In a patient on tofacitinib, can the recombinant herpes zoster vaccine (Shingrix) be administered without stopping the drug, and should tofacitinib be held if the patient develops a herpes zoster infection?

Management of Herpes Zoster Vaccination and Infection in Patients on Tofacitinib

Question 1: Can Shingrix be administered while on tofacitinib?

Yes, Shingrix (recombinant zoster vaccine) can and should be administered to patients currently taking tofacitinib without stopping the drug. 1, 2, 3

Key Points on Vaccination While on Tofacitinib

• Shingrix is the only appropriate vaccine option for patients on tofacitinib because it is a non-live recombinant vaccine that is safe for immunocompromised individuals. 1, 2, 3

• Live-attenuated Zostavax is absolutely contraindicated in patients receiving JAK inhibitors like tofacitinib due to the risk of disseminated vaccine-strain infection. 1, 3

• No interruption of tofacitinib is required around the time of Shingrix administration—continue the drug without modification. 3

• Administer the standard two-dose series with doses given 2–6 months apart (minimum 4 weeks). 1, 2

Optimal Timing Strategy

While vaccination can occur at any time during tofacitinib therapy, ideally complete both Shingrix doses before initiating tofacitinib to maximize immune response while the patient is not yet immunosuppressed. 1, 3 However, if the patient is already on tofacitinib:

• Proceed with vaccination immediately without delay—do not postpone protection while waiting to stop the drug. 1, 3

• If urgent tofacitinib initiation is needed, administer at least the first Shingrix dose before starting therapy, then complete the second dose 1–2 months later (shortened schedule for immunocompromised patients). 1

Important Clinical Caveats

• Patients on tofacitinib have significantly elevated herpes zoster risk through JAK1/2 inhibition, which impairs interferon-mediated antiviral pathways. 1

• Vaccine response may be somewhat reduced in patients already on tofacitinib compared to pre-treatment vaccination, but protection is still meaningful and clinically important. 1

• Breakthrough infections can still occur even after complete vaccination (vaccine efficacy ~92%), as demonstrated in case reports of patients developing shingles despite prior Shingrix completion. 4 However, vaccinated individuals generally experience less severe disease. 1

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Question 2: Should tofacitinib be held if the patient develops herpes zoster infection?

Discontinue tofacitinib immediately upon diagnosis of herpes zoster and do not restart until all cutaneous lesions have fully resolved (typically 15–22 days after onset). 1

Immediate Management Algorithm

Step 1: Stop tofacitinib immediately

• Never continue tofacitinib during active herpes zoster infection, as ongoing JAK inhibition impairs interferon-mediated viral clearance and heightens the risk of severe or disseminated disease. 1
• This principle is critical—the case report of herpes zoster meningitis in a patient on tofacitinib demonstrates the potential for severe complications when the drug continues during active infection. 5

Step 2: Initiate antiviral therapy promptly

• Start oral valacyclovir 1 g three times daily for 7 days, initiating therapy within 48–72 hours of rash onset for maximal antiviral efficacy. 1
• For severe or disseminated disease (such as meningitis or eye involvement), use intravenous acyclovir instead of oral agents. 1, 5

Step 3: Wait for complete resolution

• Do not restart tofacitinib until all cutaneous lesions have fully resolved, which typically takes 15–22 days after onset. 1
• When antiviral therapy has been started and acute symptoms are controlled, tofacitinib may be resumed earlier than the usual 15-day waiting period, provided that lesions are crusted and pain has subsided. 1

Re-initiation Strategy

For first episode of herpes zoster:

• Resume tofacitinib once lesions are fully healed and crusted. 1
• Consider continuing valacyclovir prophylaxis during tofacitinib re-initiation, though this is not mandatory for first episodes. 1

For recurrent (second) episode of herpes zoster:

• Strongly consider long-term antiviral prophylaxis with valacyclovir when restarting tofacitinib, as this strategy aims to lower the observed 8% recurrence rate in rheumatoid arthritis cohorts. 1
• The case report demonstrates this approach: the patient restarted tofacitinib with concurrent oral valacyclovir prophylaxis after recovering from herpes zoster meningitis. 5

Post-Episode Vaccination

Administer Shingrix after complete resolution of the acute episode:

• Wait at least 2 months before vaccination after all symptoms have resolved. 1, 2
• This provides additional protection against future herpes zoster events, even in patients who have already experienced an episode. 1
• In the case report, Shingrix was administered 2 years after the acute episode, at which point oral valacyclovir was discontinued. 5

Critical Pitfalls to Avoid

• Do not continue tofacitinib "just a few more days" after diagnosing herpes zoster—stop immediately. 1
• Do not restart tofacitinib before lesions are fully crusted, even if the patient feels better. 1
• Do not skip post-episode vaccination—having one episode does not provide reliable protection (10.3% 10-year recurrence risk). 1, 2
• Do not use live Zostavax vaccine for post-episode vaccination in patients who will resume tofacitinib—only Shingrix is appropriate. 1, 3