Is the shingles vaccine recommended for a patient over 50 years old with a history of respiratory issues or eosinophilic disorders before starting Benralizumab (anti-interleukin-5 receptor alpha subunit monoclonal antibody)?

Shingles Vaccine Before Benralizumab

Yes, the shingles vaccine (Shingrix) is strongly recommended before starting benralizumab in patients over 50 years old, following the same principles established for other biologic therapies.

Primary Recommendation

While specific guidelines for benralizumab and shingles vaccination are not explicitly detailed in rheumatology literature, the American College of Rheumatology establishes clear principles for biologic therapy that directly apply here:

• Administer the herpes zoster vaccine before starting biologic therapy in patients aged ≥50 years 1
• Wait 2 weeks after vaccination before initiating the biologic agent 1
• Complete the full 2-dose Shingrix series (doses separated by 2-6 months) before starting benralizumab whenever possible 2

Why This Matters for Benralizumab

Benralizumab is a biologic monoclonal antibody that targets IL-5 receptor alpha, creating immunosuppression that increases infection risk:

• Patients with respiratory conditions and eosinophilic disorders already have elevated baseline infection susceptibility 1
• Biologic therapy further impairs immune responses to vaccines, reducing their effectiveness if given after treatment initiation 1
• Shingrix demonstrates 97.2% efficacy when given to immunocompetent adults aged ≥50 years, but this response may be diminished once immunosuppression begins 2

Optimal Vaccination Strategy

For elective benralizumab initiation:

• Administer the first Shingrix dose immediately 2
• Wait 2-6 months and give the second dose 2
• Wait an additional 2 weeks after the second dose 1
• Then start benralizumab 1

If urgent benralizumab initiation is required:

• Administer at least the first Shingrix dose 2
• Wait 2-3 weeks after the first vaccine dose 1
• Start benralizumab to address the urgent respiratory condition 2
• Complete the second Shingrix dose 1-2 months later (though immune response may be somewhat reduced) 2

Critical Safety Points

• Never use live-attenuated Zostavax in patients about to start or currently on biologic therapy - only the recombinant Shingrix is appropriate 1, 3
• Live vaccines are contraindicated once biologic therapy has started 1
• Shingrix is a recombinant (non-live) vaccine containing only a viral protein fragment, making it safe for immunocompromised patients 2, 4

Expected Side Effects

Prepare the patient for common but transient reactions:

• Injection-site reactions (pain, redness, swelling) occur in 9.5% as grade 3 reactions 2
• Systemic symptoms (fatigue, myalgia, headache) occur in 11.4% of recipients 2
• These symptoms typically resolve within 4 days 2
• No serious safety concerns or increased mortality have been identified in large trials 2, 3

Common Pitfalls to Avoid

• Don't delay vaccination - the 2-week waiting period after vaccination is brief compared to the long-term infection risk on biologic therapy 1
• Don't assume prior shingles provides adequate protection - natural immunity is insufficient, with 10.3% cumulative recurrence risk at 10 years 2
• Don't confuse the minimum 4-week interval between Shingrix doses with the optimal 2-6 month interval - while 4 weeks is acceptable, 2-6 months is preferred for optimal immune response 2
• Don't skip the second dose - the full 2-dose series is essential for the 97.2% efficacy 2, 3