Powerful new medicines used to suppress the immune system don't increase the risk of the skin disease shingles, a study finds. People who have had chickenpox can develop shingles. The virus that causes chickenpox stays hidden in the body. If it becomes active again, it can cause shingles. The study focused on people with autoimmune diseases. These diseases are caused by an attack of the immune system on part of the body. Examples include rheumatoid arthritis and Crohn's disease. The newest medicines for some of these conditions are called anti-tumor necrosis factor (anti-TNF) drugs. They suppress the immune system. As a result, they can increase the risk of some infections. The new study looked at records for about 60,000 people with autoimmune diseases. It compared shingles rates for those who took anti-TNF drugs and those who took other drugs. There was no increase in shingles among people taking anti-TNF drugs. People taking high doses of another type of medicine called a corticosteroid had twice the odds of developing shingles. The Journal of the American Medical Association published the study. HealthDay News wrote about it March 6.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Have you seen the ads for the shingles vaccine?

Seeing the rash and hearing about the pain is enough to worry anyone. But it's especially worrisome for the elderly and those with abnormal immune systems. These groups are at the highest risk to get shingles. And they're at the highest risk for further problems caused by shingles.

Shingles is a painful rash that usually affects a single patch of skin and lasts two to four weeks. It's caused by a herpes virus called varicella-zoster. This is the same virus that causes chickenpox.

After a bout of chickenpox, usually during childhood, the virus stays in the body. It lives in an inactive state near nerves beneath the skin. Then, many years later, the "sleeping" virus suddenly awakens, causing shingles. If you've had chickenpox in the past -- and most of us have -- you could develop shingles in the future.

Shingles can strike just about anyone. But those at highest risk include:

• The elderly -- Up to half of all people age 85 or older have had or will have shingles.
• People with a disease that impairs immune function, such as AIDS or cancer.
• Those who take medicines that suppress the immune system -- Cancer treatments and corticosteroids are common examples.

A new study examined the risk of shingles among nearly 60,000 people. All were taking anti-tumor necrosis factor (anti-TNF) drugs to suppress the immune system. These drugs are taken for rheumatoid arthritis, colitis and other inflammatory conditions.

The study compared rates of shingles over time among people starting anti-TNF medicines and those starting other treatments. Here's what it found:

• The rate of shingles was similar between users of anti-TNF drugs and other treatments.
• There was no difference in the shingles rate based on the specific anti-TNF drug taken or the condition for which it was taken.
• Among those with rheumatoid arthritis, an increased risk of shingles was seen in some groups. They were:
  
  • Older
  • Female
  • Taking higher doses of corticosteroids

Previous research has found that shingles risk is up to three times higher for people with rheumatoid arthritis than for people without the disease. Anti-TNF drugs are powerful medicines that increase the risk of other infections, particularly tuberculosis. So I would have predicted that people taking these medicines would have a greatly increased risk of shingles. It's reassuring that they did not.

This study is important. Anti-TNF drugs are still relatively new. Yet they are used regularly by millions of people worldwide. The benefits of these new drugs are remarkable. However, we must continue to assess their safety in careful research studies such as this one.

What Changes Can I Make Now?

See your doctor if you think you may have shingles. Treatment is more effective if started right away.

Symptoms include:

• A swath of red skin with small, fluid-filled blisters (called vesicles)
• Pain, tingling or numbness over a patch of skin -- This may precede the rash. It may also linger for months or years after the rash has disappeared. This condition is called post-herpetic neuralgia.
• Fever
• Chills
• Headache

It's particularly important to seek medical care if your eye or the skin near your eye is affected by shingles or if you have a suppressed immune system.

Shingles is contagious and can be a dangerous illness for certain people. So, if you have shingles, avoid close contact with:

• Newborns
• Pregnant women
• People who have a suppressed immune system
• People who have never had chickenpox

Vaccination for shingles is approved for people who are age 50 and over. However, some doctors limit its routine use to those ages 60 and older. Pregnant women and those with certain immune impairments should NOT receive this vaccine. Check with your doctor if you aren't sure about whether you should get the shingles vaccine.

Finally, vaccination for chickenpox is also available. The shots are recommended for all healthy children. The first dose is given between the ages of 12 and 15 months. The second dose is given between 4 to 6 years old. The prevention of chickenpox should reduce the rate of shingles later in life.

What Can I Expect Looking to the Future?

Anti-TNF drugs are a major success in treating serious diseases. But it's important that we continue to evaluate the safety of new drugs even after they are approved for widespread use.

Not so long ago, shingles was thought to be an unavoidable risk for older adults and people with immune systems impaired by disease or medicines. The future will be different. Where vaccinations for chickenpox and shingles are widespread, you can expect the rate of shingles to plummet. Considering the suffering this condition causes and the estimated $1 billion spent each year on treatment, prevention of shingles will continue to be a priority as well.