The live, attenuated vaccine Zostavax for the prevention of Herpes Zoster (Shingles) has been available for use in immunocompetent persons over the age of 60, but its use has been restricted to persons broadly labeled as immunocompromised. This has limited the use of the effective vaccine for almost all rheumatic disease patients treated with medications, even those on medications or doses not thought to lead to substantial systemic immunosuppression. On June 6, 2008, the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices released updated directives for the appropriate use of this vaccine in such patients.
The American College of Rheumatology (ACR) has released a Hotline detailing the CDC recommendations.
The recommendations continue to discourage use of the vaccine in patients receiving biologics, those receiving high dose daily prednisone (> 20 mg per day), and those with cellular immunodeficiency (i.e. hypogammaglobulinemia). However, consideration for giving the vaccine can be made for those receiving low dose prednisone, azathioprine, and methotrexate (< 0.4 mg/kg/week). The ACR suggests administering the vaccine at least two weeks prior to the initiation of a biologic DMARD in those appropriate for the vaccine (i.e. age greater than 60 years). The FDA is collecting all reports on suspected incident shingles thought to be vaccine related in these patients. Thus, any such suspected cases should be reported to the FDA’s Medwatch passive surveillance system.
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