Can a patient on immunosuppressive (IS) therapy take the shingles vaccine?

Can a Patient on Immunosuppressive Therapy Take the Shingles Vaccine?

Yes, patients on immunosuppressive therapy should receive the recombinant zoster vaccine (RZV/Shingrix), which is safe and approved for immunocompromised adults, but must NOT receive the live zoster vaccine (ZVL/Zostavax). 1

Critical Distinction Between Vaccine Types

The answer depends entirely on which shingles vaccine you're considering:

Recombinant Zoster Vaccine (RZV/Shingrix) - SAFE and RECOMMENDED

• RZV is not a live vaccine and is safe for immunocompromised patients 2, 1
• RZV is the first and only HZ vaccine approved specifically for immunocompromised adults aged ≥18 years globally, including in Europe and the US 3
• RZV is the preferred vaccine for ALL patients, including those on immunosuppressive therapy 2
• Can be administered at any time during immunosuppressive therapy 1
• Requires 2 doses administered 2-6 months apart 1

Live Zoster Vaccine (ZVL/Zostavax) - CONTRAINDICATED

• Live vaccines are generally considered unsafe during immunosuppression 2
• ZVL is contraindicated in patients on biological therapy (TNF inhibitors, anti-CD20 agents, etc.) due to theoretical risk of disseminated vaccine-strain infection 2, 1
• Must wait 1-6 months after stopping immunosuppressive therapy before administering live vaccines 2

Specific Timing Recommendations by Drug Class

If RZV is unavailable and ZVL must be considered, specific waiting periods apply after stopping immunosuppression 2:

• Steroids (prednisone): Stop 1 month before, restart 1 month after
• Thiopurines (azathioprine/mercaptopurine): Stop 3 months before, restart 1 month after
• Methotrexate: Stop 1 month before, restart 1 month after
• TNF inhibitors (infliximab, adalimumab, etc.): Stop 3 months before, restart 1 month after
• JAK inhibitors (tofacitinib): Stop 1 month before, restart 1 month after

Exception: Low-Level Immunosuppression with ZVL

ZVL may be considered in patients on low-level immunosuppression only 2:

• Prednisolone ≤20 mg/day for >14 days, either alone OR
• In combination with low-dose non-biological immunomodulators (methotrexate ≤25 mg/week, azathioprine ≤3 mg/kg/day, or mercaptopurine ≤1.5 mg/kg/day)
• Evidence from controlled studies shows ZVL is safe in IBD patients on thiopurines, methotrexate, and even anti-TNF agents, though antibody responses may be reduced 2

Safety Data Supporting RZV Use

• No cases of disseminated VZV infection or shingles reactivation occurred in 617 patients on anti-TNF agents who received ZVL in ongoing RCT 2
• Among 633 Medicare patients inadvertently vaccinated with ZVL while on biologics, no cases of shingles occurred in the 6 weeks post-vaccination 2
• RZV has a clinically acceptable safety profile in immunocompromised adults 3

Important Caveats About Disease Flares

There is theoretical concern that the adjuvant in RZV may trigger disease flares 2, 1:

• Retrospective studies show conflicting results: one found 7% flare rate within 12 weeks, another found 16% 2
• These rates may be similar to expected baseline flare rates, but prospective controlled studies are needed 2
• Despite this concern, the benefit of preventing severe HZ and its complications in immunocompromised patients outweighs this risk 4, 3

Optimal Vaccination Strategy

Ideally, vaccinate BEFORE starting immunosuppressive therapy 2, 1:

• Administer vaccine ≥4 weeks before initiating immunosuppression 2
• Vaccine should be given during quiescent disease if possible 2
• If already on immunosuppression, RZV can be given at any time 1

Why This Matters for Immunosuppressed Patients

• Patients on immunosuppressive therapy have 20-100 times higher risk of developing herpes zoster 5
• Immunocompromised patients are more likely to have severe HZ, including disseminated forms and life-threatening complications 6, 4
• TNF inhibitors specifically increase HZ risk 1
• Vaccination reduces both incidence and severity of HZ and its complications, including postherpetic neuralgia 3

Common Pitfall to Avoid

Do not assume all shingles vaccines are the same - the critical error is giving live ZVL to immunosuppressed patients when RZV is the appropriate choice 1. Always verify which vaccine formulation is being used before administration.