Stop, then go: Shingles shot for those with RA

Clinical Brief – September, 6th

The Brief

People living with rheumatoid arthritis (RA) are at increased risk of shingles.

For those on biologics, a shingles vaccine followed by a 2-week delay is generally recommended. Less is known about how to give shingles shots if a patient is on tofacitinib (Xeljanz) for RA.

A study found that people over 50 should wait 2-3 weeks after their shingles shot before starting tofacitinib.


What’s RA got to do with shingles?

RA meds like biologics and tofacitinib are generally tied to the risk of shingles. Anyone who’s had shingles will say that it’s not a fun experience.

To prevent shingles, the American College of Rheumatology recommends getting vaccinated 2 weeks before starting on a biologic.

They also recommend getting vaccinated before starting on tofacitinib, but at the time they didn’t know how much delay to give before starting treatment.


How much risk of shingles is tied RA?

RA is a chronic condition where the immune system acts in ways it shouldn’t. It’s estimated that patients with RA had a 2.4-fold higher risk of shingles than those without RA.


How much risk of shingles is tied to treatments for RA?

Biologic treatments for RA generally act by suppressing the immune system. As one might expect, such treatments may be linked to risks of shingles as well.

It’s been estimated that the incidence rate of shingles per 100 patient-years of someone taking one of eight biologics for RA ranged between 1.6 to 2.5.

In translation, an episode of shingles would hit between 2 in 4 to 3 in 4 patients on biologics for RA within 30 years of their treatment.

Tofacitinib is a bit newer than biologics, which means we are still learning about everything it can do to the body. The risk of shingled tied to tofacitinib was estimated at 4.4 per 100 patient-years of treatment.

Put this beside biologics, I’d say that tofacitinib is about twice as risky as biologics when it comes to shingles. This is a very back-of-the-envelope comparison, so take this with a bucket of salt.


How long should we wait before starting tofacitinib?

In a recently published study, researchers recruited about 100 Americans over 50 with active RA. All patients were taking methotrexate for their condition.

Everyone got a shingles shot and 2-3 weeks after, about half of the patients started treatment with tofacitinib and the other half got a placebo.

The safety profile was overall unremarkable, which is what we would like to see. Serious adverse events were found in three patients on tofacitinib vs none on placebo.

There was one case though, where the shingles vaccine broke through the immune system and triggered a serious skin infection. This happened just 2 days after they started tofacitinib. This patient had a 2-week delay between vaccination and treatment.

The authors concluded that vaccination 2-3 weeks before starting tofacitinib “appeared safe in all but one [patient].”


Bottom line

It’s risky to start treatment too early because the shingles vaccine is a live virus that’s a weaker version of the real thing.

Ideally, we want the shingles vaccine to go in and train the immune system, which then clears all the live viruses from the body. RA treatments are generally immune suppressants. So, if we take them before the virus is all cleared out, it’s possible for the virus to break through the immune system.

For patients with RA who would like to start on tofacitinib, consider getting a shingles shot at least 2 weeks before treatment. If it can wait, 3 weeks might be safer than 2.

Now, this study only looked at tofacitinib 5 mg twice daily. We don’t know how long we should wait between the shingle’s shot and treatment if we needed tofacitinib 10 mg twice daily. We also don’t know about the extended-release version of tofacitinib.

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