Herpes Zoster and IBD: What Are the Risks?

June 7, 2019

Two studies outline the risks of shingles for patients with IBD.

Inflammatory Bowel Disease (IBD) puts its sufferers at greater risk for developing life-threatening infections, including herpes zoster (HZ), a risk that could be prevented through immunization, according to two recent studies.

IBD encompasses chronic inflammatory conditions caused by the body’s immune attacks on the gastrointestinal tract. The two most common IBDs are ulcerative colitis and Crohn’s disease.

The majority of IBD patients are diagnosed by the age of 35. The CDC says three million adults in the United States report being diagnosed with it, although that number does not include children under 18 years old. There is no cure for IBD, but treatment can help reduce and control the symptoms of the disease.

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IBD patients’ susceptibility to the varicella zoster virus (VZV) is linked to the immunosuppressive treatments they receive. For example, at least one drug approved by the FDA to treat ulcerative colitis-tofacitinib (Xeljanz)-lists an added risk for herpes zoster in its black box warning

The link between IBD and herpes zoster was underscored by a population-based cohort study conducted in the United States that analyzed data collected by the National Inpatient Sample between 2012 and 2015. Researchers identified 7,180 IBD patients who were hospitalized with a primary diagnosis of a vaccine-preventable disease, including HZ, pneumococcal pneumonia, hepatitis B, varicella zoster, meningococcal meningitis, and influenza. Approximately 589,000 weighted patients without IBD who were hospitalized for a vaccine-preventable disease were also identified.

Among the IBD patients, herpes zoster was the most frequent primary diagnosis, causing 39.6% of the hospitalizations. This compared to a rate of 30.3% in the non-IBD patients. The HZ infection rate was 110% higher among the ulcerative colitis patients and 140% higher in patients with Crohn’s disease when compared to the general population.

Reporting on the study at the Digestive Disease Week 2018 conference, researcher Daniela G. Vinsard, MD, noted that IBD patients should receive the full course of the Shingrix vaccine before starting an immunosuppressive regimen.

This advice follows the clinical guidelines for preventive care for IBD established by the American College of Gastroenterology (ACG). “In particular, documentation of up-to-date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations,” the ACG notes.

A second large population-based study was conducted in Canada and included all patients in the Québec provincial health administrative database from 1996 to 2015. Almost 40,000 patients diagnosed with IBD and 2,158 cases of herpes zoster were identified.

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As expected, the incidence of HZ was markedly increased in IBD patients over the age of 50, which is when the risk begins to rise in the general population. A novel finding, however, was that the incidence was also high in children with IBD under the age of 18. Women were found to have a higher incidence of shingles than men at all ages.

The authors of the study attributed the high incidence of HZ in the IBD patients to an increased use of immune-suppressing biologics and JAK inhibitors, both established risk factors. In addition to initiating HZ vaccination for IBD patients as young as 50 years of age, they concluded that “the high incidence of HZ in young IBD patients should also raise the indication to vaccinate this at-risk population.”