As with any chronic disease, patients with arthritis are often taking many medications at once to manage their condition. These medications can of course interact with one another, so being cautious and talking with a provider before taking anything new is always important. What about vaccinations? The Center for Disease Control (CDC) recommends that people over the age of 60 receive the shingles vaccine. In some cases, though, it is recommended that people avoid getting the shingles vaccine. However, one study has shown that a particular RA medication may enhance the effectiveness of the shingles vaccine. So, what should patients do?
What is shingles?
Shingles is a rash that develops on the body and is very painful. It often occurs on the face and/or torso. The rash forms blisters that will scab over in about 7-10 days and overall it can take 2-4 weeks for the rash to clear completely. In some instances, the pain can last for months. This is called Post Herpetic Neuralgia, or PHN. The risk of a person developing shingles also increases with age and with decreased immune function.
Shingles is caused by the same virus that causes chicken pox. This virus is called the varicella-zoster virus. After a person recovers from chicken pox, that virus remains inactive in the nerve tissue near the spinal cord and brain. Eventually this virus can reactive and travel along dermatomes, or nerve paths throughout the body. Not everyone who has had chicken pox will get shingles. People who have shingles can spread the virus to people who are not immune. This means anyone who has not had chicken pox or has not been vaccinated against it is susceptible. If the patient does not think he/she is immune (i.e., they have never had the chicken pox or been vaccinated against it), the patient can still get the shingles vaccine. If an analysis of the patient’s blood proves that he/she is not immune to varicella, then he/she should be given the chicken pox vaccine. Despite being caused by the same virus, there are some differences in the vaccine for chicken pox and the vaccine for shingles. For patients who have had shingles before, receiving the vaccine can still help prevent future outbreaks.
How does the vaccine work?
There is currently only one vaccine available in the US for shingles. It is given by a shot in the fatty tissue under the skin in the upper arm. The vaccine contains an inactive form of the varicella-zoster virus that causes your body to mount an immune response. Essentially it tricks your body into thinking you’ve been infected with the live virus. This results in your body producing antibodies that will recognize future varicella-zoster infections and “remember” how to fight it. This way, if the inactive varicella-zoster virus living in the nerves near the spine and brain reactivates, your body will fight it off and prevent you from getting shingles.
Vaccine interaction with arthritis medications
There are some instances in which the shingles vaccine is not recommended. People who have had certain allergic reactions to components of the vaccine such as gelatin, should not get the vaccine. Additionally, people who have weakened immune systems due to certain diseases, or taking medications that weaken the immune system should not get the vaccine. The catch though, is that many RA medications that weaken the immune system, also make patients more susceptible to developing shingles, so it can be hard to know what the right choice is. However, some new research is showing that one RA medication may actually make the shingles vaccine more effective.
One article discusses how Kevin Winthrop MD, MPH of the Oregon Health and Science University and his colleagues studied the effect of the RA medication tofacitinib on the shingles vaccine. Tofacitinib is an RA medication that is used alone or in combination with DMARDs. It works by decreasing the activity of the immune system, which is responsible for causing RA. In this study, they looked at 112 patients with RA who were vaccinated and split into two groups. One group received the tofacitinib and the other received a placebo 2-3 weeks after.
The results showed that patients who received the tofacitinib did not have reduced immunity to shingles. In fact, some patient’s that were treated with tofacitinib had a higher immune response to the vaccine than the placebo group. Ultimately what this study showed is that treatment with tofacitinib will not decrease your immunity to shingles if you receive the vaccine, and may increase it.
This study also demonstrated the importance of giving the shingles vaccine only to people who have had chicken pox in the past, or people who demonstrate immunity to the varicella-zoster virus. One study participant developed a varicella infection after vaccination. It was later discovered that this person had never had chicken pox. It is also possible for people with reduced immunity to get a varicella infection after vaccination. It is important for RA patients to check with their provider to see if their RA medications are suppressing their immune system to the point where they should avoid vaccination.
The rate of shingles in RA patients in this study were lowest for people who were not taking corticosteroids or conventional systemic disease modifying antirheumatic drugs (csDMARDs). This makes sense since drugs some drugs like steroids can blunt the immune system. The authors of this study conclude that tofacitinib can help reduce the incidence of shingles in RA patients, especially when patients are not taking corticosteroids of csDMARDs.
So, what should you do?
Know your history and educate yourself. The first step to protecting yourself against shingles is knowing if you are susceptible in the first place. In other words, have you ever had the chicken pox? Remember: shingles is cause by the inactive varicella-zoster virus from the chicken pox reactivating in the body. Immunology is complicated. Understanding how vaccines work can empower patients to make informed decisions about their health. There is a ton of misinformation about vaccines out there which is why you should get your information from a reputable source. Vaccines are one of the greatest public health interventions the world has ever seen. Without them we would see a huge resurgence of diseases that used to be responsible for the deaths of millions of people.
Talking to your provider is also always important. Make sure that your healthcare team knows your immunity status. If they do not know, request that they check your blood before administering the shingles vaccine. Try to make sure that your RA is well managed and that your overall health is in good condition. This will all hopefully help prevent you from having to take medications that further weaken your immune system. If taking tofacitinib, and if you have had the chicken pox in the past, ask your provider about getting the shingles vaccine.