How to Write Orders for RSV and Shingrix Vaccination

Administer RSVPreF3 (Arexvy) 0.5 mL IM in the left deltoid today and Shingrix (RZV) dose 1 of 2,0.5 mL IM in the right deltoid today, with the second Shingrix dose scheduled in 2-6 months.

Order Set for a 60-Year-Old Current Smoker

RSV Vaccine Order

For this 60-year-old patient, RSV vaccination is indicated based on age alone (≥60 years), and smoking status may represent an additional risk factor if associated with chronic lung disease. 1, 2

Order:

RSVPreF3 (Arexvy) 0.5 mL intramuscular injection, left deltoid, administer today 3
Alternative: RSVpreF (Abrysvo) 0.5 mL IM if Arexvy unavailable 3
Document as single lifetime dose—no booster doses indicated 1, 2
Patient counseling: Inform about potential Guillain-Barré syndrome risk (rare, estimated <1 case per million doses, with benefits substantially outweighing risks) 1

Shingrix (Recombinant Zoster Vaccine) Order

All adults ≥50 years should receive the 2-dose Shingrix series, administered 2-6 months apart, regardless of prior herpes zoster history. 4

Order:

Shingrix (RZV) 0.5 mL intramuscular injection, right deltoid, administer today (dose 1 of 2) 4
Schedule dose 2 in 2-6 months (minimum interval 4 weeks; if given too soon, repeat the dose) 4
Document in patient chart: "Shingrix dose 1 administered [date]; dose 2 due between [date +2 months] and [date +6 months]" 4
Set reminder/recall system for second dose (70-80% complete series within 6-12 months) 5, 6

Administration Details

Site Selection and Technique

Use separate deltoid muscles (e.g., RSV vaccine in left deltoid, Shingrix in right deltoid) to allow for proper adverse event attribution 4, 1
Both vaccines are administered as 0.5 mL intramuscular injections 3
Standard adult IM technique: 22-25 gauge needle, 1-1.5 inches in length, inject at 90-degree angle into deltoid muscle 4

Co-Administration Considerations

RSV vaccine can be safely co-administered with Shingrix at different injection sites 1
Co-administration with influenza vaccine is explicitly supported by guidelines, and the same principle applies to other non-live vaccines 4, 1
No data suggest interference between RSV and zoster vaccines when given simultaneously 4, 1

Timing Optimization

RSV Vaccine Timing

Ideally administer between September and November (before RSV season peaks) for maximum benefit 1, 2
However, vaccination can occur at any time of year if the patient presents outside this window 1, 2
For this 60-year-old, immediate vaccination is appropriate regardless of current month 2

Shingrix Timing

No seasonal considerations—can be initiated any time of year 4
The 2-6 month interval between doses is critical: minimum 4 weeks, optimal 2-6 months 4
If dose 2 is administered <4 weeks after dose 1, it must be repeated 4

Patient Counseling Points

Expected Adverse Effects

Shingrix: Expect local reactions (injection site pain, erythema) and systemic symptoms (myalgia, fatigue, fever) in up to 85% of recipients; approximately 17% experience grade 3 reactions that may interfere with normal activity 7, 8
RSV vaccine: Generally well-tolerated; common reactions include injection site pain, myalgia, fatigue, and headache 4, 8
Advise that Shingrix reactions are typically more pronounced than RSV vaccine but resolve within 2-3 days 7

Importance of Second Shingrix Dose

Emphasize that both doses are required for optimal protection against herpes zoster 4
Approximately 20-30% of patients fail to complete the series within 12 months 5, 6
Schedule the second dose appointment before the patient leaves the clinic to improve completion rates 6

Common Pitfalls to Avoid

RSV Vaccination Errors

Do not administer multiple RSV vaccine doses—only a single lifetime dose is recommended 1, 2
Do not delay vaccination while seeking extensive medical documentation of risk factors; patient attestation of smoking history or chronic conditions is sufficient 1, 2
Do not withhold RSV vaccine from adults ≥60 years based on lack of documented comorbidities—age alone is an indication 1, 2

Shingrix Series Errors

Do not accept a single Shingrix dose as complete vaccination—the 2-dose series is required 4
Do not administer dose 2 earlier than 4 weeks after dose 1 (if this occurs, repeat the dose) 4
Do not substitute live zoster vaccine (Zostavax) for the second dose—both doses must be RZV 4
Missed opportunities are common: 36% of patients who receive only one dose have a subsequent healthcare visit for another vaccine within 2-12 months 6

Documentation Template

Sample order entry:

1. RSVPreF3 (Arexvy) 0.5 mL IM, left deltoid, single lifetime dose
   - Indication: Age ≥60 years
   - Patient counseled on GBS risk vs. benefit
   - VIS provided and discussed

2. Shingrix (RZV) 0.5 mL IM, right deltoid, dose 1 of 2
   - Indication: Age ≥50 years, herpes zoster prevention
   - Dose 2 due: [date 2-6 months from today]
   - Appointment scheduled for dose 2: [specific date]
   - VIS provided and discussed
   - Patient counseled on expected reactogenicity

Special Considerations for This Patient

Smoking Status

Current smoking may indicate underlying chronic lung disease (COPD, chronic bronchitis), which is a specific risk factor for severe RSV disease in adults 60-74 years 1, 2
If the patient has diagnosed COPD or other chronic respiratory conditions, document this as an additional indication for RSV vaccination 1, 2
Smoking status alone does not contraindicate either vaccine 4, 1

Age 60 Years

This patient falls into the age group where RSV vaccination is universally recommended (all adults ≥60 years) 1, 2
For Shingrix, age 60 is well within the recommended range (≥50 years), and efficacy data are robust for this age group 4
Both vaccines have demonstrated safety and efficacy in this age cohort 4, 8

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