Risk of Herpes Zoster and Opportunistic Infections with Treatments for Autoimmune Rheumatic Disease

Abstract Purpose of review New advances in the treatments of autoimmune rheumatic diseases have altered the landscape of opportunistic infection risk, including infections such as herpes zoster, tuberculosis and pneumocystis jirovecii pneumonia. Recommendations for preventative strategies, including vaccination and prophylaxis, have also evolved in response to availability of new vaccines and decreased reliance on glucocorticoid therapy. Recent findings The newest treatment options, including Janus Kinase (JAK) inhibitors and the type 1 interferon receptor inhibitor, anifrolumab, have been associated with an increased risk of herpes zoster compared to other existing immunosuppressive agents in rheumatology, beyond the already high baseline risk. The adjuvanted zoster virus has allowed safe immunization of rheumatology patients in attempt to reduce the incidence of herpes zoster albeit with recent population based studies demonstrating less effectiveness than in immunocompetent patients. Summary Infection risk assessment requires stratification of host, disease and treatment factors. Despite advances in immunosuppressive therapy, glucocorticoid use is still substantial and contributes to risk of opportunistic infections. Introduction of Shingrix, a non-live vaccine has made immunization for HZ more straight forward for immunocompromised patients. It is important to assess risk for other opportunistic infections, like pneumocystis jirovecii and tuberculosis, and prescribe prophylaxis.