Case Report: Advising a Patient on Shingles Vaccine

What's the best advice for a patient who is interested in a vaccine against shingles?

LL is a 66-year-old woman who is looking for papain tablets. She said that she read that the tablets can help with herpes zoster. Some of LL’s friends had shingles, and a few of them tried the tablets and found them beneficial. She has never had shingles but wants to take the tablets preventively. LL’s immunization card shows that she has the influenza vaccine yearly and that she had the pneumococcal conjugate vaccine 13 at age 65, the pneumococcal polysaccharide vaccine 23 at age 66, and the tetanus, diphtheria, and pertussis vaccine at age 63. All her childhood vaccinations are up-to-date. LL’s medical history includes hypertension, but she manages it through diet. Upon questioning, she says that she has not received the herpes zoster vaccine. LL was confused about which to get, so she avoided both. What recommendations do you have?

A: LL should be told that the results of 1 study show that papain may be beneficial for herpes zoster symptoms, but the trial was a small study. More studies would need to be conducted before recommending papain for symptom management. There are no studies whose results show that papain would be beneficial for the prevention of herpes zoster. The Advisory Committee on Immunization Practices (ACIP) recommends Shingrix (recombinant zoster vaccine) over Zostavax (zoster vaccine live) for the prevention of herpes zoster (shingles) and related complications. In clinical studies, the results of the recombinant zoster vaccine showed that 2 doses administered 2 months apart had an efficacy of 97.2% in reducing the risk of herpes compared with placebo. The zoster vaccine live had an initial efficacy of 51%, which increased slightly in phase 4 studies. As a result, the ACIP has replaced zoster vaccine live with recombinant zoster vaccine as its first-line recommendation for the prevention of shingles. If patients have previously received a dose of zoster vaccine live, they should be revaccinated with the recombinant zoster vaccine. Another difference between the 2 vaccines is that zoster vaccine live is a 1-dose (0.5-mL) vaccine, while 2 doses (0.5 mL) must be given for the recombinant zoster vaccine. The second dose must be given within 2 to 6 months of the first dose. Also, zoster vaccine live is a live attenuated vaccine approved for patients 60 years and older, while recombinant zoster vaccine is recombinant and approved for patients 50 years and older. According to the CDC, increased zoster vaccine demand has resulted in intermittent shipping delays; for more information on vaccine delays, consult the CDC's vaccine shortages and delays website for more information.1

Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

Reference

1. Current Vaccine Shortages & Delays. Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/vaccines/hcp/clinical-resources/shortages.html. Accessed September 5, 2018.