Can Patients on Rinvoq Receive the Zoster Vaccine?
Yes, patients on Rinvoq (upadacitinib) should receive the recombinant zoster vaccine (RZV/Shingrix), but must avoid the live zoster vaccine (ZVL/Zostavax). The FDA label explicitly states that patients should be brought up to date with herpes zoster vaccinations prior to initiating Rinvoq, and the recombinant vaccine is safe and effective in this population 1.
Vaccine Selection
The recombinant zoster vaccine (Shingrix) is the only appropriate option for patients on Rinvoq, as it is a non-live vaccine that is safe for immunocompromised individuals 2, 3.
The live zoster vaccine (Zostavax) is absolutely contraindicated in patients receiving JAK inhibitors like upadacitinib due to the theoretical risk of disseminated vaccine-strain infection 2, 3.
JAK inhibitors cause significant immunosuppression that makes live vaccines unsafe 3.
Optimal Timing Strategy
Ideally, administer both doses of Shingrix before starting Rinvoq to maximize immune response 2, 3.
If vaccination must occur while on Rinvoq, the American College of Rheumatology recommends holding methotrexate (if co-administered) for 2 weeks after each vaccine dose to optimize response 2.
For patients already on Rinvoq, no modification of upadacitinib dosing is required around vaccination time 2.
The standard dosing schedule is two doses given 2-6 months apart 2, 4.
Immunogenicity on Rinvoq
87.8% of patients on upadacitinib 15 mg daily with background methotrexate achieved satisfactory antibody responses (≥4-fold increase) 4 weeks after the second RZV dose 5.
Over 60% achieved cell-mediated immune responses at all measured time points through 60 weeks 5.
Age and concomitant corticosteroid use (median 5 mg prednisone daily) did not significantly affect vaccine response 5.
JAK inhibitors can reduce vaccine immunogenicity compared to healthy individuals, but responses remain clinically meaningful 2, 5.
Critical Safety Considerations
Breakthrough herpes zoster infections can still occur despite vaccination, even in patients who received both RZV doses before starting upadacitinib 6, 7.
One case report documented disseminated herpes zoster in a 60-year-old woman on high-dose upadacitinib despite completing the RZV series, requiring IV acyclovir and drug discontinuation 7.
The risk of herpes zoster is particularly elevated in Japanese patients with RA on JAK inhibitors compared to Western populations 8.
No serious adverse events were reported in the primary immunogenicity study of RZV in patients on upadacitinib 5.
Common Pitfalls to Avoid
Do not delay vaccination indefinitely waiting for "optimal" disease control—the vaccine can be given during stable disease on Rinvoq 2, 3.
Do not confuse the two zoster vaccines—only Shingrix (RZV) is safe; Zostavax (ZVL) is contraindicated 2, 3, 1.
Do not assume vaccination provides complete protection—counsel patients that breakthrough infections remain possible, though likely less severe 6, 7.
Do not hold upadacitinib around vaccination time—only methotrexate (if co-administered) requires temporary interruption 2.
Clinical Algorithm
- Verify vaccine type: Confirm Shingrix (RZV), not Zostavax (ZVL) 2, 3
- Check vaccination history: If never vaccinated, proceed with 2-dose series 2, 4
- Optimize timing: Give before starting Rinvoq if possible; if already on Rinvoq, proceed without delay 2, 3
- Manage concomitant methotrexate: Hold for 2 weeks after each dose if co-administered 2
- Maintain upadacitinib: Continue without interruption 2
- Monitor for breakthrough: Counsel patients on herpes zoster symptoms despite vaccination 6, 7
Special Population Considerations
For patients over 50 years, RZV is recommended regardless of prior herpes zoster history 2, 4.
For immunocompromised adults aged 18-49 years at increased risk, RZV can be given with a shortened schedule (1-2 months between doses) 2, 4.
Patients who previously received Zostavax should still receive the full 2-dose Shingrix series, with at least 2 months between the last Zostavax dose and first Shingrix dose 2, 4.