What are the recommendations for administering the Shingrix (recombinant zoster vaccine) and RSV (respiratory syncytial virus) vaccines to a patient with Crohn's disease on Infliximab (infliximab)?

Vaccination Recommendations for Crohn's Disease Patients on Infliximab

Direct Answer

Both Shingrix and RSV vaccines should be administered to your patient with Crohn's disease on infliximab—these are inactivated/recombinant vaccines that are safe and strongly recommended for immunosuppressed IBD patients. 1

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Shingrix (Recombinant Zoster Vaccine) Administration

Primary Recommendation

All adults with IBD aged 19 years and older receiving infliximab should receive the Shingrix 2-dose series. 1 This is a strong recommendation based on the 2025 AGA Clinical Practice Update, which explicitly addresses IBD patients on immune-modifying therapies. 1

Dosing Schedule for Immunosuppressed Patients

• For patients on infliximab: Administer doses 4-8 weeks apart (accelerated schedule compared to immunocompetent patients who receive doses 8-12 weeks apart) 1
• The minimum interval is 4 weeks between doses 2
• Do not delay infliximab therapy to give the vaccine—administer at the earliest opportunity regardless of biologic dosing schedule 1

Safety Profile

• Shingrix is safe in IBD patients on infliximab and does not cause disease flares. 1 Multiple studies demonstrate that inactivated vaccines with adjuvants (including recombinant herpes zoster vaccine) are not associated with exacerbation of IBD activity. 1
• Adverse events are mainly local or mildly systemic and do not significantly differ from the general population 1
• This is a non-live recombinant vaccine, making it fundamentally safe for immunocompromised patients, unlike the older live-attenuated Zostavax which is contraindicated 3, 2

Critical Timing Considerations

• Preferably administer when not on corticosteroids or at the lowest dose, as concomitant corticosteroids reduce vaccine-induced humoral immune responses 1
• However, do not delay vaccination if the patient is on steroids—the benefit of protection outweighs the potentially reduced immune response 1
• Vaccination timing relative to infliximab infusion does not matter—immune responses are not influenced by biologic dosing schedule 1

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RSV Vaccine Administration

Age-Based Recommendations

RSV vaccination is recommended based on specific age and risk criteria for IBD patients: 1

• Age ≥75 years: Single dose recommended for all IBD patients 1
• Age 60-74 years: Single dose recommended if the patient has certain medical conditions or risk factors for severe RSV disease 1
• Age <60 years: Not routinely recommended unless pregnant (32-36 weeks gestation, September-January only) 1

Vaccine Options

Either recombinant vaccine (Abrysvo/Pfizer) or adjuvanted recombinant vaccine (Arexvy/GlaxoSmithKline) can be used—there is no preference for any specific RSV vaccine 1

Safety in Immunosuppressed Patients

• RSV vaccines are inactivated/recombinant and safe for patients on infliximab 1
• Like all inactivated vaccines, RSV vaccination is not associated with IBD flares 1
• Administer at the earliest opportunity, preferably when not on corticosteroids or at the lowest tolerable dose 1

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Key Principles for All Vaccinations in IBD Patients on Infliximab

Overarching Safety Framework

1. All inactivated vaccines are safe and should not be delayed due to infliximab therapy 1
2. Never withhold or pause infliximab for vaccination—the risk of disease flare outweighs any theoretical benefit of improved vaccine response 4, 1
3. Vaccines can be administered during any clinic visit—do not wait for "optimal" timing 1

Contraindications to Remember

• Live-attenuated vaccines (MMR, varicella, Zostavax, yellow fever) should be avoided in patients on infliximab 4, 1
• The case report of a newborn whose mother used infliximab during pregnancy dying from vaccine-induced tuberculosis after BCG vaccination underscores the danger of live vaccines in this population 4

Optimizing Vaccine Response

• Concomitant immunosuppressants (azathioprine, 6-mercaptopurine, methotrexate) with infliximab may reduce vaccine response, but this should not delay vaccination 5, 6
• Corticosteroids are associated with lower vaccine-induced humoral responses—administer vaccines when off steroids or at the lowest dose when feasible 1
• However, annual seasonal vaccinations (influenza, COVID-19 boosters) should be offered regardless of treatment regimen, even if on high-dose corticosteroids 1

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Common Pitfalls to Avoid

1. Do not confuse Shingrix with Zostavax—only Shingrix (recombinant) is appropriate for immunosuppressed patients 3, 2, 7
2. Do not delay necessary infliximab therapy to complete vaccination series 1
3. Do not refuse vaccination because the patient is on combination therapy (infliximab + immunomodulator)—the vaccines remain safe even if response may be somewhat reduced 1
4. Do not check antibody titers after vaccination to determine "protection"—this is not recommended for routine practice in IBD patients 1
5. Do not withhold RSV vaccine from eligible patients (≥60 years) simply because they are on biologics—these are inactivated vaccines 1

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Practical Implementation Algorithm

For Shingrix:

1. Confirm patient is ≥19 years old (or ≥50 years if not on immunosuppression) 1, 2
2. Administer first dose immediately at any clinic visit 1
3. Schedule second dose 4-8 weeks later (accelerated schedule for immunosuppressed) 1
4. Counsel patient about expected local reactions and systemic symptoms (common but not dangerous) 2
5. Continue infliximab without interruption 1

For RSV:

1. Determine patient age 1
2. If ≥75 years: Administer single dose immediately 1
3. If 60-74 years: Assess for risk factors (chronic lung disease, heart disease, diabetes, immunosuppression itself qualifies) 1
4. If risk factors present: Administer single dose 1
5. Choose either available RSV vaccine (no preference) 1