Anti-IL5 therapy and Herpes zoster
Question:
8/14/2018
As I am starting to use more Nucala and Fasenra, I am interested to know your approach to discussing the risk of Herpes Zoster with patients. For patients over 50, I recommend the Zoster vaccine if they have not received it. Do you recommend that patients younger than 50 get the Zoster Vaccine if they are starting Nucala or Fasenra? Also, do you feel like it is OK to give the zoster vaccine while they are on the medication, or should they wait until the vaccine course is complete before starting the Nucala or Fasenra?
Answer:
The approved product label for mepolizumab (Nucala™) states that “herpes zoster infections…happened in people who received Nucala™. In the clinical trials, two mepolizumab treated-subjects and zero placebo-treated subjects developed shingles in studies of over 1300 subjects. The label states that clinicians consider varicella vaccination in whom such protection is medically appropriate. No cause and effect or explanation for an association with herpes zoster and IL5 in general and mepolizumab in particular is known. The other IL5 or IL5 receptor monoclonal products did not have herpes zoster during the trial and there is no mention of shingles in the labels for reslizumab or benralizumab.
Subsequent to approval, additional cases of herpes zoster have been reported with mepolizumab use (Nucala prescribing information) A post approval “real world” experience with mepolizumab in an academic practice reported that in 24 patients, mean age 51 years, one 36 year old experienced shingles (Benjamin). There are increased reports of herpes zoster in children with asthma and eosinophilia (Wi). There I cannot find any information to suggest that a reduction of eosinophil number or function would increase risk.
In summary, I would share with a potential patient to be treated with mepolizumab that there has been an increased occurrence of herpes zoster in treated subjects and patients. I would emphasize that we do not know why and that other eosinophil reducing therapy has not been associated with this condition. Therefore, we do not have an explanation of this occurrence, which may be random. It would be difficult though to explain why other products have not been associated with zoster if this is a random occurrence. I would only suggest vaccination if the patient was over 50 years of age, the age of indication for the vaccine. I would not require that the vaccine had to be given before I would treat with mepolizumab. Although there are no reports with other anti-IL5 or IL5-receptor monoclonals being associated with herpes zoster, I would not be surprised if this develops. I would not discuss herpes zoster with other anti-IL5 or -IL5 Receptor antibodies at this time or suggest the shingles vaccination unless the patient met criteria for herpes zoster vaccination.
Benjamin, Mariel Rosati, Bruce S. Bochner, and Anju T. Peters. "Mepolizumab for Treatment of Asthma: Post-Approval Academic Practice Experience." Journal of Allergy and Clinical Immunology 141.2 (2018): AB11.
Wi, Chung-Il, et al. "Risk of herpes zoster in children with asthma." Allergy and asthma proceedings. Vol. 36. No. 5. OceanSide Publications, 2015.
I hope this information is of help to you and your practice.
All my best.
Dennis K. Ledford, MD, FAAAAI