New Shingles Vaccine Shows Efficacy for Older Adults

In October 2017, the U.S. Food and Drug Administration (FDA) licensed the Shingrix® vaccine for adults aged 50 years and older to prevent shingles. The CDC recommends two doses of Shingrix, two to six months apart for healthy adults aged 50 and older.

On Oct. 25, the Advisory Committee on Immunization Practices (ACIP) voted that Shingrix is the preferred vaccine for preventing shingles and related complications. It is also recommended for adults who previously received the current shingles vaccine (Zostavax®).

Similar to Zostavax, Shingrix will be covered as a Medicare Part D benefit, and Zostavax will be removed from Health Maintenance. A new Shingrix Health Maintenance topic will be developed.

A study reported in the New England Journal of Medicine by Cunningham et al, estimates the Shingrix vaccine’s efficacy to prevent postherpetic neuralgia (PHN) at 88.8 percent in patients above the age of 70. According to the CDC, up to 15 percent of people with shingles currently experience the pain of postherpetic neuralgia, and the risk increases with age.

Ardeshir Z. Hashmi, MD, Director of Cleveland Clinic’s Center for Geriatric Medicine, notes that approximately a million cases of herpes zoster occur annually in the United States, which can lead to PHN.

“Postherpetic neuralgia can significantly impair the quality of life for our geriatric patients,” Dr. Hashmi says. “This is compounded by the absence of any evidenced-based treatment of choice for PHN. These promising results suggest the Shingrix vaccine as potentially, a cost-effective means for promoting preventive health and optimizing quality of life for our vulnerable geriatric patient population.”

Further, Dr. Hashmi notes that ACIP is meeting in February 2018 to discuss approving Shingrix for immunocompromised patients.

At this time, Cleveland Clinic’s Medicine Institute Clinical Practice Committee suggests the following:

1. Shingrix is preferred to Zostavax to prevent post herpetic neuralgia.

​For patients who ask for vaccination at this time, we suggest they wait for Shingrix to ensure maximal benefit. The only subset of patients where Zostavax might be preferred is those who will not return for the second vaccine of the series.

1. It appears to be most cost effective to start immunizing at age 60.

​Although the vaccine is approved for ages 50 and older, some theoretical models suggest Shingrix’s effectiveness may wane after 20 years. Based on this, and the low prevalence rates of shingles and postherpetic neuralgia in the 50s, we suggest age 60 as the best age to commence vaccination.

1. Shingrix should be encouraged for patients vaccinated with Zostavax more than 5 years ago.

As it is unknown if the supply of Shingrix will meet demand, we suggest Shingrix is less crucial for those who have had Zostavax within 5 years and likely still have antibody protection.

1. Shingrix has higher rate of local reactions than many vaccines. Patients should be warned about the possibility of local reaction. Acetaminophen and supportive care are encouraged.

This article was written with assistance from Nida Riaz, MD, a Geriatrics Fellow in Cleveland Clinic’s Center for Geriatric Medicine.