Rheumatoid arthritis (ra), the prevention and management of herpes zoster | clinical necessary

2022-06-10 0 By

Edited by Yimai Tong, please do not reprint without authorization.Patients with rheumatoid arthritis (RA) are at a higher risk of infection than the general population due to disease-related immune disorders and long-term use of immunosuppressants and glucocorticoids.Clinically, the more common pathogens causing infection include bacteria, fungi and viruses, among which herpes zoster virus infection is the more common viral infection.The risk of shingles in patients with autoimmune diseases is 1.5 to 2 times higher than in the general population.Some patients with shingles develop postherpetic neuralgia, resulting in disability and reduced quality of life.Therefore, it is recommended that patients with autoimmune diseases such as RA be pre-vaccinated to prevent shingles.The necessity of prevention of herpes zoster infection in PATIENTS with RA The presence of autoimmune disorders in patients with rheumatoid disease, combined with the effect of immunosuppressive therapy, increases the risk of herpes zoster infection in patients with rheumatoid disease.Treatment with glucocorticoids and JAK inhibitors has been shown to increase the risk of shingles;Traditional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), including methotrexate, leflunomide, sulfonazine and hydroxychloroquine, have also been reported to increase the risk of shingles;However, there is no consensus on whether biological-modifying anti-rheumatic drugs (bDMARDs) also increase the risk of shingles.In addition, RA complicated with herpes zoster infection is more common in female patients, and age is an important risk factor for herpes zoster infection.Therefore, attention should be paid to elderly female RA patients and preventive measures should be taken before infection.Vaccination for RA Patients is currently the most effective way to prevent shingles virus infection.There are two types of shingles vaccines available: live attenuated and recombinant.A recent systematic review and meta-analysis showed that the recombinant vaccine was superior to live attenuated vaccine in preventing shingles in patients > 50 years of age, but injection site reactions were also more pronounced.The 2015 American College of Rheumatology (ACR) RA guidelines recommend live attenuated vaccines for patients aged ≥50 years 2 weeks prior to initiation of bDMARDs or toftib treatment, and not for patients undergoing bDMARDs.The 2019 European Union against Rheumatism (EULAR) vaccination recommendations for adults with autoimmune inflammatory rheumatic Disease (AIIRD) state that live attenuated vaccines can be given 4 weeks before the start of bDMARDs or tsDMARDs, but not during treatment.Due to a lack of data, there are no recommendations for the recombinant vaccine.However, multiple reports indicate that less than 10% of RA patients are vaccinated against shingles.Therefore, it is necessary for doctors and patients to be more aware of and pay attention to the risk of shingles.Treatment of PATIENTS with RA complicated with shingles Shingles is usually presented as a blister eruption (most commonly on the thorax) with mild to moderate pain in the area of the rash, and general discomfort.Note that in some cases, herpes zoster may have no obvious skin symptoms and may present as conjunctivitis or uveitis.When RA patients are complicated with shingles, immunosuppressive therapy should be discontinued until shingles is cured.Discontinuation of immunosuppressive therapy is recommended for severe infections, even if only localized.For specific treatment, standard antiviral therapy, such as oral acyclovir, faciclovir, famiclovir, or brovudine, should be started within 48 to 72 hours of diagnosis of shingles, for ≥7 days until the lesions scab.The treatment helps control rash symptoms and relieve acute pain.Intravenous acyclovir can be used to treat disseminated shingles.Nonsteroidal anti-inflammatory drugs and opioid painkillers can be used to relieve acute pain.Longer term pain management is needed in patients with postherpetic neuralgia characterized by chronic persistent pain ≥3 months and paresthesia.1. Mo Hailu, Hong Xuezhi, Fu Xiaonan, et al.Rheumatoid arthritis (ra) patients complicated with herpes zoster clinical characteristics and risk factors [J]. Journal of guangxi medicine, 2019, 9 (5) : 537-540. The DOI: 10.11675 / j.i SSN. 0253-4304.2019.05.01.2. Winthrop KL, Tanaka Y,Lee EB, Wollenhaupt J, Al Enizi A, Azevedo VF, Curtis JR. Prevention and management of herpes zoster in patients with rheumatoid arthritis and psoriatic arthritis: a clinical review. Clin Exp Rheumatol. 2022 Jan-Feb;Epub 2021 May 28. PMID: 34128786.3.DOI:10.16138/ J.1673-6087.2019.01.014. (in Chinese with English abstract)