Does taking Simponi (golimumab) increase the risk of developing shingles?

Increased Risk of Shingles with Simponi (Golimumab) Treatment

Yes, taking Simponi (golimumab) does put you at increased risk for developing shingles (herpes zoster) due to its immunosuppressive effects as a TNF inhibitor.

Risk Assessment and Mechanism

Simponi (golimumab) is a TNF inhibitor that works by suppressing parts of the immune system, which creates vulnerability to certain infections, including the reactivation of latent varicella-zoster virus (VZV) that causes shingles. This risk is well-established with TNF inhibitors and other immunosuppressive medications.

The risk factors for shingles while on Simponi include:

• TNF inhibition directly compromising immune surveillance
• Combination therapy with other immunosuppressants
• Age (risk increases with age regardless of medication)
• Prior history of chickenpox infection
• Comorbid conditions that affect immune function

Evidence for Increased Risk

The evidence clearly demonstrates an elevated risk:

• Patients on TNF inhibitors have a higher likelihood of developing herpes zoster compared to the general population 1
• Guidelines specifically mention that immunosuppressants, including TNF inhibitor biologics, increase susceptibility to infections including shingles 1
• A study in patients with inflammatory bowel disease found that those treated with immunosuppressants like TNF inhibitors had a higher incidence of shingles than those not on such therapy 2, 3

Prevention Strategies

Given this increased risk, preventive measures are recommended:

1. Vaccination before starting therapy (when possible):

   • The recombinant zoster vaccine (Shingrix) is preferred for patients on immunosuppression as it's not a live vaccine 4
   • Vaccination should ideally be completed 2-3 weeks before starting Simponi 5

2. Vaccination considerations while on Simponi:

   • The recombinant zoster vaccine (Shingrix) can be safely administered while on TNF inhibitors 1
   • The live zoster vaccine (Zostavax) is generally contraindicated in patients on TNF inhibitors due to theoretical risk of infection 1

3. Monitoring:

   • Be vigilant for early signs of shingles (localized pain, burning, tingling followed by rash)
   • Prompt reporting of symptoms to healthcare providers

Management if Shingles Develops

If shingles develops while on Simponi:

1. Immediate antiviral therapy:

   • Valacyclovir 1000mg three times daily for 7 days
   • Famciclovir 500mg three times daily for 7 days
   • Acyclovir 800mg five times daily for 7 days 4

2. Temporary discontinuation of Simponi:

   • Consider temporarily stopping Simponi until severity is established 2
   • Restart once the infection is controlled if the underlying condition warrants continued treatment

3. Pain management:

   • Gabapentin is recommended as first-line for severe shingles pain 4
   • Consider pregabalin for post-herpetic neuralgia 4

Special Considerations

• Patients on Simponi may experience more severe or disseminated shingles compared to immunocompetent individuals 4
• The risk of post-herpetic neuralgia (persistent pain after the rash heals) may be higher in immunosuppressed patients
• Prompt treatment within 72 hours of rash onset is crucial to reduce complications

Conclusion

The evidence clearly shows that Simponi therapy increases the risk of shingles. Preventive vaccination with the recombinant zoster vaccine (Shingrix) is recommended, especially for patients aged 50 and older or those at higher risk. Early recognition and prompt treatment are essential to minimize complications if shingles develops while on Simponi.