From the Guidelines
Shingrix (recombinant zoster vaccine) is the recommended shingles vaccine for immunocompromised patients, as it provides strong protection against shingles with efficacy rates over 90% and does not pose the risk of disseminated disease associated with live attenuated vaccines like Zostavax. The use of live-attenuated vaccines, such as Zostavax, in immunocompromised patients is generally contraindicated due to the risk of uncontrolled viral replication 1. In contrast, Shingrix is a non-live, recombinant vaccine that can be safely administered to immunocompromised individuals.
The safety and efficacy of Shingrix have been demonstrated in several studies, including the ZOE-50 and ZOE-70 trials, which showed that the vaccine provides strong protection against shingles and postherpetic neuralgia, with efficacy rates of 97.2% and 91.3%, respectively 1. Common side effects of Shingrix include injection site pain, fatigue, and muscle aches, which typically resolve within 2-3 days.
For immunocompromised patients, the second dose of Shingrix can be administered 1-2 months after the first dose if needed. It is essential to inform immunocompromised patients that they might experience more pronounced side effects, but these are generally outweighed by the substantial protection against shingles and its complications. The use of Shingrix in immunocompromised patients is supported by guidelines, such as those from the EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases, which suggest that non-live vaccines can be administered to patients with AIIRD during the use of glucocorticoids and DMARDs 1.
In terms of specific risks, such as fever and cholestatic liver injury, the available evidence suggests that Shingrix is generally well-tolerated, with no significant increase in serious adverse events or deaths compared to the placebo group 1. However, as with any vaccine, there is a potential risk of adverse reactions, and patients should be monitored accordingly.
Overall, the benefits of Shingrix in preventing shingles and its complications in immunocompromised patients outweigh the potential risks, making it the recommended vaccine for this population.
From the FDA Drug Label
The efficacy of SHINGRIX was evaluated in one Phase 3 randomized, placebo-controlled, observer-blind clinical study in immunocompromised adults aged ≥18 years who received an auHSCT 50 to 70 days prior to Dose 1 and who were expected to receive prophylactic antiviral therapy for ≤6 months post-transplant The post hoc analysis showed SHINGRIX was 87.2% (95% CI [44.2; 98.6]) effective against development of HZ. In a descriptive analysis, including all subjects aged ≥18 years in the mTVC, 1 case of PHN was reported in the vaccine group compared with 9 cases reported in the placebo group. Vaccine efficacy against PHN was 89.3% (95% CI: [22.5; 99. 8]).
The recommended shingles vaccine for an immunocompromised patient is SHINGRIX (inactivated recombinant zoster vaccine).
- Fever: The label does not directly mention fever as an adverse effect.
- Cholestatic liver injury: The label does not mention cholestatic liver injury.
- SHINGRIX efficacy in immunocompromised adults: SHINGRIX is effective in preventing HZ in immunocompromised adults, with an efficacy of 87.2% (95% CI [44.2; 98.6]) against development of HZ and 89.3% (95% CI: [22.5; 99. 8]) against PHN 2.
From the Research
Shingles Vaccine Options for Immunocompromised Patients
- The live attenuated zoster vaccine (Zostavax) is not recommended for immunocompromised patients due to the risk of disseminated varicella zoster virus infection, as reported in a case study 3.
- The inactivated recombinant zoster vaccine (Shingrix) is considered a safe and effective option for immunocompromised patients, as it is non-replicating and has been shown to be effective in preventing herpes zoster and post-herpetic neuralgia 4.
Risks and Benefits of Shingles Vaccines
- Live vaccines, such as Zostavax, can cause adverse events and exacerbate underlying conditions in immunocompromised patients 5.
- Inactivated vaccines, such as Shingrix, may not ensure complete immune responses and may lead to lower and shorter protection rates depending on the extent of immunosuppression 5.
- Shingrix has been shown to be more effective than Zostavax in preventing herpes zoster and post-herpetic neuralgia 4.
Administration of Shingles Vaccines to Immunocompromised Patients
- Vaccines should preferably be administered prior to planned immunosuppressive therapies 6, 5.
- Immunocompromised patients should be vaccinated against pneumococcal disease and influenza, as these infections are vaccine-preventable and can have severe outcomes in this population 6, 7.
- Household contacts of immunocompromised patients should receive vaccines to protect the patient from infectious diseases 6, 5.
Side Effects of Shingles Vaccines
- Fever is a common side effect of vaccines, but there is no specific information available on the risk of fever associated with shingles vaccines in immunocompromised patients.
- Cholestatic liver injury is not a commonly reported side effect of shingles vaccines, but the risk of adverse events is higher in immunocompromised patients 3.