Zoster vaccination may be feasible for lupus patients

Shingles from reactivation of herpes zoster is a significant problem for patients with autoimmune diseases but a small trial of live attenuated zoster vaccine in people with systemic lupus erythematosus (SLE) has raised hope that vaccination may be possible for this group.

Patients with SLE are ten times more likely to develop shingles than healthy individuals and it affects them at an earlier age. But recommendations about the vaccination against herpes zoster in SLE patients have been lacking, largely due to the theoretical concern of vaccine-induced infection as well as the lack of clinical or experimental data upon which to base recommendations.

Although rarely life-threatening, shingles is associated with significant pain and associated morbidity and may lead to disruption or discontinuation of otherwise necessary immunosuppressant medications in people with autoimmune diseases.

Presented at EULAR, results from the first randomised controlled study to look at the use of vaccine against herpes zoster in patients with SLE showed that live attenuated vaccine (Zostavax) was well tolerated and provoked an antibody response in patients with stable disease not receiving intensive immunosuppression.

The Hong Kong trial included 90 patients with stable SLE who had a history of herpes zoster/chickenpox and were not receiving intensive immunosuppression. Patients were randomised to either Zostavax or placebo vaccine (saline) given subcutaneously.

After six weeks antibody titre levels (Anti-VZV IgG) in the vaccine group increased by 59.8% compared with a reduction of 2.1% in the control group (p=0.01).  The increase remained significant after adjustment for baseline value, lymphocyte count, immunoglobulin levels, SLE Disease Activity Index (SLE DAI), and other clinical variables.

No serious adverse events were reported, but, as expected, significantly more patients in the vaccine group reported injection site mild pain and redness, which subsided in a few days. None of the patients had clinical shingles infection post vaccination, and only three patients in the vaccine group and one patient in the placebo group exhibited mild SLE activity (all mild thrombocytopenia).

Antibody titres seemed to rise following herpes zoster vaccination regardless of any immunosuppressive therapy that they had received, although the rise was less pronounced when prednisolone was used with or without immunosuppressant therapy.

“We hope our results will inform guidelines and ultimately lead to the safe administration of the vaccine in appropriate SLE patients to reduce the burden of shingles in these individuals,” said lead study investigator Dr. C.C. Mok of the Department of Medicine, Tuen Mun Hospital, Hong Kong, who presented the study findings at EULAR.

Commenting on the trial results, Professor Thomas Dörner, a rheumatologist at Charité University Hospitals, Berlin, told the meeting that herpes zoster reactivation was an issue with conditions such as SLE and rheumatoid arthritis. In particular, high rates of reactivation were seen in patients treated with JAK inhibitors, so it was important to do something to enhance protective immunity in this group.

However he cautioned that antibody levels were a surrogate indicator of response to the vaccine, so while the trial results were a promising development it was probably a little too early to base recommendations on.

“We need to see how this turns out in really preventing the reactivation of herpes zoster in clinical practice,” he said.

In addition, the improvement in antibody titres was “very low to lousy” in patients who received prednisolone with or without immunosuppression, Professor Dörner noted.

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