What is the recommended prescription protocol for the Shingrix (zoster vaccine) in adults aged 50 years and older, including dosage, administration, and considerations for patients with a history of severe allergic reactions or immunocompromised states?

How to Prescribe Shingrix Vaccine

Shingrix is administered as a two-dose intramuscular series with the second dose given 2-6 months after the first dose for adults aged ≥50 years, or 1-2 months apart for immunocompromised adults aged ≥18 years who would benefit from a shorter schedule. 1

Standard Dosing and Administration

Dose preparation and route:

• Reconstitute the lyophilized gE antigen powder with the supplied AS01B adjuvant suspension immediately before use 1
• Administer 0.5 mL intramuscularly into the deltoid muscle 1
• Use reconstituted vaccine immediately or store refrigerated at 2-8°C and use within 6 hours 1

Standard schedule for immunocompetent adults ≥50 years:

• First dose at Month 0, second dose at 2-6 months later 2, 1
• Minimum interval between doses is 4 weeks; if given earlier, repeat the dose 2
• Second doses given beyond 6 months maintain full effectiveness 2, 3

Accelerated schedule for immunocompromised adults ≥18 years:

• First dose at Month 0, second dose at 1-2 months later 2, 1
• This shorter schedule applies to patients with immunodeficiency or immunosuppression from known disease or therapy 1

Patient Eligibility

Approved indications:

• All adults aged ≥50 years, regardless of prior shingles history or previous Zostavax vaccination 2, 1
• Adults aged ≥18 years who are or will be immunocompromised due to disease or therapy 4, 1

Immunocompromised populations who qualify for vaccination at age 18+:

• Hematologic malignancies, solid organ malignancies 4
• Hematopoietic stem cell transplant recipients (give 50-70 days post-transplant) 2
• HIV/AIDS 4
• Autoimmune diseases requiring immunosuppressive therapy 2, 4
• Chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 4
• Patients on biologics, JAK inhibitors, or other immunomodulators 5

Special Clinical Scenarios

Previous Zostavax vaccination:

• Administer full 2-dose Shingrix series regardless of prior Zostavax 2
• Minimum interval: 2 months after last Zostavax dose 2
• Rationale: Zostavax efficacy drops to only 14.1% by year 10 2

After a shingles episode:

• Wait until acute symptoms resolve, typically at least 2 months after the episode 2
• Prior shingles does not provide reliable protection (10.3% recurrence risk at 10 years) 2
• Vaccination is strongly recommended to prevent future episodes 2

Patients starting immunosuppressive therapy (e.g., tofacitinib):

• Complete full 2-dose series before starting therapy whenever possible 2
• If urgent therapy initiation required, give at least first dose before starting, complete second dose after therapy begun 2
• Never use live Zostavax in patients on or about to start immunosuppression 2

Patients on glucocorticoids:

• Safe to administer even on low-dose glucocorticoids (<10 mg/day prednisone) 2
• Vaccine maintains effectiveness in patients on immunosuppressive therapy 2
• Mild disease flares possible (4-17%) but no serious adverse events 2

During neutropenia:

• Not contraindicated during neutropenic periods in cancer patients 2
• Consider timing between chemotherapy cycles (>7 days after last treatment) when feasible 2

Concurrent with other vaccines:

• Can be administered simultaneously with inactivated influenza vaccine 2
• No required waiting period between Shingrix and other inactivated vaccines 2
• Wait until acute illness symptoms (fever, severe malaise) resolve before vaccinating 2

Contraindications

Absolute contraindication:

• History of severe allergic reaction (anaphylaxis) to any vaccine component or previous Shingrix dose 1

Important limitation:

• Not indicated for prevention of primary varicella (chickenpox) 1
• VZV-seronegative individuals should receive varicella vaccine (2 doses, 4 weeks apart) instead 5

Safety Monitoring and Common Adverse Reactions

Expected local reactions (very common):

• Pain at injection site (78-88%) 1
• Redness (30-38%) and swelling (18-26%) 1
• Grade 3 injection site reactions in 9.5% vs 0.4% placebo 2

Expected systemic reactions (common):

• Myalgia (45-58%), fatigue (45-64%), headache (38-44%) 1
• Shivering (27-31%), fever (18-28%), GI symptoms (17-28%) 1
• Most reactions transient, resolving within 4 days 2
• Systemic symptoms in 11.4% vs 2.4% placebo 2

Serious safety considerations:

• Increased risk of Guillain-Barré syndrome during 42 days post-vaccination observed in postmarketing study 1
• Syncope can occur; have procedures to prevent falling injury 1
• No increased mortality or serious adverse events in clinical trials 2

Clinical Efficacy

Vaccine effectiveness:

• 97.2% efficacy against herpes zoster in adults ≥50 years 2
• Real-world effectiveness: 70.1% for 2-dose series, 56.9% for 1 dose 3
• Protection sustained >83.3% for at least 8 years 2
• 76.0% effectiveness against postherpetic neuralgia 3

Advantages over Zostavax:

• Significantly higher efficacy across all age groups 2
• Zostavax efficacy: 70% in ages 50-59 vs only 18% in ages ≥80 2
• Safe for immunocompromised patients (Zostavax contraindicated) 2, 6

Key Clinical Pitfalls to Avoid

• Never use live Zostavax in immunocompromised patients—only Shingrix is appropriate 2, 6
• Don't delay second dose unnecessarily—effectiveness maintained even if given beyond 6 months 2, 3
• Don't skip vaccination in patients with prior shingles—recurrence risk remains significant 2
• Don't confuse varicella vaccine with zoster vaccine—VZV-seronegative individuals need varicella vaccine first 5
• Don't assume age <50 means no indication—immunocompromised adults ≥18 qualify 4, 1
• Complete the 2-dose series—single dose effectiveness significantly lower (56.9% vs 70.1%) 3