title: Association between the initiation of anti-tumor necrosis factor therapy and the risk of herpes zoster.
abstract: OBJECTIVE
  Herpes zoster reactivation disproportionately affects patients with rheumatoid arthritis (RA). It is unclear whether anti-tumor necrosis factor (anti-TNF) therapy elevates herpes zoster risk.
  
  
  OBJECTIVE
  To ascertain whether initiation of anti-TNF therapy compared with nonbiologic comparators is associated with increased herpes zoster risk.
  
  
  METHODS
  We identified new users of anti-TNF therapy among cohorts of patients with RA, inflammatory bowel disease, and psoriasis, psoriatic arthritis, or ankylosing spondylitis from 1998 through 2007 within a large US multi-institutional collaboration combining data from Kaiser Permanente Northern California, Pharmaceutical Assistance Contract for the Elderly, Tennessee Medicaid, and national Medicaid/Medicare programs. We compared herpes zoster incidence between new anti-TNF users (n=33,324) and patients initiating nonbiologic disease-modifying antirheumatic drugs (DMARDs) (n=25,742) within each inflammatory disease cohort (last participant follow-up December 31, 2007). Within these cohorts, we used Cox regression models to compare propensity score-adjusted herpes zoster incidence between new anti-TNF and nonbiologic DMARD users while controlling for baseline corticosteroid use.
  
  
  METHODS
  Incidence of herpes zoster cases occurring after initiation of new anti-TNF or nonbiologic DMARD therapy.
  
  
  RESULTS
  Among 33,324 new users of anti-TNF therapy, we identified 310 herpes zoster cases. Crude incidence rates among anti-TNF users were 12.1 per 1000 patient-years (95% CI, 10.7-13.6) for RA, 11.3 per 1000 patient-years (95% CI, 7.7-16.7) for inflammatory bowel disease, and 4.4 per 1000 patient-years (95% CI, 2.8-7.0) for psoriasis, psoriatic arthritis, or ankylosing spondylitis. Baseline use of corticosteroids of 10 mg/d or greater among all disease indications was associated with elevated risk (adjusted hazard ratio [HR], 2.13 [95% CI, 1.64-2.75]) compared with no baseline use. For patients with RA, adjusted incidence rates were similar between anti-TNF and nonbiologic DMARD initiators (adjusted HR, 1.00 [95% CI, 0.77-1.29]) and comparable between all 3 anti-TNF therapies studied. Across all disease indications, the adjusted HR was 1.09 (95% CI, 0.88-1.36).
  
  
  CONCLUSIONS
  Among patients with RA and other inflammatory diseases, those who initiated anti-TNF therapies were not at higher risk of herpes zoster compared with patients who initiated nonbiologic treatment regimens.
authors: Division of Infectious Diseases, Public Health and Preventive Medicine, Oregon Health and Science University, OR 97239, USA. Winthrop@ohsu.edu
authors: Kevin L
authors: KL
authors: Winthrop
authors: John W
authors: JW
authors: Baddley
authors: Lang
authors: L
authors: Chen
authors: Liyan
authors: L
authors: Liu
authors: Carlos G
authors: CG
authors: Grijalva
authors: Elizabeth
authors: E
authors: Delzell
authors: Timothy
authors: T
authors: Beukelman
authors: Nivedita M
authors: NM
authors: Patkar
authors: Fenglong
authors: F
authors: Xie
authors: Kenneth G
authors: KG
authors: Saag
authors: Lisa J
authors: LJ
authors: Herrinton
authors: Daniel H
authors: DH
authors: Solomon
authors: James D
authors: JD
authors: Lewis
authors: Jeffrey R
authors: JR
authors: Curtis
mesh_terms: D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy* / Q000276:immunology; D001327:Autoimmune Diseases / Q000150:complications / Q000188:drug therapy* / Q000276:immunology; D016022:Case-Control Studies; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006562:Herpes Zoster / Q000139:chemically induced / Q000453:epidemiology* / Q000276:immunology; D006801:Humans; D016867:Immunocompromised Host; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012306:Risk; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D014481:United States / Q000453:epidemiology
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha