Herpes zoster is associated with prior statin use: a population-based case-control study

Herpes Zoster Infection as a Presentation for Hidden Diabetes Mellitus

The incidence of undiagnosed diabetes mellitus (DM) is high among patients with herpes zoster (HZ) due to complex immune defects. The DM and HZ affect each other's course aggressively.

We introduced three cases of HZ for two men and one woman who were nondiabetic at presentation. Later on, their treating physicians diagnosed them with DM with different degrees of severity of hyperglycemia. They referred the three patients to us for a second opinion and for managing their DM in the presence of HZ. We managed them according to their glycemic figures. The patients were asymptomatic at different follow-up visits.

The innate immune responses are lower in patients with DM, which is not enough for cutaneous protection during the reactivation of the dormant varicella-zoster virus (VZV). HZ and post-herpetic neuralgia (PHN) show an aggressive course in patients with DM and reduce the patient's quality of life. We illustrated three quiescent risk factors for our patients, in addition to undiagnosed DM, prior statin use, and comorbidity with coronary artery disease (CAD) and thyroid disease. These risk factors might affect the immunomodulatory responses and proinflammatory cytokines in various degrees. The management of patients with HZ and underlying DM is challenging. The therapy relies on antiviral medications for infection control, pain control, and a specific management plan for DM in which premixed insulin and metformin are the main components.

Nondiabetic patients with acute HZ infection, whatever the severity, need to be screened for diabetes and/or hyperglycemia at the baseline interview and on frequent intervals thereafter to diagnose possible underlying DM.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.

Association between statin use and herpes zoster: systematic review and meta-analysis

OBJECTIVE

Statins are commonly prescribed worldwide. In addition to being potent lipid-lowering agents, statins have immunomodulating properties that may increase the risk of varicella zoster virus reactivation. This adverse effect may have substantial public health implications.

DESIGN

We performed a meta-analysis of observational studies to assess the association between statin use and the risk of herpes zoster infection. We searched PubMed, Embase, Web of Science and Cochrane databases to identify studies published from 1980 to 2018. The multivariate-adjusted ORs were pooled using random-effect models, and subgroup and sensitivity analyses were performed to examine the source of heterogeneity.

RESULT

Six studies were analysed, with a total of more than two million participants. We determined if the use of statins might increase the risk of infection of herpes zoster (OR 1.18, 95% CI 1.11 to 1. 25). We detected significant heterogeneity (I²=91.2%; p<0.000), and determined that the heterogeneity arises from regional differences.

CONCLUSION

The use of statins may increase the risk of herpes zoster infection. Because the studies included are limited and there may be potential bias, further studies are warranted.

Recurrence Rate of Herpes Zoster and Its Risk Factors: a Population-based Cohort Study

BACKGROUND

Herpes zoster (HZ) is generally thought to occur once in a lifetime and recurrence is considered to be limited to immunocompromised individuals. Although HZ recurrence rates seem to be increasing, there have been few studies exploring these rates in the general population. We investigated the recurrence rate and associated risk factors in the general population.

METHODS

We used the population-based samples of the National Health Insurance Service database to identify cases of initial HZ episodes from January 1, 2002 to December 31, 2013. We also followed up on these cases through December 31, 2013 to identify recurrence.

RESULTS

Overall, the incidence rate of HZ is 5.1 per 1,000 person years and the recurrence rate is 12.0 per 1,000 person years. There were 2,100 recurrent cases out of 39,441 initial episodes with 4.4 years of the mean follow-up period. We identified significant risk factors for recurrence such as old age (51-70 years) (hazard ratio [HR], 1.447; 95% confidence interval [CI], 1.311-1.598), women (1.476; 1.345-1.619), zoster-related pain (ZRP) longer than 30 days (cases of ZRP lasting 31-90 days [1.200; 1.042-1.383], and ZRP lasting longer than 90 days [2.293; 1.990-2.643]). Concurrent hematologic malignancies (2.864; 1.929-4.251), autoimmune diseases (1.466; 1.252-1.715), dyslipidemia (1.390; 1.263-1.530), and hypertension (1.222; 1.107-1.350) were also significant risk factors.

CONCLUSION

Our results suggest that the recurrence of HZ is much more common than generally expected, and that the associated risk factors can play an important role in predicting recurrence.

Herpes zoster infection and statins: which implications in clinical practice?

Herpes zoster (HZ), which is caused by reactivation of latent varicella zoster virus (VZV), constitutes a major public health concern in both short- and long-term periods. Over the last years, several epidemiological studies have demonstrated that statin use is associated with increased risk of HZ at cerebral level. Because statins are among the most popular and best-selling drugs in western countries, this potential negative pleiotropic effect could have important implications in the daily clinical practice. In the present manuscript, we reviewed the available data on the statin use and the relative risk of HZ infection.

Do outpatient statins and ACEIs/ARBs have synergistic effects in reducing the risk of pneumonia? A population-based case-control study

Whether statins and an angiotensin-converting enzyme inhibitors (ACEIs) / angiotensin receptor blockors (ARBs) are associated with reduced risks of infection events is still inconclusive. This study aimed to explore the risk of hospitalization for pneumonia among patients who had received treatment with ACEIs/ARBs and/or statins using a population-based dataset. This study included 19,281 patients as cases who were hospitalized for pneumonia and 19,281 controls. We used a logistic regression to compute the odds ratio (OR) and 95% confidence interval (CI) for having previously used statins or an ACEI/ ARB between patients who were hospitalized for pneumonia treatment and controls. We found there were significant associations between hospitalization for pneumonia and statin-only users (p<0.001), ACEI/ARB-only users (p<0.001), and statin and ACEI/ARB users (p<0.001). The logistic regression analysis suggested that statin-only users (adjusted OR = 0.38, 95% CI = 0.34~0.43), ACEI/ARB-only users (adjusted OR = 0.86, 95% CI = 0.82~0.91), and statin and ACEI/ARB users (adjusted OR = 0.47, 95% CI = 0.44~0.50) were all less likely to be hospitalized for pneumonia treatment than were non-users. Furthermore, we found that statin-only users (adjusted OR = 0.44, 95% CI = 0.40~0.50) and statin and ACEI/ARB users (adjusted OR = 0.55, 95% CI = 0.52~0.58) were less likely to be hospitalized for pneumonia treatment compared to ACEI-only users. However, combined statin and ACEI/ARB users (adjusted OR = 1.24, 95% CI = 1.10~1.40) were more likely to have been hospitalized for pneumonia treatment compared to statin-only users. Although we found use of both statins and ACEI/ARB were significantly associated with a lower risk of pneumonia, the combination of the two medications did not provide additional protection against pneumonia risk.

Statins increase the risk of herpes zoster: A propensity score-matched analysis

OBJECTIVES

Statins, which are lipid-lowering agents, have anti-inflammatory and immunomodulatory properties that may affect the occurrence of various infectious diseases. We assessed whether statins increase the risk of herpes zoster (HZ) with propensity score-matching.

METHODS

The study was based on the National Health Insurance database and its subset database of the "medical check-up" population of South Korea. These cohorts consist of about one million and 570,000 people, respectively, representative of the entire population of South Korea. We identified 103,930 statin users and 430,685 non-statin users. After propensity score-matching, 25,726 statin users and the same number of non-statin users were finally analyzed. The development of HZ was monitored in these matched pairs over the 11 years from 2003 to 2013.

RESULTS

Statin users had a significantly higher risk of HZ than non-statin users: hazard ratio (HR) 1.25 (95% CI, 1.15 to 1.37) (p < .0001). The risk of HZ associated with statins was especially high in the elderly: HR 1.39 (95% CI, 1.12 to 1.73) in the over 70-year-olds (p = 0.003) and HR 1.18 (95% CI, 1.00 to 1.39) in the 60-to-69-year-olds (p = 0.056). Furthermore, there was a significant p for trend in terms of cumulative dose effect between the risk of HZ and the duration of statin use (p < .0001).

CONCLUSIONS

These epidemiologic findings provide strong evidence for an association between HZ and statin use, and suggest that unnecessary statins should be avoided.

Herpes Zoster in Persons Living with HIV-1 Infection: Viremia and Immunological Defects Are Strong Risk Factors in the Era of Combination Antiretroviral Therapy

In a cohort of 4,225 persons living with human immunodeficiency virus type 1 (HIV-1) infection (PLWH) enrolled at a southeastern US clinic, the overall rate of incident herpes zoster (HZ) was 101 per 10,000 person-years (PY) between January 1999 and 2017, which nearly quadruples the rate reported for the general US population. In the same cohort, the median age of HZ diagnosis was 39.5 years [interquartile range (IQR) 31.5-49.2] in African American (AA) and 39.1 years (IQR 34.9-45.2) in European American (EA) PLWH, with the highest incidence seen in PLWH who were over 50 years old (144 and 93 per 10,000 PY in AA and EA, respectively, P = 0.18), showing no bias between men (100 per 10,000 PY) and women (101 per 10,000 PY). In multivariable models that were applicable to 245 HZ cases and 3,713 controls, age, nadir CD4+ T-cell (CD4) count, plasma viral load (VL), and duration of combination antiretroviral therapy were independent correlates of incident HZ (adjusted P ≤ 0.006 for all). Regardless of other factors, viremic PLWH (VL > 50 copies/mL) was at the highest risk of HZ [adjusted odds ratio (OR) > 3.0, P < 0.0001]. PLWH with a nadir CD4 count of ≥500 cells/μL showed a relatively low risk (adjusted OR = 0.48, P = 0.003). By contrast, similar risk estimates were observed with three advancing age groups (30-39, 40-49, and ≥50) when compared with age <30 (adjusted OR = 1.86-2.17, P ≤ 0.010). These findings indicate that efforts for HZ diagnosis and prophylaxis should target viremic PLWH who are over 30 years old and with CD4 count <500 cells/μL.

Risk Factors for Herpes Zoster: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review studies examining risk factors for herpes zoster (HZ).

METHODS

We performed a literature search using PubMed, EMBASE, and Web of Science for articles published from January 1, 2003, to February 1, 2017. A random-effects model was used to summarize the risk ratio (RR) or odds ratio (OR) and 95% CI.

RESULTS

Of the 3450 studies screened, we included 84 studies in the systematic review and conducted meta-analysis in 62 studies. Women were at increased risk of HZ compared with men (pooled adjusted RR, 1.31; 95% CI, 1.27-1.34). Black individuals had almost half the risk of HZ as white individuals (pooled RR, 0.54; 95% CI, 0.47-0.63). Family history was found to be a risk factor for HZ (pooled OR, 3.59; 95% CI, 2.39-5.40). Autoimmune diseases, including rheumatoid arthritis (pooled RR, 1.67; 95% CI, 1.41-1.98) and systemic lupus erythematosus (pooled RR, 2.10; 95% CI, 1.40-3.15), were associated with an elevated risk of HZ. Other comorbidities were associated with an increased risk of HZ, with the pooled RRs ranging from 1.25 (95% CI, 1.13-1.39) for asthma to 1.30 (95% CI, 1.17-1.45) for diabetes mellitus and 1.31 (95% CI, 1.22-1.41) for chronic obstructive pulmonary disease.

CONCLUSION

Our review revealed that female sex, race/ethnicity, family history, and comorbidities are risk factors for HZ. Efforts are needed to increase the uptake of zoster vaccination.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.