Administering Shingles Vaccine Prior to Initiation of Biologics Therapy

A Systematic Review

Abstract

Background
Shingles, also known as herpes zoster, is a viral infection caused by the varicella zoster virus. The classic feature is a painful dermatomal rash. Although the disease is often self-limiting, complications such as postherpetic neuralgia can cause long-lasting morbidity. Patients who are immunosuppressed are more susceptible to developing shingles, and disease may be more severe. The purpose of this paper is to systematically review the evidence for prophylactic use of the shingles vaccine prior to initiating biological therapy.

Objectives
To evaluate the evidence for shingles vaccine prophylaxis prior to initiating biologics therapy.

Methods
We performed a comprehensive Boolean search of PubMed and EMBASE for the following terms: prophylaxis, prior, shingles vaccine, varicella zoster, infliximab, biological therapy, guidelines. Eligible studies met the following criteria: published in English, published since 2000, any shingles vaccine type and dose, vaccine monotherapy, autoimmune disease biological therapy. There was no specific target for gender, age or population. Randomised controlled trials, meta analyses and systematic reviews were included. Studies were excluded based on the following criteria: duplicate studies, non-English language papers, papers not addressing autoimmune disease therapy, clinical trials and cohort studies.

Results
32 studies met the search criteria, of which 8 were selected for the literature review. All studies had generally differing conclusions as to whether shingles vaccination in autoimmune patients undertaking biologic therapy was safe and effective.

Conclusions
Patients with autoimmune disease should be considered for the herpes zoster vaccine prior to initiating biological therapy, though the specifics of vaccination administration is unclear. Our findings support the use of the live attenuated vaccine, Zostavax or the non-live vaccine, Shingrix. However, further research is required to evaluate specific autoimmune conditions and specific biological agents with a view to the formulation of national clinical guidelines on the use of the herpes zoster vaccine in the immunocompromised.