Can You Get the Shingles Vaccine While Taking Imuran?
Yes, you can receive the recombinant shingles vaccine (Shingrix) while taking Imuran (azathioprine), but you must NOT receive the live-attenuated vaccine (Zostavax). 1, 2
Vaccine Selection: Only Shingrix Is Appropriate
The recombinant zoster vaccine (Shingrix) is the only acceptable shingles vaccine for patients on azathioprine. 2, 3 This is a non-live vaccine containing only a viral protein fragment with an adjuvant, making it safe for immunosuppressed individuals. 3, 4
The live-attenuated vaccine (Zostavax) is absolutely contraindicated in patients taking azathioprine due to the theoretical risk of disseminated vaccine-strain infection. 1, 2
Dosing Guidelines Based on Your Azathioprine Dose
If Your Azathioprine Dose Is ≤3 mg/kg/day:
According to current ACIP and UK guidelines, you fall into the "low-level immunosuppression" category, which provides two options: 1
Option 1 (Preferred): Receive the recombinant vaccine (Shingrix) as a 2-dose series, with doses given 2-6 months apart (minimum 4 weeks). 2, 5 This is the safest and most effective approach.
Option 2 (Less preferred): In the UK, the live-attenuated vaccine may be considered for those on azathioprine ≤3 mg/kg/day after careful risk-benefit discussion, but this contradicts broader international guidance and is not recommended in most settings. 1
The recombinant vaccine (Shingrix) is strongly preferred regardless of your azathioprine dose because it offers superior efficacy (>90% vs 51% for Zostavax), longer-lasting protection, and no infection risk. 2, 4
If Your Azathioprine Dose Is >3 mg/kg/day:
You are considered significantly immunosuppressed, and only Shingrix is appropriate—the live vaccine is absolutely contraindicated. 1, 2
Practical Administration Algorithm
Step 1: Confirm Your Eligibility
- Age ≥50 years: Standard recommendation for all adults on immunosuppressants. 2, 5
- Age 18-49 years on azathioprine: You qualify for Shingrix as an immunocompromised adult. 2, 3
Step 2: Timing Considerations
Ideal scenario: Complete the 2-dose Shingrix series before starting azathioprine, with the vaccine given at least 4 weeks before initiating immunosuppression. 1, 2 This maximizes immune response.
Already on azathioprine (your situation): You can receive Shingrix at any time while taking azathioprine. 2, 3 Do not delay vaccination—the protection outweighs any theoretical reduction in immune response.
Modified schedule for immunocompromised patients: Some guidelines recommend a shorter interval of 1-2 months between doses (rather than 2-6 months) for patients on immunosuppressants to achieve earlier protection. 2, 5
Step 3: Medication Holds (Optional, Based on Recent Guidelines)
Recent European guidance suggests considering holding azathioprine for 3 months before and 1 month after each Shingrix dose to optimize immune response. 2 However, this is not mandatory and should only be done if:
- Your underlying disease is well-controlled
- Your physician agrees it is safe to interrupt therapy
- The benefit of enhanced vaccine response outweighs the risk of disease flare
In most real-world scenarios, you should receive Shingrix without interrupting azathioprine rather than delaying protection. 2, 3
Safety Profile and Expected Response
Common side effects: Injection-site pain, redness, swelling (9.5% grade 3 reactions), and systemic symptoms like fatigue and myalgia (11.4% vs 2.4% placebo). 5 These resolve within approximately 4 days. 2
Serious adverse events: No increased risk compared to placebo in large trials. 5, 4
Immune response: Your antibody response may be somewhat reduced compared to healthy individuals, but Shingrix still provides clinically meaningful protection even in immunosuppressed patients. 1, 3
Disease flares: Studies show only mild flares (4-17%) after Shingrix in patients with autoimmune conditions, with no serious adverse events. 2
Critical Pitfalls to Avoid
Never receive Zostavax (live vaccine) while on azathioprine—this is contraindicated regardless of dose. 1, 2
Do not delay vaccination to obtain antibody titers—serologic testing is not recommended before zoster vaccination in adults ≥50 years. 2
Do not restart the series if you miss the second dose—there is no maximum interval; simply complete with a single second dose whenever possible. 2
Do not confuse varicella (chickenpox) vaccine with zoster vaccine—if you've had chickenpox or shingles, you need the zoster vaccine, not varicella vaccine. 2
If you previously received Zostavax, you still need the full 2-dose Shingrix series (wait at least 2 months after Zostavax). 2, 5
Why Vaccination Matters on Azathioprine
Patients on immunosuppressive therapy like azathioprine have a significantly increased risk of herpes zoster reactivation and are more likely to experience severe disease and complications like post-herpetic neuralgia. 6, 7 Shingrix reduces this risk by >90% in clinical trials and maintains efficacy >83% for at least 8 years. 2, 5
Bottom line: Schedule your first Shingrix dose now without interrupting azathioprine, and complete the second dose 2-6 months later (or 1-2 months if your physician prefers the accelerated schedule for immunocompromised patients). 2, 5, 3