Can elderly patients with myasthenia gravis receive the Shingrix (recombinant zoster vaccine) vaccine?

Shingrix Vaccination in Elderly Patients with Myasthenia Gravis

Elderly patients with myasthenia gravis can and should receive the Shingrix vaccine, as it is a non-live recombinant vaccine that is safe for immunocompromised individuals, including those on immunosuppressive therapy commonly used to treat MG. 1, 2

Primary Recommendation

• The Centers for Disease Control and Prevention explicitly recommends Shingrix for immunocompromised adults aged ≥18 years, which includes patients with autoimmune conditions like myasthenia gravis who are on immunosuppressive therapy. 3, 2

• Shingrix is the only appropriate zoster vaccine for patients with MG, as the live-attenuated vaccine (Zostavax) is absolutely contraindicated in immunocompromised patients due to risk of disseminated VZV infection. 2

• For elderly patients (≥50 years), Shingrix is universally recommended regardless of underlying conditions, with demonstrated efficacy of 97.2% in adults aged 50+ years and 89.8% in adults aged 70+ years. 1, 3

Vaccination Schedule for MG Patients

• Administer the 2-dose series with doses given 1-2 months apart for immunocompromised adults, which is a shortened schedule compared to the standard 2-6 month interval for immunocompetent individuals. 3, 2

• The minimum interval between doses is 4 weeks if earlier administration is needed. 1

Safety Profile in Autoimmune Conditions

• Shingrix can be safely administered to patients on immunosuppressive therapy, including glucocorticoids, biologics, JAK inhibitors, and rituximab. 2

• Concomitant low-dose glucocorticoids (prednisone equivalent <10 mg/day) do not adversely impact vaccine response. 1, 2

• Studies of patients with autoimmune conditions taking glucocorticoids showed only mild disease flares (4-17%) after Shingrix vaccination, with no serious adverse events. 1

• Large database studies found no statistically significant increase in autoimmune disease flares following either dose of recombinant vaccine. 1

Evidence from MG-Specific Vaccine Studies

While the provided evidence focuses on COVID-19 vaccines rather than Shingrix specifically in MG patients, the safety data are reassuring:

• COVID-19 mRNA vaccination in 91 patients with well-controlled MG showed no myasthenic crises and only 2 patients developed mild deterioration compared to baseline, with no clinical exacerbation regardless of age, immunosuppressant use, or history of myasthenic crisis. 4

• This demonstrates that vaccines can be safely administered to stable MG patients, even those on immunosuppressants. 4

Important Clinical Considerations

• The only absolute contraindication to Shingrix is a history of severe allergic reaction (anaphylaxis) to any vaccine component or after a previous dose—myasthenia gravis itself is not a contraindication. 2

• Patients over 65 years develop fewer adverse effects from vaccination. 4

• Common side effects include injection-site pain (most frequent), fatigue, myalgia, chills, fever, and headache, which are transient and resolve within days. 1, 4

• Grade 3 injection site reactions occur in 9.5% of vaccine recipients compared to 0.4% with placebo. 1

Timing Considerations

• Vaccination can proceed regardless of current MG disease activity, as long as the patient is clinically stable. 4

• If the patient is starting or adjusting immunosuppressive therapy, ideally complete the 2-dose series before initiating treatment to maximize immune response, though vaccination can proceed even after immunosuppression has begun. 2

• Consider administering between chemotherapy cycles (>7 days after last treatment) when feasible for patients on intensive immunosuppression, though this is not mandatory. 2

Critical Pitfall to Avoid

• Never use live-attenuated Zostavax in patients with myasthenia gravis—only Shingrix (recombinant zoster vaccine) is appropriate for this population. 3, 2

• Prior receipt of Zostavax does not preclude Shingrix vaccination; patients should receive the full 2-dose Shingrix series at least 2 months after any previous Zostavax dose. 1, 2

Clinical Rationale

• Elderly patients with MG face elevated baseline risk for herpes zoster due to both advanced age and immunosuppressive therapy. 1, 2

• The recombinant vaccine contains only a viral glycoprotein fragment with an adjuvant, not live virus, eliminating any theoretical risk of vaccine-strain infection. 2

• Real-world effectiveness demonstrates 70.1% vaccine effectiveness for 2 doses and 56.9% for 1 dose, emphasizing the importance of completing the full series. 2

• Protection persists for at least 8 years with minimal waning, maintaining efficacy above 83.3% during this period. 1, 2