Are there special indications for administering Shingrix (zoster vaccine recombinant) to individuals under 50 years old?

Special Indications for Shingrix Under Age 50

Yes, Shingrix is indicated for adults aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression caused by known disease or therapy. 1

FDA-Approved Indications

The FDA label explicitly states two approved populations 1:

• Adults aged 50 years and older (standard indication)
• Adults aged 18 years and older who are or will be immunocompromised due to:
  • Known immunodeficiency disease
  • Immunosuppressive therapy

Specific Immunocompromised Populations Under Age 50

Hematologic malignancies and transplant recipients represent the clearest indication for early vaccination 2:

• Patients with multiple myeloma, leukemia, or lymphoma 2
• Hematopoietic stem cell transplant recipients (autologous or allogeneic) 2
• Solid organ transplant recipients on chronic immunosuppression 2

HIV/AIDS patients are explicitly included in the immunocompromised category eligible for vaccination under age 50 2.

Autoimmune disease patients on immunosuppressive therapy qualify for early vaccination 3, 2:

• Patients on chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 4
• Those receiving biologic disease-modifying drugs (anti-TNF agents, rituximab, etc.) 3
• Patients on combination immunosuppressive regimens 2

Dosing Schedule for Immunocompromised Patients Under 50

Use a shortened vaccination schedule for immunocompromised adults 5, 3:

• First dose at Month 0
• Second dose at 1-2 months (rather than the standard 2-6 months) 5, 3
• Minimum interval remains 4 weeks between doses 3

Timing Considerations for Planned Immunosuppression

Ideally vaccinate ≥4 weeks before initiating immunosuppressive therapy when possible 4:

• This allows for optimal immune response before immunosuppression begins 4
• For patients on methotrexate, consider holding for 2 weeks after vaccination 3
• For rituximab recipients, vaccinate ≥6 months after last dose and 4 weeks before next dose when feasible 3

Important Contraindications and Caveats

Shingrix is NOT indicated for prevention of primary varicella (chickenpox) 1. Patients without prior varicella immunity should receive varicella vaccine first if not contraindicated.

The live-attenuated zoster vaccine (Zostavax) remains contraindicated in immunocompromised patients of any age 4, 2. Only Shingrix should be used in this population.

Common adverse reactions are more frequent than in older adults 1:

• In transplant recipients aged 18-49 years: pain (88%), fatigue (64%), myalgia (58%), headache (44%) 1
• Grade 3 injection-site reactions occur in approximately 9.5% 3
• These reactions are transient and do not represent safety concerns 3

Clinical Decision-Making Algorithm

For patients under age 50, ask:

1. Is the patient currently immunocompromised or will they become immunocompromised? If yes → Shingrix is indicated 1
2. What is the cause of immunosuppression? (disease vs. therapy) → Both qualify 1
3. Is immunosuppression planned or ongoing? If planned → vaccinate ≥4 weeks before starting therapy 4; If ongoing → use shortened 1-2 month schedule 5
4. Is the patient on specific immunosuppressants requiring timing adjustments? If yes → adjust timing around methotrexate or rituximab 3

There is no indication for Shingrix in healthy, immunocompetent adults under age 50 based on current FDA approval and guidelines 1, 4.