Conventional, biological disease-modifying anti-rheumatic drugs and Janus kinase inhibitors and varicella zoster virus

ABSTRACT

Introduction

The advent of biological disease-modifying anti-rheumatic drugs (bDMARDs), and more recently of Janus kinase inhibitors (JAKi), has had a major impact on the herpes zoster (HZ) reactivation, which represents an important clinical challenge in the treatment of inflammatory arthritis (IA) in patients with a complete pharmacological control of peripheral inflammation.

Areas covered

In this review, we provide an overview on the effects of conventional DMARDs/ bDMARDs and JAKi on HZ reactivation. Furthermore, we underline the controversial findings and the potential management strategies. We searched PubMed, Medline, and the Cochrane Library for papers published between 1995 and November 2022.

Expert opinion

The overall data showed a slightly higher risk of HZ in patients treated with bDMARDs, and more pronounced for those treated with JAKi. As management strategies, we suggest an effective vaccination campaign and a focus on early diagnosis.

KEYWORDS:

• Herpes zoster
• HZ
• JAK inhibitors
• cDMARDs
• bDMARDs
• rheumatoid arthritis
• spondyloarthritis

Article highlights

• The risk of herpes zoster (HZ) reactivation in patients with systemic inflammatory arthritis differs according to the type of the disease-modifying anti-rheumatic drugs (DMARDs) received.

• HZ reactivation occurs almost two-fold more frequently in Rheumatoid Arthritis (RA) patients compared to the general population.

• Several risk factors are associated with HZ including disease activity, medium-high dose corticosteroid assumption, age, and comorbidities. This suggests that clinicians need to be aware of them in order to prevent HZ reactivation.

• Tumour necrosis factor inhibitors (TNFi) are associated with a slightly increased risk of HZ reactivation in RA, with no obvious differences between anti-TNF drugs.

• Janus kinase inhibitors (JAKi) are associated with a significant increase of the risk of HZ reactivation, especially at high dose and in combination with other conventional DMARDs.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.