SAN FRANCISCO -- Patients with an autoimmune disease, such as rheumatoid arthritis (RA), have a significantly elevated risk for having a stroke within a month of developing herpes zoster, researchers reported here.
After adjustment for multiple potential confounders, the incidence rate ratio for autoimmune disease patients being hospitalized with an ischemic stroke within 30 days after developing herpes zoster reactivation was 1.50 (95% CI 1.06-2.12) compared with their rate in subsequent years 2 to 6, according to , of the Cleveland Clinic, and colleagues.
Action Points
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
The risk of stroke remained high throughout the first year after the shingles episode, with an incidence rate ratio of 1.30 (95% CI 1.05-1.61) compared with their risk in year 2, he reported in a plenary session at the at the American College of Rheumatology annual meeting.
"These data are important as we now live in an era of increasing concern over herpes zoster," Calabrese said.
Zoster is associated with significant morbidity even in its less serious forms, and stroke is one of its potential complications.
"Among patients with immune-mediated diseases on certain biologics and immunomodulators the rates [for herpes zoster] are extremely high. In general, we believe that patients in rheumatology practices have a 50% to 100% increased rate of herpes zoster," he said.
Previous studies have suggested that the risk of stroke may rise shortly after an episode of varicella zoster virus reactivation. In four earlier studies, hazard ratios for stroke ranged from 1.26 to 4.52, depending on the type of zoster, timing, and antiviral therapy.
However, little is known about the risk among patients with autoimmune diseases -- who have an elevated risk for both zoster and stroke.
Calabrese and colleagues analyzed Medicare data for the years 2006 to 2013 for patients with diagnoses of RA, ankylosing spondylitis, psoriatic arthritis, psoriasis, or inflammatory bowel disease plus a diagnosis of zoster and prescription for antiviral therapy within 1 week.
They identified 50,929 patients with an autoimmune disease plus incident zoster. Three-quarters of the patients were women, their mean age was 71, and 85% were white.
During the first 6 months after the zoster diagnosis, the crude incidence rate of hospitalization for ischemic stroke was 9.8 per 1,000 patient-years, while the rate in years 2 to 6 was 8.7 per 1,000.
The researchers also performed a subgroup analysis for more complicated forms of zoster.
Two-thirds of patients classified as having complicated disease had zoster of the head and neck. For the overall group and the more serious, complicated group, after adjustment for multiple factors, the hazard ratio for stroke was 1.6 in the uncomplicated group and 3.2 in the complicated group in the first 30 days.
The researchers also conducted a sensitivity analysis to see if prompt diagnosis and treatment might mitigate the incidence of stroke.
Among patients who had no antiviral therapy, the hazard ratio for ischemic stroke was 1.4 (95% CI 0.8-2.5) during the first 30 days, similar to the overall group, but this persisted and did not decrease in the subsequent 2 months.
"There was a 16% lower risk when antivirals were administered within 7 days," Calabrese noted.
He urged clinicians to advocate for zoster vaccination.
"There is now a new urgency for vaccination for zoster, as prevention of stroke may be an additional downstream benefit," he said. "Unfortunately, the herpes zoster vaccine has had a low penetration in the general population as well as among patients with immune mediated diseases, and effective measures are needed to increase vaccination rates."
Calabrese also supported the use of antiviral therapy on zoster diagnoses.
"Our data also suggest that prompt antiviral therapy may actually reduce the rate of stroke following zoster, and thus prompt diagnosis and treatment are needed more than ever," he said.
Limitations of the study included the use of administrative data, and a lack of information about stroke type and anatomic distribution.
Disclosures
Calabrese disclosed relevant relationships with Bristol-Myers Squibb, Crescendo, AbbVie, Genentech, Biogen IDEC, Pfizer, Sanofi-Aventis, and Johnson & Johnson.
Primary Source
American College of Rheumatology
Calabrese L, et al "Herpes zoster and the short term risk for ischemic stroke in patients with autoimmune diseases" ACR 2015; Abstract 896.