Immunosuppressed patients have increased risk for stroke immediately after herpes zoster

SAN FRANCISCO — The risk of stroke is greatest for patients with complex herpes zoster, particularly those affecting the head and neck, according to a presentation during the Plenary Session of the American College of Rheumatology Annual Meeting, here. However, the research suggest that “prompt antiviral therapy for herpes zoster is associated with lower subsequent stroke with risk consistent with previous studies.”

“Herpes zoster is a public health concern given a lifetime risk of approximately one in three with an expected 1 million cases annually can be observed in the United States,” Leonard H. Calabrese, DO, Chief Medical Editor of Healio Rheumatology and vice chairman of the Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, said. “We, as rheumatologists, have a particular interest in herpes zoster as our patient population is disproportionately affected.”

Leonard H. Calabrese

Calabrese said stroke is associated complication of herpes zoster (HZ) and new knowledge had led to the belief that the relationship between stroke and HZ is more common. As no study has specifically looked at immune-mediated disease patients to assess the risk, Calabrese said he and his and colleagues examined this risk.

The researchers used the 2006 to 2013 Medicare database with 100% of the patient sample having rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, psoriasis or ankylosing spondylitis. The main inclusion/exclusion criteria were that the index date was set as the first occurrence of HZ by ICD-9 diagnosis code plus a prescription for antiviral therapy within 7 days; two or more diseases of interest had to be defined; no stroke diagnosis prior to the index date; and no antiviral drugs given prior to the index date, Calabrese said.

Follow-up started the day after HZ diagnosis and the outcome of interest was hospitalized stroke. For patients with autoimmune diseases, he said the incident herpes zoster was associated with a 50% increase risk for stroke in the subsequent month.

The crude incidence rate of hospitalized ischemic stroke was 9.8/1000 patient-years in the 6 months after HZ, compared to 8.7/1000 patient-years in year 2 through year 6. After multivariate adjustment for multiple stroke-related factors, the incidence rate ratios for the risk in the first year compared to the second year was 1.30 (1.05-1.61) compared to month 12 to month 18, according to the abstract.

“More impressively, we examined stroke in those patients with serious or more complicated forms of zoster,” Calabrese said. “The spike in cases is 2.5 times that of the overall group in the first 30 days and remains elevated in the next time window through 3 months.”

There was 16% lower risk for subsequent stroke when antiviral therapy was administered within 7 days, he said. Calabrese and colleagues also found patients with immune-mediated illnesses who developed HZ had a similar increased risk of hospitalized stroke consistent with the literature for the general population, particularly in early time windows.

“Current data suggest that our patients – immune-mediated disease patients – are underprotected due to low vaccine rates,” Calabrese said. “They may be missing an additional ‘downstream’ benefit of vaccination of subsequent reduction of stroke.”

“New strategies to optimize prompt diagnosis and treatment, as well as preventative measures for HZ, are urgently needed,” he said. – by Joan-Marie Stiglich, ELS

Reference:

Calabrese LH, et al. Abstract #896. Presented at: American College of Rheumatology Annual Meeting; Nov. 7-11, 2015; San Francisco.

Disclosures: Calabrese reports financial disclosures with AbbVie, Bristol-Myers Squibb, Biogen, Crescendo Bioscience, Genentech, Johnson & Johnson, Pfizer and Sanofi-Aventis Pharmaceuticals. See the abstract for additional authors’ financial disclosures.