Shingles Vaccination for Immunocompromised Patients

Introduction to Shingles Vaccines

• The American College of Rheumatology recommends that patients taking Renflexis (infliximab) should not receive the live shingles vaccine (Zostavax), but can safely receive the recombinant shingles vaccine (Shingrix) 1
• There are two types of herpes zoster (shingles) vaccines: Recombinant zoster vaccine (RZV, Shingrix) - a non-live vaccine, and Live zoster vaccine (ZVL, Zostavax) - a live attenuated vaccine, according to the Annals of the Rheumatic Diseases 2, 3

Vaccination Recommendations for Patients on Biological Therapy

• Live vaccines, including the live zoster vaccine (Zostavax), are contraindicated in patients on biological therapy such as infliximab due to the theoretical risk of infection from vaccination, as stated by the Gut journal 4, 1
• TNF inhibitors like infliximab cause immunosuppression that may lead to serious infections if live vaccines are administered, according to the Mayo Clinic Proceedings 5, 6

Safe Alternative: Recombinant Shingles Vaccine

• The recombinant zoster vaccine (Shingrix) is not live and is considered safe for immunocompromised patients, as reported by the Annals of the Rheumatic Diseases and the Journal of the American Academy of Dermatology 3, 7
• The recombinant vaccine requires two doses administered 2-6 months apart, although the exact timing may vary depending on the patient's condition 7, 8

Clinical Considerations

• Ideally, patients should receive vaccination before starting immunosuppressive therapy like infliximab, according to the Mayo Clinic Proceedings and the Gut journal 6, 4
• For patients already on infliximab, the recombinant vaccine (Shingrix) can be administered at any time, as stated by the Journal of the American Academy of Dermatology 7, 8
• Patients on TNF inhibitors like infliximab have an increased risk of developing herpes zoster, as reported by the Annals of the Rheumatic Diseases 2
• The vaccine remains effective for at least 8 years after administration, although effectiveness gradually wanes over time, according to the Annals of the Rheumatic Diseases 2

Potential Concerns and Benefits

• There has been theoretical concern that the adjuvant in Shingrix may cause a flare of underlying inflammatory disease, but retrospective studies show variable results, as reported by the Annals of the Rheumatic Diseases 3
• Recent research suggests that the recombinant shingles vaccine may have additional benefits beyond preventing shingles, although more studies are needed to confirm this, as reported by the Journal of the American Academy of Dermatology 7, 8

Shingles Vaccination in Immunosuppressed Patients

Vaccine Selection and Safety

• The European Crohn's and Colitis Organisation recommends that patients on immunosuppressive therapy receive the recombinant zoster vaccine (RZV/Shingrix), which is safe and approved for immunocompromised adults 9
• Live vaccines, such as the live zoster vaccine (ZVL/Zostavax), are generally considered unsafe during immunosuppression, with a theoretical risk of disseminated vaccine-strain infection 9, 10, 11
• The American Gastroenterological Association suggests that ZVL is contraindicated in patients on biological therapy (TNF inhibitors, anti-CD20 agents, etc.) due to theoretical risk of disseminated vaccine-strain infection 12

Vaccination Timing and Drug Interactions

• The American College of Rheumatology recommends that patients on steroids (prednisone) stop 1 month before and restart 1 month after RZV administration 9
• The European League Against Rheumatism suggests that patients on thiopurines (azathioprine/mercaptopurine) stop 3 months before and restart 1 month after RZV administration 9
• The Infectious Diseases Society of America recommends that patients on methotrexate stop 1 month before and restart 1 month after RZV administration 9
• The American College of Gastroenterology suggests that patients on TNF inhibitors (infliximab, adalimumab, etc.) stop 3 months before and restart 1 month after RZV administration 9

Special Considerations

• The Centers for Disease Control and Prevention (CDC) states that ZVL may be considered in patients on low-level immunosuppression, such as prednisolone ≤20 mg/day for >14 days, either alone or in combination with low-dose non-biological immunomodulators 12, 13
• The CDC also notes that evidence from controlled studies shows ZVL is safe in patients with inflammatory bowel disease (IBD) on thiopurines, methotrexate, and even anti-TNF agents, though antibody responses may be reduced 9, 10, 14

Optimal Vaccination Strategy

• The American Academy of Pediatrics recommends that patients ideally receive the shingles vaccine before starting immunosuppressive therapy 9, 10, 11
• The CDC suggests that the vaccine should be administered ≥4 weeks before initiating immunosuppression 13
• The European Crohn's and Colitis Organisation recommends that the vaccine be given during quiescent disease if possible 9, 10, 11

Shingrix Vaccination in Patients Receiving Azathioprine

Vaccine Selection

Dosing Based on Azathioprine Dose

Low‑level immunosuppression (≤ 3 mg/kg/day)

High‑level immunosuppression (> 3 mg/kg/day)

Timing and Administration

Medication Management Around Vaccination

Immunogenicity and Safety