From the Guidelines
Shingrix is recommended for patients on methotrexate (MTX) as it is a non-live recombinant vaccine, making it safe for those with suppressed immune systems. Patients taking MTX for conditions like rheumatoid arthritis or psoriasis can safely receive the Shingrix vaccine without needing to pause their methotrexate therapy, as supported by the 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases 1. The vaccine should be administered as a two-dose series, with the second dose given 2-6 months after the first dose.
Key Considerations
- Shingrix is preferred over the older live zoster vaccine (Zostavax) for immunocompromised patients because it is a non-live recombinant vaccine, making it safe for those with suppressed immune systems.
- Patients on MTX have an increased risk of herpes zoster (shingles) due to their immunosuppression, making vaccination particularly important.
- Common side effects include injection site pain, fatigue, and muscle aches, which typically resolve within 2-3 days.
- These patients should be monitored for vaccine response, as immunosuppressive medications like MTX may potentially reduce vaccine effectiveness, though studies show Shingrix generally maintains good efficacy even in immunocompromised populations 1.
Administration and Safety
- The safety of Shingrix has been demonstrated in elderly adults, and its efficacy is higher compared to the live-attenuated vaccine 1.
- Although specific data on the safety and efficacy of Shingrix in patients with autoimmune inflammatory rheumatic diseases (AIIRD) is limited, its non-live nature suggests it can replace the live-attenuated vaccine in these patients 1.
- Administration of the vaccine to active RA patients ≥50 years old treated with MTX, 2 to 3 weeks before starting tofacitinib, was reported to be safe and immunogenic at 14 weeks follow-up, supporting its use in patients on MTX 1.
From the Research
Shingrix Vaccine Effectiveness
- The Shingrix vaccine has been shown to be effective in preventing herpes zoster, with a vaccine effectiveness of 70.1% (95% confidence interval [CI], 68.6-71.5) for 2 doses and 56.9% (95% CI, 55.0-58.8) for 1 dose 2.
- The vaccine effectiveness was not significantly lower for beneficiaries aged >80 years, for second doses received at ≥180 days, or for individuals with autoimmune conditions, including those on methotrexate (MTX) 2.
Methotrexate and Herpes Zoster Risk
- There is conflicting evidence on the association between MTX and herpes zoster (HZ) infection, with some studies suggesting a positive association and others finding no link 3.
- A systematic literature review found that the data regarding the role of MTX in HZ development is conflicting, and there is no evidence to support an association between MTX and varicella zoster virus (VZV) infection in rheumatoid arthritis patients 3.
Shingrix Vaccine in Patients on MTX
- A post hoc analysis of data from a phase IIIb/IV randomized study found that live zoster vaccine (LZV) was well tolerated in patients with rheumatoid arthritis treated with tofacitinib ± MTX, or adalimumab plus MTX, and herpes zoster incidence rates were generally similar between vaccinated and nonvaccinated patients 4.
- However, the study noted that LZV has been shown to be effective only in ~50% of individuals, and the study was not powered for comparisons between vaccinated and nonvaccinated patients because <20% of all patients were vaccinated 4.
Considerations for Patients on MTX
- Patients on MTX should be closely monitored for signs of infection, including herpes zoster, and vaccinated against herpes zoster if recommended by their healthcare provider 3.
- Nurses should be aware of the potential risks and benefits of MTX treatment, including the risk of herpes zoster, and provide supportive care to mitigate MTX toxicity 5.