Rheumatoid Arthritis Raises Shingles Risk
Older adults with RA are more likely to develop this viral infection if they’ve had chickenpox.
Updated by Linda Rath | April 7, 2023
Older adults with rheumatoid arthritis (RA) have a higher risk than those without the disease of developing shingles, a virus related to chickenpox that causes pain and a blistering rash.
Most adults have been exposed to varicella zoster virus, which causes chickenpox. This virus is never completely cleared from our bodies, but lies quietly in spinal nerve cells. If it’s reactivated, it causes shingles, explains Jeffrey Curtis, MD, a rheumatologist and epidemiologist at the University of Alabama at Birmingham. The reactivated virus is called herpes zoster or shingles.
Shingles often begins as burning, tingling or itching in a limited area on one side of the body. Days or weeks later, fluid-filled blisters appear, often in a single band wrapping around the torso, though shingles also can affect the face and eyes. Pain can be relatively mild or so intense even a light touch is unbearable.
“As we get older, our immune systems are not as effective at protecting us from infection, and this makes it easier for the shingles virus to ‘escape’ and reactivate,” says Dr. Curtis, who notes shingles is most common in people older than 60. “If you have RA, your immune system is already disordered, and then if you are prescribed medications that further impair your immune defenses, it becomes even more likely the virus will reactivate.”
RA Medications and Shingles Risk
Many medications for RA suppress the immune system and can increase the risk of developing shingles. The clearest association is found with corticosteroids, says Kevin Winthrop, MD, MPH, professor of infectious diseases, ophthalmology and public health at Oregon Health & Sciences University in Portland.
“Almost every study shows that using prednisone at dosages commonly prescribed for RA [10 mg/day] doubles the risk of developing shingles,” he says.
Recent studies have reported even higher risks with other RA drugs. A study published in The BMJ in 2022 analyzed health data from 14,000 patients between 2007 and 2020. All had RA and were treated with a variety of medications, including JAK inhibitors such as tofacitinib (Xeljanz) and baricitinib (Olumiant); biologic drugs including tumor necrosis factor (TNF) blockers like adalimumab (Humira), B-cell targeted therapies like rituximab (Rituxan), interleukin (IL)-6 inhibitors such as tocilizumab (Actemra); and conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate. The study found that patients on JAK inhibitors had nearly four times greater chance of getting shingles compared to those taking conventional DMARDs. The biologics also posed a significantly higher risk.
Treatment
Starting treatment with anti-viral drugs no more than three days after the rash starts often resolves symptoms in a few weeks. The decision to take antiviral drugs depends on a person’s age, where and how long they’ve had shingles and the potential for complications.
One analysis of 21 randomized controlled trials found that acupuncture reduced pain and cleared shingles blisters and scabs better than anti-virals, while also reducing complication risk by 83%.
Still, the virus usually clears on its own in three to five weeks without any treatment, although the chance of complications may be higher. Experts say having RA does not appear to increase the virus’ severity or its complications.
Complications
The most common — and feared — complication of shingles is a chronic pain condition called postherpetic neuralgia (PHN), which develops in about 10% to 15% of older adults who have had shingles. PHN usually improves gradually but can sometimes last for years.
Other potential complications include inflammation of the eye or retina that can cause pain and vision loss, and ear inflammation that can lead to hearing loss or facial weakness on the affected side.
An increased risk of stroke — already elevated in people with RA — is another possible complication of shingles. The risk seems to last at least a year after infection, leading the authors of one large 2022 study to report that virus-induced proteins and activated platelets may contribute to stroke risk. They recommend adding anti-platelet therapy to standard shingles treatment.
Prevention
One way to prevent shingles is to get vaccinated against the virus with Shingrix, a safer and more effective version of an older shingles vaccine called Zostavax, which is no longer available in the U.S. Shingrix contains live, weakened virus. It’s approved for people older than 50 and for young adults over 19 who are immunocompromised. Shingrix is the first shingles vaccine approved for immunocompromised people.
Keep in mind that you can spread the virus to people who haven’t had chickenpox or the vaccine if they’re exposed to fluid-filled blisters. While your rash is active, take care around kids, older adults and anyone who is immunocompromised, including those with RA.
Older adults with rheumatoid arthritis (RA) have a higher risk than those without the disease of developing shingles, a virus related to chickenpox that causes pain and a blistering rash.
Most adults have been exposed to varicella zoster virus, which causes chickenpox. This virus is never completely cleared from our bodies, but lies quietly in spinal nerve cells. If it’s reactivated, it causes shingles, explains Jeffrey Curtis, MD, a rheumatologist and epidemiologist at the University of Alabama at Birmingham. The reactivated virus is called herpes zoster or shingles.
Shingles often begins as burning, tingling or itching in a limited area on one side of the body. Days or weeks later, fluid-filled blisters appear, often in a single band wrapping around the torso, though shingles also can affect the face and eyes. Pain can be relatively mild or so intense even a light touch is unbearable.
“As we get older, our immune systems are not as effective at protecting us from infection, and this makes it easier for the shingles virus to ‘escape’ and reactivate,” says Dr. Curtis, who notes shingles is most common in people older than 60. “If you have RA, your immune system is already disordered, and then if you are prescribed medications that further impair your immune defenses, it becomes even more likely the virus will reactivate.”
RA Medications and Shingles Risk
Many medications for RA suppress the immune system and can increase the risk of developing shingles. The clearest association is found with corticosteroids, says Kevin Winthrop, MD, MPH, professor of infectious diseases, ophthalmology and public health at Oregon Health & Sciences University in Portland.
“Almost every study shows that using prednisone at dosages commonly prescribed for RA [10 mg/day] doubles the risk of developing shingles,” he says.
Recent studies have reported even higher risks with other RA drugs. A study published in The BMJ in 2022 analyzed health data from 14,000 patients between 2007 and 2020. All had RA and were treated with a variety of medications, including JAK inhibitors such as tofacitinib (Xeljanz) and baricitinib (Olumiant); biologic drugs including tumor necrosis factor (TNF) blockers like adalimumab (Humira), B-cell targeted therapies like rituximab (Rituxan), interleukin (IL)-6 inhibitors such as tocilizumab (Actemra); and conventional disease-modifying antirheumatic drugs (DMARDs) like methotrexate. The study found that patients on JAK inhibitors had nearly four times greater chance of getting shingles compared to those taking conventional DMARDs. The biologics also posed a significantly higher risk.
Treatment
Starting treatment with anti-viral drugs no more than three days after the rash starts often resolves symptoms in a few weeks. The decision to take antiviral drugs depends on a person’s age, where and how long they’ve had shingles and the potential for complications.
One analysis of 21 randomized controlled trials found that acupuncture reduced pain and cleared shingles blisters and scabs better than anti-virals, while also reducing complication risk by 83%.
Still, the virus usually clears on its own in three to five weeks without any treatment, although the chance of complications may be higher. Experts say having RA does not appear to increase the virus’ severity or its complications.
Complications
The most common — and feared — complication of shingles is a chronic pain condition called postherpetic neuralgia (PHN), which develops in about 10% to 15% of older adults who have had shingles. PHN usually improves gradually but can sometimes last for years.
Other potential complications include inflammation of the eye or retina that can cause pain and vision loss, and ear inflammation that can lead to hearing loss or facial weakness on the affected side.
An increased risk of stroke — already elevated in people with RA — is another possible complication of shingles. The risk seems to last at least a year after infection, leading the authors of one large 2022 study to report that virus-induced proteins and activated platelets may contribute to stroke risk. They recommend adding anti-platelet therapy to standard shingles treatment.
Prevention
One way to prevent shingles is to get vaccinated against the virus with Shingrix, a safer and more effective version of an older shingles vaccine called Zostavax, which is no longer available in the U.S. Shingrix contains live, weakened virus. It’s approved for people older than 50 and for young adults over 19 who are immunocompromised. Shingrix is the first shingles vaccine approved for immunocompromised people.
Keep in mind that you can spread the virus to people who haven’t had chickenpox or the vaccine if they’re exposed to fluid-filled blisters. While your rash is active, take care around kids, older adults and anyone who is immunocompromised, including those with RA.
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