title: Risk of Herpes Zoster in Individuals on Biologics, Disease-Modifying Antirheumatic Drugs, and/or Corticosteroids for Autoimmune Diseases: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Studies examining the risk of herpes zoster (HZ) associated with immunosuppressants, such as biologics, nonbiological disease-modifying antirheumatic drugs (nbDMARDs), or corticosteroids, have generated conflicting results.
  
  
  METHODS
  We conducted a systematic literature search from January 1946 to February 2016. Search terms related to HZ, rheumatoid arthritis, psoriasis, psoriatic arthritis, systemic lupus erythematous, or inflammatory bowel disease, biologics, nbDMARDS, and corticosteroids were used. We included randomized controlled trials (RCTs) and observational studies reporting associations between immunosuppressants and HZ outcomes in adults. For RCTs, we used the Mantel-Haenszel fixed-effects model to estimate pooled odds ratios (ORs) and 95% confidence intervals (CIs) for HZ risk. For observational studies, adjusted ORs were pooled separately using random-effects inverse variance models.
  
  
  RESULTS
  Data were pooled from 40 eligible RCTs (20136 patients) and 19 observational studies (810939 patients). Biologics were associated with a greater risk of HZ than control (RCTs: OR = 1.71, 95% CI = 1.11-2.64; observational studies: OR = 1.58, 95% CI = 1.39-1.81). In RCTs, the OR of non-tumor necrosis factor (TNF) blockers was 2.19 (95% CI 1.20-4.02), but that of TNF blockers was not significantly different from control. Increased risks of HZ with nbDMARDs (OR = 1.21; 95% CI = 1.15-1.28) and corticosteroids (OR = 1.73; 95% CI = 1.57-1.89) were observed in observational studies, but few RCTs examined these comparisons.
  
  
  CONCLUSIONS
  Immunocompromised patients receiving biologics were associated with an increased risk of HZ. The risk is also increased with corticosteroids and nbDMARDs. These findings raise the issue of prophylaxis with zoster vaccine in patients initiating immunosuppressive therapy for autoimmune diseases.
authors.affiliation: University of British Columbia , Vancouver, Canada.
authors.forename: Fawziah
authors.initials: F
authors.lastname: Marra
authors.affiliation: Hong Kong University, China,; National University Hospital, Singapore.
authors.forename: Elaine
authors.initials: E
authors.lastname: Lo
authors.affiliation: University of British Columbia , Vancouver, Canada.
authors.forename: Viktor
authors.initials: V
authors.lastname: Kalashnikov
authors.affiliation: University of East Anglia , United Kingdom.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Richardson
keywords: DMARDs; biologics; herpes zoster; immunocompromised; rheumatoid arthritis.