Is it safe to administer the Respiratory Syncytial Virus (RSV) vaccine and the shingles vaccine to a patient with a likely diagnosis of an autoimmune disorder, such as rheumatoid arthritis, who is currently taking plaquenil (hydroxychloroquine) and methotrexate?

RSV and Shingles Vaccination in Patients on Plaquenil and Methotrexate

Yes, it is safe to administer both the RSV vaccine and shingles vaccine (Shingrix) to patients taking plaquenil and methotrexate, as these are non-live vaccines that can be safely given to immunosuppressed patients with autoimmune inflammatory rheumatic diseases. 1, 2

Key Principle: Non-Live vs. Live Vaccines

The critical distinction here is that both the RSV vaccine and the recombinant zoster vaccine (Shingrix/RZV) are non-live vaccines, which fundamentally changes their safety profile in immunosuppressed patients 1, 2:

• Non-live vaccines can be safely administered to patients on DMARDs (including methotrexate and hydroxychloroquine) and do not cause vaccine-strain infections 1
• Live-attenuated vaccines should be avoided in immunosuppressed patients due to risk of severe infections from the vaccine strain 1, 3

Specific Recommendations for Each Vaccine

Shingles Vaccine (Shingrix/RZV)

Shingrix is the preferred and recommended shingles vaccine for patients with autoimmune inflammatory rheumatic diseases on immunosuppressive therapy 1:

• The recombinant zoster vaccine demonstrated 90.5% efficacy against herpes zoster in patients with pre-existing autoimmune conditions including rheumatoid arthritis, psoriasis, and spondyloarthritis 1
• Rates of serious adverse events were similar between RZV and placebo groups in these patients 1
• The vaccine can be administered while continuing methotrexate and plaquenil without interruption 2

Important distinction: The older live-attenuated zoster vaccine (Zostavax/ZVL) would be contraindicated in this patient, but Shingrix is specifically designed for immunocompromised individuals 1, 3

RSV Vaccine

RSV vaccines (such as Abrysvo) are non-live vaccines and can be safely administered to patients on methotrexate and plaquenil 2:

• Continue methotrexate without interruption during RSV vaccination 2
• No special precautions or medication holds are required 2

Medication Management During Vaccination

Methotrexate

For most non-live vaccines, continue methotrexate without interruption 2:

• The only exception is influenza vaccine, where a 2-week hold after vaccination may be considered if disease activity allows 2
• For RSV and Shingrix specifically, do not hold methotrexate 2

Plaquenil (Hydroxychloroquine)

Continue plaquenil without any interruption during vaccination 1, 2:

• Hydroxychloroquine causes minimal immunosuppression and does not significantly impair vaccine responses 4
• No medication adjustments are needed for any non-live vaccines 2

Optimal Timing Considerations

Ideally, vaccinate during stable disease activity 1:

• While vaccination can be administered regardless of disease activity, stable disease is preferred 1
• If possible, complete vaccinations before initiating more potent immunosuppression (though this doesn't apply to methotrexate and plaquenil, which are relatively mild) 1

Both vaccines can be administered simultaneously or at any interval 1:

• Inactivated vaccines like Shingrix and RSV vaccine may be given concomitantly with each other or at any time before or after other inactivated vaccines 1
• No waiting period is required between these two vaccines 1

Common Pitfalls to Avoid

Do not confuse Shingrix with Zostavax 1, 3:

• Zostavax is a live-attenuated vaccine that would be contraindicated in immunosuppressed patients 1, 3
• Shingrix is a recombinant (non-live) vaccine specifically designed for immunocompromised individuals 1, 5

Do not unnecessarily hold DMARDs for non-live vaccines 2:

• The outdated practice of holding all immunosuppression for vaccination applies primarily to live vaccines 3
• For non-live vaccines, continuing therapy maintains disease control without significantly compromising vaccine response 2

Do not delay vaccination due to concerns about disease flares 1, 6:

• Large database studies found no statistically significant increase in disease flares following vaccination with non-live vaccines 5
• The infection prevention benefit far outweighs the minimal theoretical flare risk 1, 6

Expected Vaccine Response

Patients on methotrexate and plaquenil generally mount adequate immune responses to non-live vaccines 7, 6:

• While responses may be somewhat reduced compared to healthy individuals, they remain clinically protective 7, 6
• The combination of methotrexate and hydroxychloroquine causes less immunosuppression than biologics or high-dose corticosteroids 4
• Treatment with DMARDs does not appear to significantly impair immune responses to most vaccines 7

Dosing Schedule

Shingrix: Two doses given 2-6 months apart (minimum 4 weeks) 5

RSV vaccine: Single dose annually (specific product may vary) 2