Episode 109: Shingles vaccine before 50 - a podcast by Rio Bravo Family Medicine Residency Program

Episode 109: Shingles vaccine before 50

Prabhjot and Dr. Arreaza discuss the indications and contraindications of the zoster recombinant vaccine (Shingrix®). Shingrix is now FDA-approved to be used in people younger than 50 years old. Magic mushroom as a therapy for alcohol use disorder.

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Introduction: “Magic mushroom” as a potential treatment for alcohol addiction

By Hector Arreaza, MD.  

Addiction is one of the biggest challenges in medicine. Patients with addictions are at risk of adverse events or even death from overdose but also are at risk of withdrawal when trying to quit. As medical providers, our goal is to assist our patients to stop using substances that may be toxic and cause detrimental effects on their health in the short and long term. It is not easy to help patients overcome the discomfort, cravings, and even life-threatening symptoms that result from withdrawal.  

Out of the many addictions, alcohol use disorder is one of the most destructive addictions, and the harms from it go beyond the personal effects, as it affects families, communities, and the whole nation. It is a serious public health issue. It is estimated that 15 million people (12 and older) in the US have alcohol use disorder, and about 140,000 people die every year from alcohol-related causes.  

Many patients would like to stop drinking, but the withdrawal symptoms may be more than just discomfort and may become unbearable and even fatal. Today I want to share the news published on August 24, 2022, on JAMA and many news outlets regarding the potential use of Psylocibin as an adjunct therapy to quit drinking alcohol.  

This was a double-blind randomized clinical trial that compared Psilocybin with diphenhydramine. Psilocybin is also known as “magic mushroom”. Participants were offered 12 weeks of psychotherapy and were randomly assigned to receive psilocybin vs. diphenhydramine during 2-day-long medication sessions at weeks 4 and 8. There were 93 participants. The percentage of heavy drinking days during a 32-week period after the first dose of medication was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group. So, patients in the Psylocibin group had decreased heavy drinking, and the mean alcohol consumption was also lower. Blinding was an issue during the study because many participants could guess which medication they were receiving. Some participants described “flying over landscapes, seeing [their] late father and merging telepathically with historical figures.”  

The bottom line of the study is that administration of Psilocybin in combination with psychotherapy produced a significant reduction in the percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These are exciting news for those who are trying to quit alcohol, and it provides a foundation for additional research on psilocybin-assisted treatment for AUD.

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This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

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Shingrix before 50. 

By Prabhjot Kaur, MS4, Ross University School of Medicine.    

1. What is Shingrix?

It’s a recombinant zoster vaccine to protect against Herpes Zoster (Shingles) in adults over 50 years old.  

2. What is Herpes Zoster?

Prabhjot: It’s a viral infection that is caused by the Varicella-Zoster virus, which also causes chickenpox. Chickenpox, also called varicella, can happen in children and adults. After a person is infected with chickenpox, the virus remains dormant in the dorsal root ganglia, which are the clusters of neurons along the spinal column. As the person grows older, or his or her immunity decreases due to conditions such as an infection, malignancy, or pregnancy, the dormant virus becomes reactivated.  

Prabhjot: When the virus reactivates in adults, it presents with a painful, blistering, itchy rash over the specific dermatomes. The rash mostly occurs on the torso, face, or upper extremities, and it is usually only on one side of the body.  

Arreaza: A common belief in the Latino culture (since our audience sees a lot of patients of Latino descent) is that if the rash crosses the midline of your body and it makes a circle around your chest, you will die. If you, as a doctor, get that question from a patient, the answer is: herpes zoster normally affects the root ganglia on one side of the body. If your patient has bilateral herpes zoster, you must rule out immunodeficiency.  

The rash may be preceded or followed by pain, burning, numbing, or tingling of the skin. Some patients might even have fevers, chills, fatigue, and photosensitivity. One of the most common complications of shingles is postherpetic neuralgia, which is a long-lasting pain after the blisters and rash have resolved.  

3. What is the role of the vaccine?

Prabhjot: Shingrix® can reduce the risk of shingles and its complications, such as postherpetic neuralgia. Shingrix is recommended for everyone over 50, even if they have already had shingles, received Zostavax® (discontinued in 2019), or received the varicella vaccine.  

Arreaza: Good point. Let´s talk a little bit about varicella in adults. Patients who have received the varicella vaccine as a child can still receive Shingrix. Let’s remember the chickenpox vaccine (varicella vaccine) became available in the United States in 1995. Normally, a serology test for varicella is not required for people to receive the varicella vaccine as adults, except in certain patients who are planning immunosuppression in the near future. In such cases, if varicella immunity is not reactive, they should be vaccinated against varicella (live attenuated virus) if the immunosuppression can be delayed.  

Prabhjot: What if the patient is already immunosuppressed?

Arreaza: If the patient is already immunosuppressed, the decision is not simple. The varicella vaccine is contraindicated, but some clinicians may recommend Shingrix for the potential protection against primary varicella. Post-exposure prophylaxis with antiviral therapy or immunoglobulin in case of exposure is possible.    

4. How is Shingrix given?

Prabhjot: Shingrix is given in 2 doses, and each dose is given 2-6 months apart. Its immunity stays strong for at least 7 years. Like most vaccines, the most common side effects of the Shingrix vaccine are redness, tenderness, swelling, and discomfort at the vaccine site. Shingrix is deemed to be safe for most people over 50 but not given to pregnant women, people with active shingles, and or with a severe allergy to the vaccine.  

Arreaza: Shingrix is generally avoided in patients with a known history of Guillain-Barré syndrome (GBS) due to a probable association between Shingrix and GBS. This association was not seen with Zostavax, so in case of history of GBS, Zostavax is an option.

5. Effectiveness

Prabhjot: As for its effectiveness, according to the CDC, Shingrix is 97% effective in preventing shingles in adults 50 to 69 and 91% in adults older than 70. If one is immunosuppressed and has a weakened immune system, the vaccine was effective, ranging between 69%-91% in preventing shingles.

6. New update:

Prabhjot: New updates have been made to expand the vaccination of the population under 50 as well. On July 23, 2021, the FDA approved the vaccination for adults over the age of 18 who are at an increased risk or will be in the future due to immunodeficiency or immunosuppression. Such immunodeficiency could be secondary to a disease, malignancy, or therapy such as chemotherapy. Just like the prior recommendation, it is recommended for these individuals to receive two doses of Shingrix for the prevention of shingles and its complications. However, the interval between the two doses can be shortened from the recommended 2-6 months to 1-2 months if the person will be going through intense immunosuppression in the upcoming months. This shortened interval will prevent vaccination during an intense immunosuppressed state. The second dose must not be given before one month.  

7. When to get vaccinated?

Prabhjot: Ideally, one should get vaccinated before starting immunosuppressing therapy; if this cannot be possible, then one should aim for vaccination when their immune response is likely to be the strongest. For example, if it’s an immunity-changing disease such as malignancy, the vaccine would be ideal in the beginning stages, and if a person will receive chemotherapy, it would be ideal to vaccinate before starting chemo.  

8. Few recommendations from CDC:

For Hematopoietic cell transplant:  

Administer Shingrix at least 3-12 months after transplantation. It is important to consider the vaccine is recommended 2 months before the prophylactic antiviral therapy is discontinued. Since the prophylactic antiviral therapy is also protecting against shingles, the vaccine is preferred to be injected while the antiviral therapy is going on.  

Arreaza: For allogeneic HCT (when donor is another person), Shingrix should be given a little bit later, 6-12 months after transplant, prior to discontinuation of antiviral therapy. Acyclovir, famciclovir, and valacyclovir will not neutralize the effectiveness of Shingrix because the vaccine is not a live virus vaccine.

For cancers:

It is ideal to administer Shingrix before chemo, immunosuppressive medications, radiation, or splenectomy. If that is not possible for some reason, administer the vaccine when the patient is stable and not acutely suppressed. For patients on long-term immunosuppressive therapies, administer the vaccine when the immune response is most likely the strongest or right before starting the next cycle of therapy.  

For patients with HIV:

Prabhjot: Shingrix is recommended for patients with HIV due to the high risk of shingles. Immune response to the vaccine may be improved while the patient is on antiretroviral treatment.  

Bottom line: Shingrix is now recommended not only for those over 50 years old but also for those who are 18 and older and are immunosuppressed or will be on immunosuppressive therapy. This new change will benefit those who are receiving treatment and those who are awaiting treatment. Keep in mind to use the vaccine to prevent shingles and its complications.  

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Conclusion: Now we conclude our episode number 109, “Shingles vaccine before 50.” We are used to giving Shingrix to patients older than 50, but we were reminded today that it is also indicated in patients older than 18 who are or will be immunosuppressed. Shingrix should be given in 2 doses 2-6 months apart. Your patients may not notice it, but by giving this vaccine, you are PREVENTING a painful rash that can have long-term effects. This week we thank Jennifer Thoene, Hector Arreaza, Prabhjot Kaur, and Arianna Lundquist. Audio edition by Adrianne Silva.

 

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

• Bogenschutz MP, Ross S, Bhatt S, et al. Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online August 24, 2022. doi:10.1001/jamapsychiatry.2022.2096. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2795625.
• Osborne, Margaret. Psychedelic ‘Magic Mushroom’ Ingredient Could Help Treat Alcohol Addiction, Smart News, Smithsonian Magazine, https://www.smithsonianmag.com/smart-news/psychedelic-magic-mushroom-ingredient-could-help-treat-alcohol-addiction-180980658/
• “Shingles Vaccination.” Centers for Disease Control and Prevention, page last reviewed: 24 May 2022, https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
• “Clinical Considerations for Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years.” CDC.gov, 20 Jan. 2022.  https://www.cdc.gov/shingles/vaccination/immunocompromised-adults.html.
• “Shingles.” Mayo Clinic, 17 Sept. 2021, https://www.mayoclinic.org/diseases-conditions/shingles/symptoms-causes/syc-20353054.
• Royalty-free music used for this episode: Salsa Trap by Caslo, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/caslo/caslo-vol-1/salsa-trap/. Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.

 

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