A systematic review of herpes zoster incidence and consensus recommendations on vaccination in adult patients on systemic therapy for psoriasis or psoriatic arthritis: From the Medical Board of the National Psoriasis Foundation - 09/05/19

Doi : 10.1016/j.jaad.2019.03.017

Emily Baumrin, MD ^a,^b,^⁎ , Abby Van Voorhees, MD ^c, Amit Garg, MD ^d, Steven R. Feldman, MD, PhD ^e, Joseph F. Merola, MD, MMSc ^a,^b,^f
^a Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
^b Harvard Medical School, Boston, Massachusetts
^c Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
^d Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
^e Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
^f Department of Medicine, Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Massachusetts

^∗Correspondence to: Emily Baumrin, MD, Department of Dermatology, Brigham and Women's Hospital, 41 Avenue Louis Pasteur, EC 313, Boston, MA 02115.Department of DermatologyBrigham and Women's Hospital41 Avenue Louis Pasteur, EC 313BostonMA02115

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Abstract

Background

Herpes zoster (HZ) incidence is linked to immunosuppression. Patients with psoriasis or psoriatic arthritis (PsA) on systemic therapy might be at an increased risk for HZ.

Objective

To assess HZ risk in patients with psoriasis and PsA by systemic treatment and provide recommendations regarding HZ vaccination.

Methods

A systematic literature search was performed for HZ in patients with psoriasis and PsA. HZ vaccination guidelines were reviewed, and the medical board of the National Psoriasis Foundation made consensus recommendations in psoriasis and PsA patients using graded evidence.

Results

In total, 41 studies met inclusion criteria. Systemic corticosteroids (strong, 1), tofacitinib (strong, 1), and combination therapy with biologic and conventional synthetic disease-modifying antirheumatic drugs (weak, 2a) carry increased HZ risk while monotherapy does not. There is insufficient evidence to determine risk with interleukin 12/23, 17, and 23 inhibitors or apremilast (weak, 2a). Recombinant zoster vaccine is recommended for all psoriasis and PsA patients >50 years old and patients <50 years old on tofacitinib, systemic steroids, or combination systemic treatment. Vaccination of patients <50 years old on other systemic therapies may be considered on a case-by-case basis.

Limitations

There was significant heterogeneity between studies.

Conclusion

HZ risk depends on disease severity and treatment class. Recombinant zoster vaccine should be given to all psoriasis and PsA patients >50 years old and younger patients at increased risk.

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Key words : herpes zoster, psoriasis, psoriatic arthritis, recombinant, shingles, Shingrix, vaccination

Abbreviations used : CI, DMARD, HR, IL, HZ, IR, NPF, OR, PHN, PsA, RCT, RZV, RA, TNF-α, VZV

Plan

Targeted synthetic DMARDs

Conventional synthetic DMARDs

Herpes zoster vaccination

Conclusion

Funding sources: None.

Conflicts of interest: Dr Van Voorhees is an advisor, consultant, and/or investigator for Celgene, Corrona, Dermira, Novartis, Allergan, AbbVie, DermTech, Pfizer, Astra Zeneca and Valeant. Dr Garg is an advisor and/or researcher for AbbVie, Pfizer, Asana, National Psoriasis Foundation, and UCB. Dr Feldman is an advisor, consultant, speaker, or researcher for AbbVie, Celgene, Janssen, Lilly, Novartis, Ortho, Merck, Samsung, Almirall, Leo Pharma, and Boehringer Ingelheim. Dr Merola is a consultant and/or investigator for Merck Research Laboratories, Abbvie, Dermavant, Eli Lilly and Company, Novartis, Janssen, UCB, Samumed, Celgene, Sanofi Regeneron, GSK, Almirall, Sun Pharma, Biogen, Pfizer, Incyte, Aclaris, and Leo Pharma, and Dr Baumrin has no conflicts of interest to disclose.