Eliza F. Chakravarty

Shingles is painful. Anyone who has experienced shingles will tell you that in no uncertain terms. By now, we are quite aware of the increased risk of herpes zoster (HZ) in patients with autoimmune diseases due to immunosuppressive medication use or from immune dysregulation from the underlying disease. Unfortunately the very same risks for HZ reactivation are precisely those that raise concern for theoretical risks of contracting vaccine-strain varicella infection from the live-attenuated HZ vaccine (Zostavax, Merck); and this has resulted in undervaccination of many people with rheumatic diseases who would otherwise be eligible for vaccination. Until recombinant varicella vaccines become commercially available, the live-attenuated vaccine is the only protective measure available for our patients. While it is easy to provide arguments for increased vaccination of patients with rheumatic disease in whom levels of immunosuppression are mild to moderate (with tofacitinib being a notable contraindication1), it is also time to focus on the available data for safety, efficacy, and duration of protection provided by the HZ vaccine when given to patients who may have blunted responses because of underlying autoimmune diseases and/or chronic … Address correspondence to Dr. E.F. Chakravarty, Associate Member, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, 825 NE 13th St., Oklahoma City, Oklahoma 73104, USA. E-mail: chakravartye{at}omrf.org

Objective.: Patients with systemic lupus erythematosus (SLE) are at increased risk of herpes zoster (HZ). Although a vaccine for HZ has been approved by the US Food and Drug Administration, its use in immunocompromised individuals remains controversial because it is a live-attenuated virus vaccine. We performed a pilot study of the immunogenicity of the HZ vaccine (Zostavax) in patients with SLE.Methods.: Ten patients with SLE and 10 control subjects ≥ age 50 years participated in this open-label vaccination study. All were seropositive for varicella zoster virus (VZV). Patients with SLE were excluded for SLE Disease Activity Index (SLEDAI) > 4, or use of mycophenolate mofetil, cyclophosphamide, biologics, or > 10 mg prednisone daily. Followup visits occurred at 2, 6, and 12 weeks. Clinical outcomes included the development of adverse events, particularly HZ or vesicular lesions, and SLE flare. Immunogenicity was assessed with VZV-specific interferon-γ-producing enzyme-linked immunospot (ELISPOT) assays and with antibody concentrations.Results.: All subjects were women. Patients with SLE were slightly older than controls (60.5 vs 55.3 yrs, p < 0.05). Median baseline SLEDAI was 0 (range 0–2) for patients with SLE. No episodes of HZ, vesicular rash, serious adverse events, or SLE flares occurred. Three injection site reactions occurred in each group: mild erythema or tenderness. The proportion of subjects with a > 50% increase in ELISPOT results following vaccination was comparable between both groups, although absolute SLE responses were lower than controls. Antibody titers increased only among controls following vaccination (p < 0.05).Conclusion.: The HZ vaccination yielded a measurable immune response in this cohort of patients with mild SLE taking mild-moderate immunosuppressive medications. No herpetiform lesions or SLE flares were seen in this small cohort of patients.ClinicalTrials.govID:NCT01474720.