Safety and Effectiveness Study of the Live Zoster Vaccine in Anti-TNF Users

Herpes zoster (HZ), also known as "shingles", is caused by reactivation and multiplication
of the ubiquitous varicella zoster virus (VZV) that remains latent in everyone's sensory
neurons following varicella, or "chickenpox". Among individuals who live to age 85, the
lifetime risk for HZ is 50%, and more than one in five individuals affected by zoster
develop post-herpetic neuralgia, resulting in chronic pain. Other serious complications
include encephalitis, permanent vision loss, or more rarely, dissemination and death.
Fortunately, a live attenuated vaccine is available and can reduce HZ risk by up to 70%. For
patients with rheumatoid arthritis (RA), this vaccine has great potential to provide
improved quality of life by reducing the incidence and complications associated with zoster.
Due to the underlying disease and/or treatments (e.g. steroids) for rheumatoid arthritis
(RA), the risk of herpes zoster in RA patients is approximately double that in the general
population. This increased risk should make prevention of zoster and therefore vaccination
exceedingly important for RA patients. In fact, because of a higher overall absolute risk
for zoster in RA, the vaccine yields a comparable or even greater absolute risk reduction to
reduce the risk of shingles and post-herpetic neuralgia in an RA population as it does in
the general population. However, the use of the zoster vaccine in RA patients is very low (<
5%), and less frequently used than for the general population.

National guidelines from the Centers for Disease Control and Prevention's (CDC) Advisory
Committee on Immunization Practices (ACIP) recommend a single dose of the zoster vaccine for
all individuals age 60 or older, with the vaccine more recently gaining FDA-approval for
administration to persons age 50 and older. While a large number of RA patients would
otherwise be recommended to receive this vaccine on the basis of age, theoretical safety
concerns related to vaccination likely explain the very low vaccination rates observed.
Currently, the Federal Drug Administration (FDA), the ACIP, and the ACR consider the live
zoster vaccine contraindicated in patients receiving immunosuppressive medications, such as
biologic therapies. Such contraindication stems from the theoretical safety concern that
these individuals could develop a disseminated varicella-like infection from the vaccine
virus strain. However, the investigators hypothesize that this vaccine can safely be given
in this setting, as there are no published data to suggest that these safety concerns are
warranted, and a growing body of observational data suggest that vaccinating RA patients
receiving biologic therapies with this vaccine may in fact be safe. Moreover, and similarly
with little or no evidence, the ACIP considers the vaccine safe and acceptable for patients
using methotrexate at doses commonly used to treat RA (e.g. <= 25mg/week) and for patients
using glucocorticoids at prednisone-equivalent doses of ≤ 20 mg/day.

In light of 1) a substantial elevated HZ risk among RA patients; 2) national data showing
most RA patients are not vaccinated for HZ; and 3) the high effectiveness of this vaccine in
the general population, the investigators propose to conduct the Varicella zostER VaccinE
(VERVE) trial, a randomized, double-blind, placebo-controlled study to evaluate the safety,
tolerability, and long-term effectiveness of the live herpes zoster vaccine. This pilot
study will recruit the first 125 patients of the needed 1,000 individuals age 50 years or
older currently receiving anti-TNF therapy for RA or other inflammatory arthritis. Within a
relevant 6 week safety window, the investigators will collect serious adverse events
(satisfying a regulatory definition of a SAE) including non-serious events of vaccine-strain
varicella-like infection or herpes zoster. Beyond the key public health importance of the
clinical question being addressed, clinical trial methodological innovations proposed for
this unique large pragmatic trial. Additionally, the investigators will study vaccine
tolerability and long term effectiveness through a linkage to health plan data to allow for
cost-effective follow-up while minimizing participant and study-site burden.

Inclusion Criteria:

- Diagnosis of RA (ACR 1987 criteria) or another inflammatory arthritis

- Must be 50 years of age or older

- Must be currently treated with an anti-TNF therapy at the time of vaccination.
Specifically, most recent weekly etanercept dose must have occurred within 7 days,
most recent adalimumab dose must have occurred within 14 days, most recent
certolizumab dose must have occurred within 14 days, most recent golimumab dose must
have occurred within 30 days, and most recent infliximab infusion must have occurred
within 56 days.

- Must be receiving an anti-TNF therapy for an inflammatory arthritis (i.e. rheumatoid
arthritis or a spondyloarthropathy such as psoriatic arthritis, ankylosing
spondylitis or enteropathic arthritis). Based upon the age requirement and RA
prevalence, we expect the vast majority of patients will have rheumatoid arthritis.

- Subjects should be ambulatory, community dwelling and capable of giving informed
consent.

- The first 250 patients recruited to Phase I must test positive for VZV immunoglobulin
G (IgG).

- Subjects should have a self-reported history of prior varicella infection (i.e.
chicken pox) or long-term residence (>30 years) in the continental US.

- The first 100 patients recruited to phase I must not have received any oral or
systemic glucocorticoids within 30 days prior to vaccination. Intra-articular
glucocorticoid injections within the previous 30 days are acceptable.

- Subjects should be on stable doses of all biologic and non-biologic DMARDs for a
minimum of 30 days prior to vaccination.

- Eligible women must be post-menopausal (> 1 year since last menstrual period) or have
a surgical history of bilateral oophorectomy or hysterectomy.

Exclusion Criteria:

- Prior use of the zoster vaccine (Zostavax®, Merck)

- Glucocorticoids at a prednisone-equivalent daily dose > 10mg/day

- Any known contraindication to Zostavax® vaccine, including allergy or sensitivity to
gelatin or any other vaccine component

- Known HIV/AIDS

- Currently receiving radiation or chemotherapy for any type of malignancy

- Any current use (within the last 30 days) of acyclovir, valacyclovir, or famciclovir

- Receipt of any other immunizations within one month before study vaccination (2 weeks
in the case of inactivated influenza vaccines or other non-replicating immunization
products [e.g., diphtheria-tetanus (dT), pneumococcal vaccine, hepatitis A vaccine,
hepatitis B vaccine]), or scheduled within 6 weeks after recruitment.

- Active infection or inter-current illness (e.g., urinary tract infection, influenza)

- Participated in an investigational study within 1 month prior to study entry

- Active drug or alcohol use, dependence, or any other reason that, in the opinion of
the site investigator, would interfere with the study

- Significant underlying illness that would be expected to prevent completion of the
study (e.g., life-threatening disease likely to limit survival to less than 3 years)

- Any other reason that, in the opinion of the site investigator, would interfere with
required study related evaluations (e.g. uncontrolled comorbidity, life expectancy <
1 year)Patients who have household contact with varicella-susceptible pregnant women
or severely immunosuppressed individuals without history of primary varicella.