What Is Shingles?
Shingles is caused by a viral infection called Varicella-Zoster virus (VZV). It manifests as a rash or blisters, most commonly on your chest or back, but can occur anywhere on the body. VZV can be spread from a person with Herpes Zoster (HZ) to an individual that has never had varicella by direct contact with localized skin lesions. Less commonly, VZV can be spread by the airborne route if the affected person has disseminated HZ.
Cases last a few weeks and symptoms include numbness or a burning sensation where the rash occurred. There can be severe residual pain in the area for weeks or months or indefinitely and the more severe the rash, the more likely there will be severe ongoing pain. Most people in North America have been exposed to chickenpox so nearly everyone can get shingles.
Stress and immune suppression (drugs such as prednisone, mycophenolate mofetil [MMF], chemotherapy) increase the risk of getting shingles.
Why Is Shingles Important in Patients With Systemic Lupus Erythematosus (SLE, Lupus)?
Shingles is six times as common in immune compromised people including those with rheumatoid arthritis and SLE.
Symptoms are also more severe in patients who have SLE. People living with lupus have a very high risk of having shingles even when they are young.
Even after symptoms lessen, lingering pain can remain and can reduce a person’s quality of life as well as increase healthcare costs and reduce an individual’s productivity. Shingles is likely increased in people with lupus due to their disease (abnormal response to infections, increased risk of some viral and other infections) and due to the treatment (prednisone, MMF, cyclophosphamide, anifrolimumab, etc).
How Can We Prevent It?
According to Health Canada, vaccination is the most effective way to prevent shingles.
It used to be that starting at age 50, adults received 2 doses of the non-live vaccine. Now, the Centers for Disease Control (CDC) and Health Canada recommend that ANY immune suppressed individual above the age of 18 years be offered Shingrix.
If the vaccine is an inactive vaccine then it should be administered 2 to 4 weeks before starting or continuing immunosuppressive therapy where possible.
Shingrix vaccine was approved in Canada in 2017.
Zostavax was discontinued from the Canadian market in 2022, and is no longer available.
What Is Shingrix?
Shingrix is a vaccine that protects patients from shingles and the pain that can remain in immunocompromised patients. It is not a live vaccine and is recommended for people over the age of 18 who will be immunodeficient or immunosuppressed.
Two doses of Shingrix are more than 90% effective at preventing shingles. After completing the Shingrix series, protection for people 50+ was high (88%) and stayed strong (82%) 11 years post-vaccination.
You CAN and SHOULD get the full Shingrix vaccination even if you had Zostavax in the past.
Should You Get the Shingles Shot?
If you are going to be immunosuppressed or immunodeficient and are above the age of 18 you should get the shingles shot.
This includes having SLE (lupus). It will help to protect you from recurring flare ups as well as lingering pain that occurs after.
The CDC recommends that patients receiving vaccination should receive Shingrix if possible. Vaccination status should be assessed prior to the beginning of immunosuppressive treatment, but if eligible you should receive the shingles shot.
What Does Health Canada Say About Shingrix?
All adults (18 and over) who are immunosuppressed can be offered the shingles vaccine as it is the most effective way to prevent shingles. This includes everyone with lupus and also other autoimmune diseases, people receiving chemotherapy, people with immune deficiency diseases, etc.
Will Getting the Shingles Shot (Shingrix) Flare My Lupus?
Likely not, but if it does, it should only be transient.
In a study displaying the effects of Shingrix on patients with rheumatic diseases, only 7% of those who received the vaccine experienced a flare, with these flares being self-limited and mild. As well, only 13% of patients experienced any side effects, and symptoms they did experience were mild.
Since Shingrix has been approved for many years in Canada, it appears very safe in post-marketing surveillance studies.
How Is the Shingles Vaccine Given?
It is a vaccine given once and repeated in 2 to 6 months intramuscular like most vaccines.
For those who are at increased risk due to immunodeficiency/ immunosuppression and who may benefit from completing the series more quickly, the second dose can be administered at a minimum interval of at least 4 weeks after the first dose.
Is Shingrix a Live Vaccine?
Shingrix is not a live vaccine. Due to this, Shingrix can be administered in addition to disease-modifying antirheumatic drugs and systemic glucocorticoids.
This makes Shingrix a beneficial solution for patients with SLE or other rheumatic diseases.
Should I Hold My Immune Suppression Drugs When I Get the Vaccine?
We don’t know for sure, but holding mycophenolate mofetil (MMF, CellCept), Myfortic or methotrexate for 1 to 2 weeks after receiving the vaccine should allow for a pretty good immune response for most people.
Even if the effect is blunted in those who are immune suppressed, it is still better than not getting the vaccine course.
Who Should Not Get Shingrix?
If you already had a dose and experienced anaphylaxis, you should not receive additional Shingrix vaccines.
The safety in pregnancy and breastfeeding is unknown, so waiting is likely the best approach until no longer pregnant and breastfeeding has been completed.
How Effective Is It?
Two doses of Shingrix has shown to be over 90% effective at preventing shingles. Side effects are rare, and even in cases of reported side effects, patients still did not develop shingles.
RZV (Shingrix) efficacy against HZ and associated complications remained high through 11 years post-vaccination. Side effects such as a sore arm, swelling at the injection site, muscle aches and fatigue may occur and usually don’t last very long.
Should I Get Other Vaccines?
Yes, you should look at your provincial/country guidelines for vaccines and get the recommended vaccines.
It is very important to receive HPV vaccination, the flu shot annually, COVID boosters, pneumonia vaccines and to update other vaccines such as tetanus.
Authors: Daniel Tingey and Doctor Janet Pope
Note: Please consult your healthcare provider or local health authorities for up-to-date vaccine recommendations.