Clinical Briefs
August 15, 2012 4 minutes read
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Risk for Zoster from the Vaccine in Immunosuppressed Persons
Source: Zhang J, et al. JAMA 2012;308: 43-49.
THE PREVAILING WISDOM SUGGESTS THAT because herpes zoster vaccine (ZOS) is a live virus, it should not be administered to persons receiving immunosuppressive treatments, such as biologic agents or methotrexate for rheumatoid arthritis, or chronic prednisone therapy of 20 mg/d or more. The concern is that instead of mounting an immune response to the vaccine, vaccinees might actually experience a case of shingles as a result of the vaccine.
To examine the real-life risk of an acute zoster infection after ZOS, a retrospective analysis was performed on a large Medicare database (n = 463,541) of persons with a diagnosis of rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease. Any one of these disorders would be commonly treated with immunosuppressive agents, corticosteroids, or both.
The analysis looked at the number of cases of shingles within 42 days of ZOS, anticipating that if the live virus vaccine had induced shingles, it should certainly have happened within that 6-week window after vaccination.
No increased incidence of shingles was seen in ZOS recipients, even in patients on biologics. Indeed, ZOS was associated with a 39% lower risk of shingles during the 42-day window of observation, and a reduced risk during the subsequent 2 years (median) of follow-up. ZOS appears to be beneficial even in immunocompromised individuals, and the authors challenge the propriety of current recommendations that advise against ZOS administration in such populations.
Elucidating the ‘Best’ Interval for Bone Density Screening in Osteoporosis
Source: Yu EW, Finkelstein JS. JAMA 2012;307:2591-2592.
ONCE A BASELINE BONE MINERAL DENSITY (BMD) has been obtained, it is unclear when the study should be repeated. For one thing, the literature suggests that only about 30% of bone strength may be attributable to bone density. Additionally, some of the interventional trials using bisphosphonates have found fracture reduction despite continuation of bone density loss over the first year or two of intervention. Finally, the rate at which BMD declines has been linked to the baseline BMD.
For instance, a study that looked at menopausal women (age > 67 years) for progression of BMD loss found some fairly startling results: It would take approximately 15 years for 10% of women with normal baseline BMD (T score < -1.5) to incur sufficient loss of BMD to cross the diagnostic threshold for osteoporosis (T score < -2.5). Similarly, for women with osteopenia (T score -1.5 to -2.0) at baseline, it would require 5 years for 10% of them to progress to frank osteoporosis. At the greatest level of osteopenia (T score -2.0 to -2.5), progression to osteoporosis in 10% of women would be expected to occur within 1 year. These projections assume no addition of new risk factors known to accelerate bone loss.
Although it is tempting to get BMD more often, it may not be helpful. Although the data are sufficiently uncertain that the USPSTF has been unable to provide confirmation of a preferred schedule, Yu et al suggest the following rescreening intervals for postmenopausal women: for women with normal BMD at baseline, 10 years; for women with mild osteopenia and low fracture (FRAX) score at baseline, 5-10 years; for women with moderate osteopenia or FRAX score approaching treatment threshold, 2 years.
Cerebral Aneurysms: What’s in Your Patient’s Future?
Source: UCAS Japan Investigators. N Engl J Med 2012;366:2474-2482.
THE UCAS (UNRUPTURED CEREBRAL ANEURYSM) Japan study began enrolling patients with incidentally discovered cerebral aneurysms (CRAs) for an observational study in 2001. The primary purpose of the study was to better delineate the natural history of incidentally discovered CRAs (as opposed to discovery through neurologic signs or symptoms). Prior to this trial, it had been generally recognized that CRAs < 7 mm rarely rupture, and that posterior circulation CRAs have a greater risk than anterior.
This prospective cohort study included patients (n = 6413) with incidentally discovered CRA and minimal, if any, disability. Subjects were followed for up to 8 years. During this interval, the annual rate of CRA rupture was approximately 1%. When rupture did occur, it was fatal in 35% of cases, or led to moderate-severe disability in another 29%.
The most important predictive factors for rupture were size of the CRA, age, and gender (females are at greater risk). For example, when compared with lesions < 7 mm, a 7-9 mm lesion had a three-fold increase of rupture, and a lesion > 10 mm had a nine-fold increased risk. Risk in women was 1½ times as great as men, and persons over age 70 were 21% more likely to experience aneurysm rupture. Because the entire population of enrollees was Japanese, the generalizability of these results may have limitations, but nonetheless provide perhaps the most accurate mapping of risk factors for rupture of CRAs.
Clinical Briefs: Risk for Zoster from the Vaccine in Immunosuppressed Persons, Elucidating the Best, Cerebral Aneurysms: Whats in Your Patients Future?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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