Lupus and Vaccines: Shingles, Shingrix, and Zostavax
Knowing how lupus and vaccines interact is important since infections are one of the top two causes of death and vaccines are instrumental in preventing infections. Most people realize how incredibly painful shingles is. However, many don’t realize just how dangerous it is. A few years ago, I had a patient die from shingles. It attacked the nerves of her head, then went to her brain, causing encephalitis. Another patient now has a completely paralyzed arm from shingles. It attacked the nerves that go to the muscles of her arm. So, you can see why I am passionate about this topic.
Preventive medicine (like vaccines) is the best medicine.
I’ll first discuss shingles and the Shingrix vaccine. Then I will present the findings in this research study that showed the shingles live vaccine, called Zostavax, to be safe in people taking TNF inhibitor biologics.
Over 95% of Adults Have Had Chicken Pox
Shingles is caused by the virus that causes chickenpox (varicella-zoster). Over 95% of adults have been infected with chickenpox. Most do not know they had it because they may have had just a few chickenpox spots that were not noticed. They usually had a mild infection or mainly had other symptoms such as headache, fever, and cough. I have checked for chickenpox (varicella-zoster) antibodies in many patients who insisted they never had chickenpox. Every time the test came up positive, proving that they did have chickenpox in the past and just did not realize it.
Patients with Systemic Lupus are 3 Times More Likely to get Shingles
After getting infected with chickenpox, the varicella-zoster virus goes to the nerves of the spine and is able to live in an area called the ganglion. It lives there the rest of our lives. Our immune system is great at keeping it in check and preventing it from reproducing and attacking our body.
However, when the immune system begins to not work as well (most commonly due to age), the virus overpowers the immune system, multiplies, attacks the nerve it has been living in, and travels to the area of the skin that that nerve goes to. This shows up as a blistering, painful rash, usually just on one side of the body in a band-like area.
People who have systemic lupus erythematosus (SLE) have abnormal immune systems that are not very good at keeping the virus under control. SLE patients of all ages are at least 3 times more likely to get shingles than an elderly healthy person. Those who are on medicines that suppress the immune system (immunosuppressants such as methotrexate, azathioprine, mycophenolate, steroids, cyclophosphamide, and rituximab) are at even higher risk of shingles.
Therefore, it is very important that all patients with SLE get vaccinated against shingles to prevent it from happening. I have many patients over the years who did not get vaccinated and ended up with horrible shingles. This occurred in the young lady whose picture you see at the top of this blog post. She suffered horribly with pain.
All Patients with SLE 18 Years and Older Should get the Shingrix Vaccine
On July 26, 2021, the U.S. Food and Drug Administration (FDA) approved Shingrix in people 18 years of age and older who have compromised immune systems. Since SLE patients, including those not on immunosuppressants, are at high risk for shingles, all SLE patients should get the Shingrix vaccine.
- Shingrix is NOT a live vaccine (I will discuss the shingles live vaccine below)
- Shingrix is given once followed by a booster shot 2 to 6 months later
- The only contraindication to getting the vaccine is if someone is severely allergic to Shingrix
- Unfortunately, most insurance companies are not covering it in people less than 50 years old as of my writing this (11/27/21)
- I suspect the CDC will formally add Shingrix to its adult vaccine schedule recommendations in 2022. Then, insurance companies will most likely cover it.
- So, most 18-49-year-old SLE patients end up paying “out of pocket” for their Shingrix.
- Using an RX coupon service, such as GoodRX can help a lot.
- Most insurances do cover the Shingrix shot in 50+-year-old people.
What about Medicare?
- Unfortunately, Medicare does not seem to cover it very well.
- People 50 years old and older can usually just show up at their local U.S. pharmacy and ask for the Shingrix vaccine. No prescription is needed.
- I usually give my 18 to 49-year-old SLE patients a formal prescription for Shingrix to take to their pharmacist.
- I recommend that my patients stop most immunosuppressant drugs (such as methotrexate and mycophenolate) for 2 weeks after all vaccines, including Shingrix, so that the vaccine hopefully works better. Make sure and ask your rheumatologist. Patients at high risk of a lupus flare if they stop their medication may not be advised to stop their immunosuppressant.
- If you are on rituximab (Rituxan) it is best to try to get your Shingrix at least 6 months after your last Rituxan infusion (if possible) and 4 weeks prior to your next infusion. Ask your rheumatologist.
- If you are on intravenous (IV) abatacept (Orencia), get your Shingrix shot 4 weeks after your Orencia infusion. Reschedule the Orencia infusion you would usually get at the 4-week mark to be 1 week after your Shingrix. In other words, get your Orencia infusion 5 weeks after the previous Orencia instead of 4 weeks. The vaccine should be given at the 4-week mark.
New Research Shows a Live Vaccine to be Safe on a Biologic
For a long time, there was a concern that live vaccines may be unsafe in people who take immunosuppressants, including biologics. The theory was that the immunosuppressed person could possibly become infected from the live vaccine.
Zostavax is a live vaccine against shingles. It is approved to use with “weak” immunosuppressants, such as methotrexate, leflunomide, azathioprine, and low-dose steroids.
However, the safety of live vaccines, such as Zostavax, had not been studied well with biologic drugs, such as tumor necrosis factor (TNF) inhibitors, belimumab (Benlysta), and rituximab (Rituxan).
In November, Dr. Jeffrey R. Curtis, et al, published the results of their research that looked at 617 participants who were on a TNF inhibitor biologic (Humira, Enbrel, Cimzia, Simponi, and Remicade).
- 310 patients on a TNF inhibitor received the anti-shingles live vaccine, Zostavax. 307 patients received a fake shot (placebo).
- None of the Zostavax patients became infected with shingles!
Shingrix vs Zostavax: Which is best for lupus patients?
- Shingrix is 95% effective. Zostavax is only 65% effective.
- Zostavax tends to wear off over time.
- The safety of Zostavax is unknown with strong immunosuppressants, such as mycophenolate, cyclophosphamide, and rituximab (Rituxan). Shingrix is safe with these drugs.
- Because of these facts, it is best to get Shingrix.
- Some countries have Zostavax but not Shingrix. In those countries, please get Zostavax if you are not on a strong immunosuppressant, but ask your doctor first.
Lupus and Shingles Bottom Line
- SLE patients are at much higher risk of shingles than even elderly healthy people
- This risk exists even in those not on immunosuppressants
- More than 95% of SLE adult patients have been infected with the chicken pox virus that causes shingles (varicella zoster)
- Shingrix is more effective than Zostavax
- Shingrix is FDA-approved for immunosuppressed patients 18+ years old
- I recommend Shingrix to all my SLE patients
- Recent research shows that the live Zostavax vaccine is safe for people taking the biologics called TNF inhibitors
- Zostavax may be the only option for some people due to insurance and where they live
LEAVE COMMENTS BELOW
- Have you had shingles? Let others know what it was like.
- Have you had your shingles vaccine? If so, which one and how did you do afterward.
Curtis JR, Cofield SS, Bridges SL Jr, Bassler J, Deodhar A, Ford TL, Huffstutter J, Jankeel A, Kivitz A, Kamal S, Lindsey S, Messaoudi I, Mendoza N, Michaud K, Mikuls TR, Ridley D, Shergy W, Siegel SAR, Winthrop KL. The Safety and Immunologic Effectiveness of the Live Varicella-Zoster Vaccine in Patients Receiving Tumor Necrosis Factor Inhibitor Therapy : A Randomized Controlled Trial. Ann Intern Med. 2021 Nov;174(11):1510-1518. doi: 10.7326/M20-6928. Epub 2021 Sep 28. PMID: 34570596.