Probably like me you have seen a bit of zoster in our patients with SLE, and rarely we get severe outbreaks in multiple dermatomes or in the eyes or other vulnerable areas in patients on immune suppression. So I think of Zostavax the way I think of shingles per se: The more immune compromised you are, the higher the risk of something bad happening … maybe. But we do know with Zostavax the risk is small.

The study by Chi Chiu Mok et al. selected stable patients on moderate immune suppression, so I think the paper is pretty reassuring about stable patients. And to the extent that this immunization can stave off a significant outbreak at a later time when maybe the person will be on stronger immune-compromising medications, or is just older with the compromise of weaker defenses, prevention would be good.

Shingrix is a lot more effective than Zostavax and does not have the same issue of potentially causing the thing it prevents. But the most likely reason it works so well is that it has an adjuvant. We are generally a lot more concerned about injecting adjuvants in autoimmune patients here in the United States than they are in Europe where they have more experience with that, but this one is apparently a new adjuvant and has never been used in autoimmune patients, who were excluded from the trials of Shingrix. And a fair number of nonautoimmune patients get autoimmune-like symptoms in the Shingrix trials such as myalgias and fevers. I don’t think we have full confidence yet until we figure out just how worried we ought to be about that. In other words, if Shingrix only causes mild/moderate transient flares, then our patients might rationally consider that a fair trade for lifelong protection.

I think in some patients this is an easier decision than others. If somebody is 50 years old and healthy, hasn’t had nephritis or anything bad before (or not in the last 10 years), and is on no immune suppressant or just using stable, modest doses of such therapies, you would probably recommend doing something to avoid getting zoster. And here you can explain the choice to the patient: Zostavax provides good protection but less than Shingrix, is unlikely to make the patient flare, has very low risk of live vaccine causing much trouble in a generally healthy person; Shingrix is more effective overall, has caused some autoimmune symptoms in healthy people, and has unclear risk for a flare in a patient with a diagnosis (but that can be monitored).

For the sicker patients, we just have to weigh the risk of a natural zoster outbreak against the risk of a flare and the risk of disseminated zoster from the Zostavax, which is a pretty small risk but it is there. It’s a discussion you need to have in advance with each patient. Maybe with some patients, it is best to wait for an optimal time for either choice, when there’s not too much disease and not too much immune-compromising medication.

An unsolved issue for herpes zoster vaccination is age. Greater knowledge about how to best vaccinate would go a long way toward bolstering confidence in using the vaccines in patients a bit younger than 50 years given that zoster does occur in lupus patients at that age.

Joan Merrill, MD, is OMRF Professor of Medicine at the University of Oklahoma Health Sciences Center and a member of the Arthritis & Clinical Immunology Research Program at the Oklahoma Medical Research Foundation, both in Oklahoma City. She is a member of the editorial advisory board of Rheumatology News.