How long before starting a treatment regimen with immunosuppressive drugs like bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone for a patient with multiple myeloma should vaccines such as Hepatitis B Virus (HBV) vaccine, Shingrix (recombinant zoster vaccine), Influenza vaccine, and Prevenar 20 (pneumococcal conjugate vaccine) be administered?

Vaccination Timing Before Starting Multiple Myeloma Treatment

Patients with scheduled chemotherapy should be vaccinated at least 2 weeks before initiation of chemotherapy with bortezomib, lenalidomide, and dexamethasone. 1

Optimal Vaccination Window

The European Myeloma Network provides clear guidance that vaccination should occur at least 2 weeks before starting immunosuppressive therapy to allow adequate immune response before treatment-induced immunosuppression begins. 1 This timing is critical because:

• Immune response is substantially impaired once treatment begins, particularly with proteasome inhibitors and immunomodulatory drugs that suppress both humoral and cellular immunity 1
• Lenalidomide causes infection rates of 14-30% (grade 3-4), with the highest risk during the first three months of therapy 1, 2
• Antibody responses to vaccines are suboptimal in myeloma patients, and this response is further diminished once immunosuppressive therapy is initiated 1

Vaccine-Specific Recommendations

All Four Vaccines (HBV, Shingrix, Influenza, Prevenar 20)

• Administer at least 2 weeks before starting bortezomib/lenalidomide/dexamethasone 1
• This single timeframe applies to all inactivated vaccines being planned 1

Special Considerations by Vaccine Type

Shingrix (Recombinant Zoster Vaccine):

• Strongly recommended for all multiple myeloma patients as the preferred herpes zoster vaccine 1
• Achieves 80.4% antibody response in myeloma patients 1
• Two doses required for complete protection 1
• Safe to administer while on lenalidomide or bortezomib maintenance therapy (based on data showing safety at median 25 months post-transplant) 3

Influenza Vaccine:

• Annual vaccination is mandatory for myeloma patients and their close contacts 1
• Injectable inactivated vaccine only—never live-attenuated 1

Prevenar 20 (Pneumococcal Conjugate Vaccine):

• Preferred over polysaccharide vaccines because conjugation to carrier protein creates T-cell dependent antigens that are more immunogenic 1
• Single dose recommended for all myeloma patients 1

Hepatitis B Vaccine:

• Three-dose series required (at 0,1, and 6 months) 1
• Strongly consider antibody testing ≥1 month after completion to confirm response 1
• Revaccination recommended for non-responders 1

Critical Clinical Pitfalls to Avoid

Do not delay vaccination until after treatment starts:

• Once immunosuppressive therapy begins, vaccine efficacy drops significantly 1
• The 2-week pre-treatment window is the last opportunity for optimal immune response 1

Do not use live-attenuated vaccines:

• Live zoster vaccine (Zostavax) is contraindicated in myeloma patients on immunosuppressive therapy 1
• Only recombinant Shingrix should be used 1
• Live vaccines carry risk of vaccine-strain infection in immunocompromised patients 4

Do not assume single vaccination is sufficient:

• Consider second administration or antibody testing to confirm adequate response, particularly for hepatitis B 1
• Myeloma patients frequently require booster doses due to suboptimal initial responses 1

Post-Vaccination Monitoring

• Measure antibody titers ≥1 month after vaccination when feasible, particularly for hepatitis B 1
• Revaccinate non-responders or those with inadequate antibody levels 1
• Consider booster doses if antibody levels fall below protective thresholds (e.g., hepatitis B <10 IU/L) 1

Household Contact Vaccination

All close contacts and household members must receive:

• Annual influenza vaccination 1
• Age-appropriate pneumococcal vaccination (if ≥65 years) 1
• All routine age-appropriate vaccines to create a protective cocoon around the immunocompromised patient 4