Shingrix Vaccination in Patients on JAK Inhibitors
Direct Recommendation
Yes, Shingrix (recombinant zoster vaccine) is safe and recommended for patients currently on JAK inhibitors, and the JAK inhibitor should be continued without interruption during vaccination. 1
Evidence-Based Rationale
Safety and Indication
Shingrix is explicitly recommended for all patients aged >18 years on JAK inhibitors (including abrocitinib, upadacitinib, baricitinib, and tofacitinib) as a two-dose series separated by 2–6 months. 1
The recombinant vaccine is non-live and contains only a viral glycoprotein fragment, making it fundamentally safe for immunocompromised patients—it cannot cause herpes zoster under any circumstances. 1, 2
No interruption of JAK inhibitor therapy is required for Shingrix administration, unlike the approach sometimes considered for other vaccines. 1
Clinical Context: Why This Matters
Elevated Herpes Zoster Risk
JAK1/2 inhibition significantly increases herpes zoster risk by blocking interferon-γ signaling and impairing cellular cytotoxicity against viral pathogens. 1
Herpes zoster prevalence in patients with atopic dermatitis on JAK inhibitors is <3% in clinical trials, but this represents a meaningful increase over baseline risk. 1
Vaccination is an important tool for infection prevention in this population, and delaying vaccination leaves patients unnecessarily vulnerable. 1
Practical Implementation Algorithm
For Patients Already on JAK Inhibitors
Administer the first Shingrix dose immediately without stopping the JAK inhibitor. 1
Continue JAK inhibitor therapy without interruption during the vaccination series. 1
Give the second dose 2–6 months after the first dose (minimum interval: 4 weeks). 1, 3
For immunocompromised adults aged ≥18 years, consider a shortened schedule with the second dose at 1–2 months after the first dose. 3
Expected Immune Response
Immunogenicity Considerations
Real-world data show approximately 40% of IMID patients on JAK inhibitors achieve a fourfold increase in anti-gE antibody concentration post-vaccination, which is lower than the >90% efficacy seen in immunocompetent populations in clinical trials. 4
Despite reduced immunogenicity, real-world vaccine effectiveness remains clinically meaningful at 70.1% for the two-dose series, even in patients with immunosuppressive conditions. 5
The vaccine remains effective even when immune response is somewhat blunted—partial protection is vastly superior to no protection. 4, 5
Safety Profile in This Population
Adverse Events
Common adverse reactions include injection-site pain (22.5%), fever (23.6%), and injection-site erythema (20.1%), with most reactions being mild to moderate and transient. 6, 7
Grade 3 injection-site reactions occur in 9.5% of vaccine recipients compared to 0.4% with placebo, but these are typically self-limited. 6
No serious safety concerns have been identified in large clinical trials or post-licensure surveillance, with similar rates of serious adverse events between vaccine and placebo groups. 6, 7
In the real-world study of IMID patients on JAK inhibitors, only one serious local adverse effect was reported among 49 patients, and the vaccine was well tolerated overall. 4
Critical Pitfalls to Avoid
Common Errors
Never use live-attenuated Zostavax in patients on JAK inhibitors—this is absolutely contraindicated due to the risk of disseminated vaccine-strain varicella infection. 1
Do not delay vaccination waiting for an "optimal" time—the patient is already at increased risk, and every day without vaccination represents unnecessary exposure. 1
Do not stop the JAK inhibitor for vaccination—this is not required and may lead to disease flare without improving vaccine response. 1
Do not confuse the European Task Force recommendation for COVID-19 vaccination (which suggests a 1-week pause of JAK inhibitor treatment after vaccination) with Shingrix—no such pause is recommended for Shingrix. 1
Nuances and Divergent Evidence
Timing Considerations
Ideally, vaccination should be completed before starting JAK inhibitor therapy to maximize immune response, but this is not always feasible in clinical practice. 1, 3
When urgent JAK inhibitor initiation is required, administer at least the first Shingrix dose before starting therapy, with the second dose completed after the JAK inhibitor has been started. 1
However, for patients already on JAK inhibitors (as in this question), proceed with vaccination immediately without stopping therapy—the benefit of vaccination outweighs any theoretical concern about reduced immunogenicity. 1
Monitoring and Follow-Up
Post-Vaccination Management
Counsel patients that injection-site reactions and systemic symptoms are common but transient, typically resolving within 4 days. 6
Reassure patients that Shingrix cannot cause shingles or influenza-like illness, though coincidental respiratory illness unrelated to the vaccine can occur after vaccination. 6
For patients who experience recurrent herpes simplex virus or herpes zoster outbreaks, prophylactic antiherpetic treatment may be needed in addition to vaccination. 1
Special Considerations
Concomitant Medications
Concomitant low-dose glucocorticoids (<10 mg/day prednisone equivalent) do not adversely impact vaccine response, so these can be continued. 1, 3
Combination treatments with methotrexate, topical corticosteroids, and topical calcineurin inhibitors are acceptable, as safety data exist for these combinations. 1
Age-Related Factors
- JAK inhibitors should be used cautiously in patients aged >65 years, and vaccination is particularly important in this population given the increased baseline herpes zoster risk with age. 1