When should a patient on risankizumab (Skyrizi) receive the influenza vaccine?

Timing of Influenza Vaccination for Patients on Skyrizi (Risankizumab)

Patients on Skyrizi should receive the influenza vaccine without any need to hold or adjust their medication timing—simply administer the vaccine on schedule during flu season. 1

Key Recommendations

Continue Skyrizi Without Interruption

• No medication hold required: Unlike methotrexate or rituximab, IL-23 inhibitors like Skyrizi do not require dose timing adjustments around influenza vaccination 2
• The 2022 ACR guideline specifically addresses medication management at vaccination and only recommends holding methotrexate (for 2 weeks post-vaccination) or timing rituximab doses—all other immunosuppressive medications, including biologics like Skyrizi, should be continued 2

Vaccination Timing Relative to Treatment Status

Before starting Skyrizi (ideal scenario):

• If possible, administer inactivated influenza vaccine ≥2 weeks before initiating Skyrizi to optimize immune response 3
• This allows the immune system to mount a full response before immunosuppression begins

Already on Skyrizi (most common scenario):

• Administer influenza vaccine on the regular seasonal schedule without regard to Skyrizi dosing intervals 2, 1
• Do not delay vaccination to try to "time" it with Skyrizi doses
• The FDA label for Skyrizi explicitly states to "complete all age-appropriate vaccinations as recommended by current immunization guidelines" 1

Safety Considerations

No Increased Risk of Adverse Events

The evidence strongly supports safety of inactivated influenza vaccine in patients on immunosuppressive biologics:

• Studies in cancer patients on immune checkpoint inhibitors (which have higher immunogenicity than IL-23 inhibitors) showed no increase in immune-related adverse events from flu vaccination 4, 5
• One study even found vaccination was associated with fewer immune-related adverse events (OR 0.4,95% CI 0.2-0.9) 5

Vaccine Efficacy Maintained

• IL-23 inhibitors like Skyrizi do not profoundly suppress B-cell function the way rituximab does
• Unlike rituximab-treated patients who show severely blunted vaccine responses 6, patients on biologics targeting specific cytokine pathways generally maintain adequate humoral responses
• The ACR guideline's lack of specific timing recommendations for biologics other than rituximab reflects this preserved vaccine responsiveness 2

Common Pitfalls to Avoid

1. Do not delay seasonal flu vaccination trying to optimize timing—the seasonal window is limited and timely vaccination is more important than theoretical optimization
2. Do not confuse Skyrizi with rituximab—rituximab requires specific timing strategies due to B-cell depletion; Skyrizi does not
3. Do not use live attenuated influenza vaccine (LAIV/nasal spray)—only inactivated influenza vaccine (IIV/injection) should be used in immunosuppressed patients 3

Practical Algorithm

Is patient already on Skyrizi?
├─ YES → Give flu vaccine on seasonal schedule
│         Continue Skyrizi without interruption
│         Use inactivated (injectable) vaccine only
│
└─ NO (planning to start Skyrizi) → 
    ├─ Can delay Skyrizi start by 2+ weeks? 
    │  └─ YES → Vaccinate now, start Skyrizi ≥2 weeks later
    │  └─ NO → Start Skyrizi as needed, vaccinate on seasonal schedule
    │           (Some immunity better than delayed treatment)

The bottom line: Skyrizi does not require the medication management strategies needed for methotrexate or rituximab around influenza vaccination. Vaccinate on schedule and continue Skyrizi without interruption. 2, 1