Zostavax can be used in stable Lupus

In people with stable Lupus who are not taking intensive immunosuppressive drugs, live Herpes zoster vaccine
works well.

Introduction
Systemic lupus erythematosus (often called Lupus or SLE) is an autoimmune disease. It typically starts in women between the ages of 15 and 45, but can start at a younger age. Lupus symptoms can vary from patient to patient. People with Lupus are often very tired, have joint pain, and their skin may be sensitive to sunlight.

Lupus causes immune cells in the body to become hyperactive and produce autoantibodies. An antibody is a protein that the immune system makes to attack foreign substances in the body, such as viruses or bacteria. In autoimmune diseases, the body makes antibodies that attack its own tissues. These are called autoantibodies.

Because of how the disease affects the immune system, people with Lupus are more at risk of getting infections, such as Herpes zoster. Herpes zoster is a virus that causes chickenpox in children, and shingles in adults. Once a person has been infected, the virus can remain dormant in the body, and flare up again at some point in the future (called reactivation). There are vaccines available to help prevent Herpes zoster infection and reactivation, but many people do not take the vaccine because they are worried about safety. One of the vaccines for Herpes zoster is called a live vaccine because it contains parts of the living virus. Live vaccines are not normally used in people with weakened immunity because of the risk of causing infection.

What did the authors hope to find?
The authors wanted to find out whether it is safe to use live Herpes zoster vaccine in people with Lupus.

Who was studied?
The study looked at 90 people with Lupus at one hospital in Hong Kong. Everyone was over the age of 18 and had stable disease. 10 people without Lupus also took part. All the people taking part had been infected with Herpes zoster before at some point in their life – either as chickenpox or shingles.

People were not able to take part if they were receiving an intensive (high dose) immunosuppressive treatment. This included anyone taking prednisolone over 15 mg, azathioprine greater than 100 mg/day, mycophenolate mofetil greater than 1000 mg/day, ciclosporin A greater than 100 mg/day, tacrolimus greater than 3 mg/day, methotrexate more than 15 mg/week, or any dose of cyclophosphamide or a biological medicine.

How was the study conducted?
This was a randomized, placebo-controlled, double-blind trial. This means that patients were assigned by chance to one of two treatment groups – either to be given the live Herpes zoster vaccine, or to be given a placebo (dummy) injection. Using chance in this way means that the groups will be similar and the results can be compared. During the trial, the people and their doctors did not know which group they were in. Everyone was assessed and had blood tests at the time of their vaccination and 6 weeks later. These assessments looked at the Lupus disease activity, and measured how well the immune system had responded to the vaccine.

What were the main findings of the review?
The authors found that people with stable Lupus responded well to the live Herpes zoster vaccine, and the vaccine was able to provoke a good immune response. There were a few minor side effects in people who had received the vaccine – mainly related to the injection itself. These all cleared up in a few days. During the 6
weeks of the study, nobody had a Herpes zoster infection.

Are these findings new?
Yes. This is the first trial of this kind to show that the live Herpes zoster vaccine works well in people with stable Lupus who are not receiving high doses of immunosuppressive drugs.

What are the limitations of the study?
There are a few limitations because this was a small study over a short period of time. Also, because this study was limited to people with stable disease not receiving high doses of immunosuppressive drugs, it is not possible to say whether the live Herpes zoster vaccine would be equally safe and efficacious in patients with active lupus or those receiving more intensive therapies.

What do the authors plan on doing with this information?
The authors are planning to measure the immune responses in the same group of people 4 years after the vaccination was given.

What does this mean for me?
If you have Lupus, your risk of getting a Herpes zoster infection is higher than for people without Lupus. If you have stable disease, your doctor may offer you a live Herpes zoster vaccine to help prevent these kinds of infections.

If you have any concerns about your disease or its treatment, you should speak to your doctor.

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Date prepared: November 2019
Summary based on research article published on: 17 September 2019
From: Mok CC, et al. Safety and immune response of a live-attenuated herpes zoster vaccine in patients with systemic lupus erythematosus: a randomised placebo-controlled trial. Ann Rheum Dis 2019;78:1663–1668. doi:10.1136/annrheumdis-2019-215925

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