Herpes Zoster Vaccination in SLE: A Pilot Study of Immunogenicity

Abstract

Background Patients with systemic lupus erythematosus (SLE) are at increased risk of herpes zoster (HZ). Although a vaccine for HZ has been FDA approved, its use in immunocompromised individuals remains controversial because it is a live-attenuated virus vaccine. We performed a pilot study of the immunogenicity of Zostavax® in SLE patients. Methods Ten SLE patients and 10 controls ≥50 years old participated in this open label vaccination study. All were seropositive for varicella zoster virus (VZV). SLE patients were excluded for SLEDAI>4, use of mycophenolatemofetil, cyclophosphamide, biologics, or >10 mg prednisone daily. Follow-up 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 IFN-γ producing ELISPOT assays and with antibody concentrations. Results All subjects were women. SLE patients were slightly older than controls (60.5 vs. 55.3 years, p<0.05) Median baseline SLEDAI was 0 (range 0–2) for SLE patients. 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). Conclusions Zostavax vaccination yielded a measurable immuneresponse in this cohort of mild SLE patients on mild-moderate immunosuppressive medications. No herpetiform lesions or lupus flares were seen in this small cohort of patients.

Treatment considerations in patients with concomitant viral infection and autoimmune rheumatic diseases

“…A large study that used the Medicare database for patients with inflammatory arthritis confirmed that the herpes zoster vaccine reduced the risk of herpes zoster by 40% in 2 years, and no such cases had occurred in patients exposed to bDMARDs at the time of vaccination or within the subsequent 42 days [122]. In a small open study of herpes zoster vaccination, 10 patients with SLE had low disease activity and received low-dose corticosteroids, hydroxychloroquine, or MTX, and none developed herpes zoster within 12 weeks post vaccination [172].…”

Trigeminal herpes zoster: early recognition and treatment are crucial

“…Biological agents in particular have been associated with the reactivation of latent infectious processes, which may be viral or bacterial; tuberculosis reactivation remains a significant problem in immunomodulatory therapy 3. Although VZV vaccines exist, their routine use in immunosuppressed patients remains controversial—largely because they are high-potency live vaccines 4. There is currently no unified guidance regarding vaccination in high-risk patients.…”

Treatments for Lupus Nephritis: A Systematic Review and Network Metaanalysis

“…Thus, these very young patients with LN are at high risk of herpes zoster, with risk relatively higher than patients with noninflammatory musculoskeletal conditions 99 . Herpes zoster is a potentially preventable disease by the use of a vaccine, and patients with SLE mount a good immune response to this vaccine 100 . Given the availability of a vaccine to prevent herpes zoster, we believe that zoster vaccination should be administered prior to immunosuppressive initiation.…”