Should RA Patients Get Herpes Zoster Vaccination?

Patients with Rheumatoid Arthritis (RA) have been reported to have up to 2x higher risk of developing herpes zoster (shingles) than healthy adults, according to research.

But when should these RA patients receive the herpes zoster vaccination?

John Cush, MD, of Baylor University Medical Center in Dallas, noted that, "Most RA and psoriatic patients will receive biologic therapies during their lifetime, and thus, herpes zoster (HZ) vaccination should occur at the earliest opportunity.”

"Ideally, the zoster vaccine should be given when the patient is 50 years old and before starting a biologic. Another time is when a suspension in biologic therapy affords a window of opportunity that would allow vaccination," Dr. Cush stated.

A recent clinical trial reported that Rheumatoid Arthritis patients who started an oral JAK inhibitor less than 3 weeks after receiving live zoster vaccine (LZV) had similar varicella-zoster virus immune responses.

"To our knowledge, this is the first study directly assessing the safety and immunogenicity of LZV in RA patients," the researchers stated.

"We observed that patients with active RA developed robust immune responses to this vaccine, and the start of tofacitinib 2-3 weeks after vaccination had no negative impact on the established immune response," they stated.

Tofacitinib is an oral Janus kinase inhibitor and has been shown to increase the risk of developing herpes zoster, especially when given in combination with methotrexate or prednisone.

In this phase II trial, the investigators enrolled patients, ages ≥50, with active RA on background methotrexate into a 14-week double-blind study. The study was conducted at 27 centers from June 2014 to July 2015.

The researchers noted that the proportion of patients developing a rise in IgG of at least 1.5-fold at 6 weeks after vaccination trended higher for tofacitinib (57.4%) than placebo (43.4%).

"It is known that patients can have circulating virus for several weeks after vaccination, with even a small number of individuals with oral shedding of virus up to 4 weeks post-vaccination," the authors wrote.

"Because of this potential for prolonged viremia, some time-lag between vaccination and the start of immunosuppression makes theoretical sense to decrease further the possibility of dissemination."

Primary Varicella-Zoster Virus (VZV) infection causes varicella (chickenpox), a contagious rash illness that typically occurs among children.

VZV can clinically reactivate decades after the initial infection to cause herpes zoster (shingles), a painful cutaneous eruption that occurs most frequently among older adults.

Up to one-third of adults in the US will develop HZ within their lifetime, according to the Centers for Disease Control and Prevention (CDC).

The CDC recommends a single dose of herpes zoster vaccine for people 60 years of age or older, whether or not the person reported a prior episode of zoster.

People with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition.

Zoster vaccine is a live virus vaccine, and can be administered concurrently with influenza and pneumococcal vaccines.

Most pharmacies offer ZostaVax. The retail price of this vaccine varies based upon insurance coverage and location.

Vaccine discounts can be found at this here.

The study was supported by Pfizer. Some co-authors may have conflicts of interest as they disclosed support from Pfizer.

Dr. Cush disclosed no relevant conflicts of interest.

A study limitation was that the researchers did not study the long-term effectiveness of the vaccine in tofacitinib. The Safety and Immunogenicity of Live Zoster Vaccination in Rheumatoid Arthritis Patients Before Starting Tofacitinib: A Randomized Phase II Trial. Arthritis & Rheumatology. Accepted Author Manuscript. doi:10.1002/art.40187.