Shingles and Rheumatoid Disease

Editor's note: Since the publication of this article in 2016, there have been updates to the CDC's recommendation for the shingles vaccine. The live shingles vaccine (Zostavax) referenced in this article is no longer available for use in the United States, as of November 18, 2020. Shingrix, an inactive vaccine for the prevention of shingles, was approved by the FDA in 2017.

You’ve probably seen the commercials about getting the shingles vaccine on TV. If you had chickenpox as a child (or as an adult), you’re at risk. The chickenpox virus (varicella) remains in your body after the contagious rash and other symptoms are long gone. It mutates, nestles down somewhere in your body near a nice cozy bundle of nerve endings, and goes dormant. The commercials soberly show how painful and debilitating shingles can be.

As someone with rheumatoid disease, which makes me more than twice as likely to get shingles as a healthy person of my age in the general population, I’d sure like to bare my arm for that preventive vaccination!

But I can’t have it. Like many people who’re under treatment for rheumatoid disease, I’m taking powerful drugs that seriously weaken my immune system. They keep my body from mistaking my joints for viruses and making antibodies to destroy them, which is good. But it’s bad if the actual invaders, such as the shingles virus, attack me.

How do most vaccines work?

Vaccines work by introducing tiny amounts of whichever virus you want to protect yourself from into your body. In most vaccines, like the one we take for the flu, the virus used is dead, and it can’t make anyone sick. But these tiny amounts of virus do trigger the immune system to produce antibodies whose sole purpose is to destroy it. These antibodies stay in the body, ready to leap into action should the vaccinated-against virus ever dare to show its ugly mug. That’s why it’s a good idea for people with rheumatoid disease, even if they’re taking immune-suppressing drugs, to get a flu shot every year.

How is the shingles vaccine different from other vaccines?

The shingles vaccine, however, contains minuscule amounts of the live shingles virus. In people with normal, healthy immune systems, that’s no problem. They won’t get sick because their bodies produce more than enough antibodies to kill off the introduced virus, and then stick around for years on end, just in case.

Why is a live-virus vaccine dangerous for weakened immune systems?

But a compromised and weakened immune system may not be able to produce enough antibodies to fight off even the tiny amount of live shingles virus contained in a vaccine. It might make you very ill instead of building up your immunity against shingles. In most cases, that means those of us who take immune-suppressing drugs can't take the shingles vaccine.

Still, it’s smart to know your enemy.

Signs and symptoms of shingles

In two out of three people who’ve had chickenpox, the slumbering virus never wakes up again. But in that third person, it does, manifesting as herpes zoster, or shingles. It starts as pain, itching, burning, or tingling in a narrow band on one side of the face and scalp, on one side of the neck and shoulder, or on either side of your body across your ribs or waist.

After one to five days, a painful rash and weeping blisters develop there. People with weakened immune systems may have an all-over rash similar to chickenpox instead. Other shingles symptoms include fever, chills, headache, and nausea. The blisters scab over in seven to 10 days, and the whole thing finally clears up in about two weeks.

Serious complications

All that’s bad enough—the rash and blisters are terribly painful—but shingles are particularly evil. Sometimes, they cause other serious problems. If the rash occurs near your eye, it can impair your vision or cause blindness. Sometimes, even after the rash and blisters heal, the nerves in those areas affected by the virus remain sensitive and painful, a condition called post-herpetic neuralgia (PHN). Rarely, shingles can cause hearing loss, pneumonia, brain inflammation (encephalitis), or even death.

But don’t panic—there’s hope.

Is it safe for people with RA to get the shingles vaccine?

First, rheumatoid disease patients taking methotrexate, azathriopine, or prednisone may take the shingles vaccine if they’re taking specific small dosages of those drugs, according to an article in a recent issue of Rheumatology News. Talk to your rheumatologist about that.

Should not take the shingles vaccines

But patients taking recombinant biologic agents, such as TNF-inhibitors (Humira, Enbrel), abatacept (Orencia), rituximab (Rituxan) and Janus kinase inhibitors (Xeljanz) should not take the shingles vaccine at all, states the article.

Possible exceptions

If, however, those patients undergo a lapse in therapy with those biologic drugs (or high-dose steroids), they can take the shingles vaccine after four weeks of being off them, states the article. They’ll have to wait for two to four weeks after vaccination to restart them.

The Rheumatology News article also points out that not giving the shingles vaccine to patients who take these drugs eliminates a theoretical, not actual, risk of their contracting the disease from the vaccine. “… [A] formal retrospective study of close to a half-million Medicare patients … found there were no cases of herpes zoster or varicella within 42 days following inadvertent vaccination of 633 patients while on biologics.”

“You shouldn’t be vaccinating for herpes zoster while patients are on a biologic, but you know what? If it happens, don’t wig out. Move on and try to avoid it,” advised Dr. John Cush, rheumatologist and professor of medicine and rheumatology at Baylor University, in the article.

Current shingles treatment

Another thing to keep in mind: The shingles vaccine only reduces the risk of developing shingles by 51 percent, which is great, but about half of those who're vaccinated may still get shingles.

Seek treatment right away if you think you have shingles

The Centers for Disease Control and Prevention state that if you do get the disease, you may shorten its length and severity by taking the antiviral medicines acyclovir, valacyclovir, or famciclovir. These must, however, be taken as soon as possible after the rash appears to be effective. If you think you might have shingles, don’t wait. See your doctor right away.

How to address pain and itching symptoms

Analgesics may help the pain caused by shingles, and gabapentin, a medicine used to treat nerve pain, and some anti-depressant medications, may help as well. Oatmeal baths may help to relieve some of the itching.

Finally, the Rheumatology News article states that researchers are busy developing a shingles vaccine using the inactivated herpes zoster virus—it’s in clinical trials right now. Dr. Cush thinks it may be even more effective than the current live vaccine.

Keep your fingers crossed.