PracticeUpdate Dermatology May 2019

EDITOR’S PICKS 9

Herpes Zoster Incidence and Consensus Recommendations on Vaccination in Adults on Systemic Therapy for Psoriasis or Psoriatic Arthritis Take-home message • This systematic review of 41 studies assessed the risk of herpes zoster in patients with psoriasis and/or psoriatic arthritis receiving systemic treatment. Treatments that are associated with an increased herpes zoster risk include systemic corticosteroids (strong evidence), tofacitinib (strong evidence), and combination therapy with biologic and conventional synthetic disease-modifying antirheumatic drugs (weak evidence). There is insufficient evidence to evaluate the risk associated with apremilast or interleukin 12/23, 17, and 23 inhibitors. • Recombinant zoster vaccine is recommended for all patients with psoriasis and psoriatic arthritis who are >50 years old and for younger patients at an increased risk, including those on tofacitinib, systemic steroids, or combination systemic treatment. InYoung Kim MD, PhD Journal of the American Academy of Dermatology

Abstract BACKGROUND Herpes zoster (HZ) incidence is linked to immunosuppression. Patients with psoriasis (PsO) and/or psoriatic arthritis (PsA) on systemic therapy may be at increased risk for HZ. OBJECTIVE To assess HZ risk in patients with PsO/ PsA by systemic treatment and provide recom- mendations regarding HZ vaccination. METHODS A systematic literature search was performed of HZ in patients with PsO/PsA. HZ vaccination guidelines were reviewed and the medical board of the National Psoriasis Foun- dation made consensus recommendations in PsO/PsA patients based on graded evidence. RESULTS 41 studies met inclusion criteria. Sys- temic corticosteroids (strong, 1), tofacitinib (strong, 1), and combination therapy with biologic and conventional synthetic disease modifying antirheumatic drugs (weak, 2a) carry increased HZ risk while monotherapy does not. There is insufficient evidence to determine risk with inter- leukin 12/23, 17, and 23 inhibitors, or apremilast (weak, 2a). Recombinant zoster vaccine is rec- ommended for all PsO/PsA patients >50 years old and to patients <50 years old on tofacitinib, systemic steroids, or combination systemic treat- ment. Vaccination of patients <50 years old on other systemic therapies may be considered on a case-by-case basis. LIMITATIONS There was significant heterogeneity between studies. CONCLUSIONS HZ risk depends on disease severity and treatment class. Recombinant zoster vaccine should be given to all PsO/PsA patients >50 years old and younger patients at increased risk. A Systematic Review of Herpes Zoster Inci- dence and Consensus Recommendations on Vaccination in Adult Patients on Systemic Ther- apy for Psoriasis or Psoriatic Arthritis: From the Medical Board of the National Psoriasis Foun- dation. J Am Acad Dermatol 2019 Mar 15;[EPub Ahead of Print], E Baumrin, A Van Voorhees, A Garg, et al. www.practiceupdate.com/c/81555

COMMENT By Robert T. Brodell MD, FAAD C onsidering all patients with psoriasis “who” are seen in the dermatol- ogist’s office, the authors of this study have done a good job determining who should get the recombinant zoster vaccine prior to initiating therapy: • All patients being treated with a bio- logic over the age of 50. In any event, it has been recommended that all immunocompetent individuals should get the vaccine at this age. • Patients being treated with systemic corticosteroids, tofacitinib, and com- bination therapy with a traditional systemic psoriasis drug and a biologic at any age because of their increased risk of shingles. They also discuss “why” this should be done: • To prevent shingles when possible in at-risk patients • To reduce the severity of shingles when it is not prevented. The problem is “how” to get this done! The barriers: • The cost of the vaccine is more than USD$200. Physicians can charge about USD$20 more than this, but if only 1 in 10 patients does not pay his/her bill, the dermatology office loses money trying to do what is right. Response: I would recommend that patients be referred to their pharmacy to get their vaccine, but many will not adhere to this approach.

• Busy physicians who are well-meaning may forget to place the order for zoster vaccination. Response: A systemmust be put into place to remind the phy- sician to place the order. This might be a simple checklist reminder, which could include laboratory tests, and a reminder to dispense educational material. • Some patients may resist all vaccina- tions. Response: Education materials can be prepared, and providers, if over the age of 50, can administer the vaccine to themselves. Thus, they can tell their patients, “I took it myself!” In fact, there is a science behind convincing patients to take vaccines that is rooted in characterizing the reasons the individuals are refusing the vaccine (Table 1). 1 However, it is certainly impossible to convince some “non-vaccinators” to accept vaccines of any kind. Table 1: Reasons Patients Refuse Vaccines 1 • Complacency • Inconvenience • Lack of confidence (this would include a subset of anti-vaccinators who are fervently against vaccines of all kinds) • Rational calculation of pros and cons Reference 1. Betsch C, Bohm R, Chapman G. Using behav- ioral insights to increase vaccination policy effectiveness. Policy Insights Behavi Brain Sci 2015;2(1):61-73.

VOL. 3 • NO. 2 • 2019