When should a patient who is about to start antiviral (immunosuppressive) therapy for rheumatoid arthritis receive the Shingrix (recombinant zoster) vaccine?

Timing of Shingrix Vaccination Before Starting Immunosuppressive Therapy for Rheumatoid Arthritis

Administer Shingrix at least 2 weeks before starting immunosuppressive therapy for rheumatoid arthritis, ideally completing the full 2-dose series (with doses separated by 2-6 months) before initiating treatment. 1, 2

Optimal Vaccination Strategy

For Elective Treatment Initiation (Preferred Approach)

• Complete the full 2-dose Shingrix series before starting any biologic or targeted synthetic DMARD (disease-modifying antirheumatic drug) whenever possible. 1, 2
• Administer the first Shingrix dose immediately, followed by the second dose 2-6 months later. 2, 3
• Wait an additional 2 weeks after the second dose before initiating immunosuppressive therapy. 1, 2
• This approach maximizes immune response while the patient is not yet immunosuppressed. 2

For Urgent Treatment Initiation (When Disease Control Cannot Wait)

• Administer at least the first Shingrix dose before starting therapy. 2
• Wait 2-3 weeks after the first vaccine dose, then start the immunosuppressive medication. 1, 2
• Complete the second Shingrix dose 1-2 months later, though immune response may be somewhat reduced. 2

Why This Timing Matters

• Immunosuppressive medications impair vaccine responses, reducing effectiveness if given after treatment initiation. 2
• The American College of Rheumatology specifically recommends a 2-week waiting period after herpes zoster vaccination before starting biologics or tofacitinib. 1
• Patients with rheumatoid arthritis already have elevated baseline herpes zoster risk, which is further amplified by immunosuppressive therapy. 2
• Real-world data shows Shingrix effectiveness of 50% in patients with inflammatory arthritis on immunomodulatory treatment, demonstrating the vaccine still provides meaningful protection even when given to immunosuppressed patients. 4

Critical Safety Considerations

Vaccine Selection

• Only use Shingrix (recombinant zoster vaccine) in patients about to start or currently on immunosuppressive therapy—never use live-attenuated Zostavax. 1, 2
• Shingrix is a recombinant vaccine containing only a viral protein fragment, making it safe for immunocompromised patients. 1, 2
• Live-attenuated vaccines are contraindicated once immunosuppressive therapy has started. 1, 2

Acceptable Immunosuppression Levels for Live Vaccines (Historical Context)

• According to older ACIP guidelines, live-attenuated VZV vaccine could be given to patients on methotrexate (<0.4 mg/kg/week), azathioprine (<3.0 mg/kg/day), or low-dose prednisone (<20 mg/day). 1
• However, current guidelines favor Shingrix over live vaccines for all patients with rheumatoid arthritis due to superior efficacy and safety profile. 1, 2

Dosing Schedule Details

• The standard Shingrix schedule is 2 doses separated by 2-6 months. 2, 3
• The minimum acceptable interval between doses is 4 weeks, though 2-6 months is preferred for optimal immune response. 2, 3
• For immunocompromised adults already on therapy, a shorter schedule with the second dose at 1-2 months may be considered. 2

Expected Side Effects

• Injection-site reactions occur in 9.5% of recipients as grade 3 reactions (compared to 0.4% with placebo). 2, 3
• Systemic symptoms occur in 11.4% of recipients (versus 2.4% in placebo recipients). 2, 3
• These symptoms typically resolve within 4 days. 2
• No serious safety concerns or increased mortality have been identified in large trials. 2

Common Pitfalls to Avoid

• Don't delay vaccination indefinitely—the 2-week waiting period after vaccination is brief compared to the long-term infection risk on immunosuppressive therapy. 2
• Don't assume prior shingles provides adequate protection; the 10-year cumulative recurrence risk is 10.3%. 2
• Don't confuse the minimum 4-week interval between Shingrix doses with the optimal 2-6 month interval. 2
• Don't skip the second dose—the full 2-dose series is essential for optimal efficacy. 2
• Don't use live-attenuated Zostavax in this population, as it is contraindicated in patients on or about to start immunosuppressive therapy. 1, 2

Additional Clinical Context

• The risk of venous thromboembolic events is elevated in the 60-90 days following herpes zoster infection, providing additional rationale for prevention through vaccination. 4
• Shingrix demonstrates 97.2% efficacy in immunocompetent adults aged ≥50 years, though this response may be diminished once immunosuppression begins. 2
• The vaccine maintains protection for at least 8 years with minimal waning, maintaining efficacy above 83.3% during this period. 3