From the Guidelines
Zostavax is not recommended for patients on methotrexate due to the risk of vaccine-strain viral infection and potential interference with the immune response, instead Shingrix is the preferred shingles vaccine for these patients. Zostavax is a live attenuated vaccine for shingles prevention, and methotrexate is an immunosuppressive medication that can increase the risk of complications from live vaccines 1. The American College of Rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases recommends holding methotrexate for 4 weeks before and after live attenuated virus vaccine administration, but this may not be necessary for non-live vaccines like Shingrix 1. Shingrix requires two doses given 2-6 months apart and provides superior protection against shingles compared to Zostavax. Patients should continue their methotrexate during Shingrix vaccination as there is no need to temporarily discontinue immunosuppressive therapy for this non-live vaccine. The decision should always be made in consultation with the healthcare provider managing the patient's methotrexate therapy, who can consider the degree of immunosuppression and overall clinical situation.
Some key points to consider when vaccinating patients on methotrexate include:
- The risk of vaccine-strain viral infection from live vaccines like Zostavax
- The potential interference with the immune response to live vaccines
- The preference for non-live vaccines like Shingrix in immunocompromised patients
- The need for consultation with the healthcare provider managing the patient's methotrexate therapy
- The importance of considering the degree of immunosuppression and overall clinical situation when making vaccination decisions.
It's also important to note that the evidence from recent studies, such as the 2022 American College of Rheumatology guideline, supports the use of non-live vaccines like Shingrix in patients on methotrexate, and that the risk of complications from live vaccines can be significant in immunocompromised patients 1.
From the Research
Zostavax and Methotrexate
- The safety and efficacy of Zostavax (live zoster vaccine) in patients on methotrexate have been studied in several clinical trials 2, 3.
- A 2017 study found that patients with rheumatoid arthritis who were receiving background methotrexate and were given Zostavax had similar humoral and cell-mediated immune responses to those who received a placebo 2.
- Another study published in 2020 found that live zoster vaccine was well tolerated in patients with rheumatoid arthritis who were treated with tofacitinib with or without methotrexate, or adalimumab with methotrexate 3.
- However, it is essential to note that the studies had some limitations, such as the small number of patients who received the vaccine and the lack of long-term follow-up data.
Key Findings
- Zostavax can be safe for patients on methotrexate, but the decision to administer the vaccine should be made on a case-by-case basis, considering the individual patient's risk factors and medical history 2, 3.
- The vaccine's efficacy in preventing herpes zoster in patients on methotrexate is not well established, and more research is needed to fully understand its benefits and risks 4.
- Primary care physicians' awareness and attitudes regarding Zostavax and the new recombinant zoster vaccine (RZV) can impact vaccination rates, and education and awareness campaigns may be necessary to improve vaccination rates in at-risk populations 5.
Considerations for Patients on Methotrexate
- Patients on methotrexate who are considering receiving Zostavax should discuss the potential benefits and risks with their healthcare provider 2, 3.
- The healthcare provider should assess the patient's individual risk factors, such as age, medical history, and immune status, to determine the best course of action 4.
- Patients on methotrexate who receive Zostavax should be monitored for potential side effects and complications, such as vaccine dissemination or serious adverse events 2, 3.