
authors.forename: Matthew
authors.initials: M
authors.lastname: Helbert
authors.forename: Kath D
authors.initials: KD
authors.lastname: Watson
authors.forename: Mark
authors.initials: M
authors.lastname: Lunt
authors.forename: Kimme L
authors.initials: KL
authors.lastname: Hyrich
authors.forename: Deborah Pm
authors.initials: DP
authors.lastname: Symmons
mesh_terms: D000068879:Adalimumab; D000911:Antibodies, Monoclonal / Q000009:adverse effects; D061067:Antibodies, Monoclonal, Humanized / Q000009:adverse effects; D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy; D000068800:Etanercept; D006562:Herpes Zoster / Q000453:epidemiology*; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects; D015994:Incidence; D000069285:Infliximab; D008875:Middle Aged; D018124:Receptors, Tumor Necrosis Factor; D012307:Risk Factors; D012874:Skin Diseases, Infectious / Q000453:epidemiology*; D018461:Soft Tissue Infections / Q000453:epidemiology*; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D007074:Immunoglobulin G; D018124:Receptors, Tumor Necrosis Factor; D014409:Tumor Necrosis Factor-alpha; D000069285:Infliximab; D000068879:Adalimumab; D000068800:Etanercept