title: Systemic Therapy for Psoriasis and the Risk of Herpes Zoster: A 500,000 Person-year Study.
abstract: OBJECTIVE
  The risk for herpes zoster (HZ) in patients with psoriasis treated with biologic medications or other systemic treatments has been given little attention to date.
  
  
  OBJECTIVE
  To describe the risk for HZ in patients with psoriasis and its relation to treatment.
  
  
  METHODS
  A cohort study was performed using the administrative database of Clalit Health Services, the largest public health care provider organization in Israel, in the setting of general community clinics, primary care and referral centers, and ambulatory and hospitalized care. We extracted information for all patients who received a psoriasis diagnosis from January 2002 to June 2013. Follow-up was conducted until the end of July 2013. The study included 95,941 patients with psoriasis in the analysis, with 522,616 person-years of follow-up. Incidence of HZ events was calculated for each systemic antipsoriatic medication provided, during a follow-up period of 11 years and 7 months. We used a generalized estimating equation Poisson regression model to examine the effect of each systemic treatment for psoriasis on HZ incidence, adjusting for age, sex, psoriasis severity, Charlson comorbidity index, steroid treatment, and socioeconomic status.
  
  
  METHODS
  Incidence of HZ associated with systemic therapies.
  
  
  RESULTS
  In a multivariate analysis, it was observed that treatment with phototherapy (rate ratio [RR], 1.09 [95% CI, 0.62-1.93]; P = .99), methotrexate (RR, 0.98 [95% CI, 0.78-1.23]; P = .83), cyclosporine (RR, 1.16 [95% CI, 0.48-2.80]; P = .49), and biologic medications as a single agent (RR, 2.67 [95% CI, 0.69-10.3]; P = .14) was not associated with HZ. The use of combination treatment with biologic medications and methotrexate was significantly associated with an increased incidence of HZ (RR, 1.66 [95% CI, 1.08-2.57]; P = .02). The use of acitritin was associated with decreased incidence of HZ (RR, 0.69 [95% CI, 0.49-0.97]; P = .004).
  
  
  CONCLUSIONS
  Physicians may need to consider offering an HZ preventive vaccine to patients receiving combination treatment with biologic medications and methotrexate, particularly if they have additional risk factors for HZ.
authors: Soroka Medical Center, Beer-Sheva, Israel2Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel3Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.
authors: Guy
authors: G
authors: Shalom
authors: Carmel Medical Center, Haifa, Israel5Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
authors: Devy
authors: D
authors: Zisman
authors: Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel6Clalit Health Services, Tel Aviv, Israel.
authors: Haim
authors: H
authors: Bitterman
authors: Soroka Medical Center, Beer-Sheva, Israel2Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors: Ilana
authors: I
authors: Harman-Boehm
authors: Department of Research and Information, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.
authors: Sari
authors: S
authors: Greenberg-Dotan
authors: Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel9Hospital Division, Clalit Health Services, Tel Aviv, Israel.
authors: Jacob
authors: J
authors: Dreiher
authors: Department of Research and Information, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.
authors: Ilan
authors: I
authors: Feldhamer
authors: Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors: Hadas
authors: H
authors: Moser
authors: Department of Research and Information, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.
authors: Ariel
authors: A
authors: Hammerman
authors: Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors: Yoram
authors: Y
authors: Cohen
authors: Department of Quality Measurements and Research, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel8Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Isr.
authors: Arnon D
authors: AD
authors: Cohen
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects; D001685:Biological Factors / Q000008:administration & dosage / Q000009:adverse effects; D015984:Causality; D015331:Cohort Studies; D015897:Comorbidity; D016572:Cyclosporine / Q000008:administration & dosage; D003879:Dermatologic Agents / Q000627:therapeutic use; D004359:Drug Therapy, Combination / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006562:Herpes Zoster / Q000453:epidemiology* / Q000517:prevention & control; D053061:Herpes Zoster Vaccine / Q000008:administration & dosage; D006801:Humans; D015994:Incidence; D007555:Isoxazoles / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D015999:Multivariate Analysis; D010789:Phototherapy; D011565:Psoriasis / Q000188:drug therapy* / Q000453:epidemiology*; D012307:Risk Factors; D017678:Sex Distribution; D000069549:Ustekinumab
chemical_list: D000305:Adrenal Cortex Hormones; D061067:Antibodies, Monoclonal, Humanized; D001685:Biological Factors; D003879:Dermatologic Agents; D053061:Herpes Zoster Vaccine; D007555:Isoxazoles; D016572:Cyclosporine; D000069549:Ustekinumab; C006303:acivicin; D008727:Methotrexate