Can Shingrix (recombinant zoster vaccine) be administered to patients on Skyrizi (risankizumab)?

Shingrix Administration in Patients on Skyrizi (Risankizumab)

Yes, Shingrix can and should be administered to patients on Skyrizi (risankizumab), as it is a non-live recombinant vaccine that is safe for immunocompromised patients, including those on biologic immunosuppressive therapy. 1

Safety and Rationale

• Shingrix is specifically recommended for patients with inflammatory bowel disease on immune-modifying therapy, which includes biologic agents like risankizumab 1
• The vaccine is a non-live recombinant subunit vaccine containing only varicella zoster virus glycoprotein E with an adjuvant, making it incapable of causing infection even in immunosuppressed individuals 2, 3
• Multiple studies confirm that inactivated vaccines, including adjuvanted vaccines like Shingrix, are safe in immunocompromised patients and do not cause disease flares 1

Optimal Timing Strategy

For patients already on Skyrizi:

• Administer Shingrix immediately without delay, as vaccination should not be postponed even when patients are on immunosuppressive therapy 1
• Use the modified schedule for immunocompromised patients: 2-dose series with doses given 4-8 weeks apart (rather than the standard 8-12 weeks for immunocompetent patients) 1

For patients about to start Skyrizi:

• Ideally, complete the full 2-dose Shingrix series before initiating risankizumab to maximize immune response while not yet immunosuppressed 1
• However, do not delay initiation of appropriate immune-modifying therapy if vaccination cannot be completed beforehand 1

Dosing Schedule

• First dose: Administer immediately
• Second dose: Give 4-8 weeks after the first dose for patients on immunosuppressive therapy 1
• The minimum acceptable interval between doses is 4 weeks; if given earlier, the dose must be repeated 1

Expected Immune Response

• While immune response may be somewhat reduced compared to immunocompetent individuals, the vaccine maintains effectiveness even in patients on immunosuppressive therapy 4
• Real-world effectiveness data shows 70.1% effectiveness for the 2-dose series, which remains clinically meaningful protection 5
• Concomitant low-dose glucocorticoids (prednisone equivalent <10 mg/day) do not adversely impact vaccine response 4

Important Clinical Considerations

• Never use the live-attenuated Zostavax vaccine in patients on or about to start biologic therapy—only Shingrix is appropriate 6
• Patients with inflammatory bowel disease already have elevated baseline herpes zoster risk, which is further amplified by immunosuppressive therapy 4
• Common side effects include injection-site reactions (pain, redness, swelling) in 9.5% and systemic symptoms in 11.4%, but these are transient and resolve within 4 days 4, 1

Administration Logistics

• Administer intramuscularly, preferably in the deltoid muscle 4
• Can be given simultaneously with other inactivated vaccines (including influenza, pneumococcal, COVID-19) at separate anatomic sites 1
• If administering multiple adjuvanted vaccines simultaneously, consider giving them in different limbs to minimize local reactions 1

Critical Pitfall to Avoid

Do not withhold or delay Shingrix vaccination because the patient is on biologic therapy—this is the exact population that needs protection most urgently due to their elevated herpes zoster risk from both underlying disease and immunosuppressive treatment 1, 6