Shingles Vaccine and Rituximab Therapy

Introduction to Vaccine Administration

The American College of Rheumatology recommends administering the recombinant zoster vaccine (Shingrix) at least 2-4 weeks before initiating rituximab therapy, as rituximab profoundly impairs vaccine responses for 6-9 months after treatment 1, 2.

The European League Against Rheumatism recommends using only the recombinant zoster vaccine (RZV/Shingrix), never the live zoster vaccine (ZVL/Zostavax) in patients who will receive or are receiving rituximab, due to the risk of vaccine-strain varicella dissemination 1, 2.
The recombinant vaccine has demonstrated significant T-cell responses even in patients with hematologic malignancies on anti-CD20 therapies, making it the safer and more effective choice 1, 2.

The American College of Rheumatology suggests that if a patient is already on rituximab, they should wait at least 6 months after the last dose (ideally 9-12 months when B-cell recovery is complete) before vaccinating, then delay the next rituximab dose by at least 4 weeks post-vaccination 5, 6.

Rituximab causes profound B-cell depletion lasting 6-9 months, with full recovery typically occurring 9-12 months after therapy, severely hampering humoral antibody responses to vaccines during this period 4, 5, 6.

Patients with autoimmune inflammatory rheumatic diseases have significantly increased risk of herpes zoster compared to the general population, which is further amplified by rituximab treatment itself 6, 7.

The National Comprehensive Cancer Network recommends measuring VZV-specific antibody titers 4 weeks after completing the vaccine series to confirm adequate response, and considering revaccination if titers are inadequate and rituximab has been discontinued for ≥9 months 3, 4.
The recombinant zoster vaccine is non-live and safe to administer to immunocompromised patients, and prophylactic antiviral therapy for herpes zoster may be considered in high-risk patients during rituximab treatment 1, 2, 8.