Shingles Prevention and Management

Contraindications and Precautions

Shingrix is not contraindicated in immunocompromised individuals, according to the Centers for Disease Control and Prevention (CDC) guidelines, which is a change from the older live zoster vaccine, Zostavax 1
Shingrix is not contraindicated in patients with autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease, as stated by the CDC and the European League Against Rheumatism (EULAR) guidelines 2, 3, 4
Patients on low-dose immunosuppressive therapy, such as methotrexate (≤0.4 mg/kg/week), azathioprine (≤3.0 mg/kg/day), or 6-mercaptopurine (≤1.5 mg/kg/day), can receive Shingrix, as recommended by the CDC 2
Patients on JAK inhibitors, TNF inhibitors, or other biologics can receive Shingrix, as stated by the EULAR guidelines 4

Shingrix requires 2 doses, 2-6 months apart, for optimal protection, as recommended by the CDC 5, 6
A single dose of Shingrix provides insufficient protection, according to the CDC guidelines 5, 6

Shingrix demonstrates 97.2% efficacy against herpes zoster in adults 50 years and older, with high efficacy across all age groups and protection maintained above 83.3% for up to 8 years, as supported by the American Academy of Ophthalmology and the CDC 5, 6, 7, 8
Shingrix provides 88.8% efficacy against postherpetic neuralgia (PHN), a painful complication of shingles, and is significantly more effective than Zostavax (51.3-69.8% efficacy) 5
Zostavax efficacy wanes considerably over time (from 51.3% to 21.2% over 7-11 years) and decreases with age (70% at 50-59 years vs. 18% at 80+ years), whereas Shingrix remains effective across all age groups 5

Vaccination with Shingrix can be considered in adults aged ≥18 years who are or will be immunocompromised due to disease or therapy, as stated by the CDC 6, 5, 7, 8
Patients with autoimmune inflammatory rheumatic diseases, diabetes mellitus, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease should receive RZV vaccination due to increased risk, with relative risks (RR) of 1.51 for rheumatoid arthritis and 2.08 for systemic lupus erythematosus 9, 5
Patients who previously received ZVL should still receive RZV for better protection, as recommended by the American Academy of Ophthalmology 6, 7

Shingrix commonly causes temporary local and systemic reactions, such as injection site reactions (pain, redness, swelling) and systemic reactions (myalgia, fatigue, headache, fever), which should not be confused with contraindications for the second dose, as stated by the CDC 5
Both Shingrix and Zostavax have acceptable safety profiles with no significant differences in serious adverse events compared to placebo, although Shingrix is associated with higher rates of injection site reactions and systemic symptoms 5

The American Academy of Ophthalmology recommends avoiding contact with high-risk individuals, such as pregnant women who haven't had chickenpox, immunocompromised individuals, and infants 7
The American Academy of Ophthalmology recommends covering lesions and keeping the shingles rash covered until all lesions have crusted over, frequent handwashing with soap and water, and isolation precautions, such as avoiding close contact with others, especially in healthcare or childcare settings, and using separate towels and pillows 7, 6
The CDC recommends varicella zoster immune globulin (VZIG) administration as soon as possible but within 96 hours after close contact with a patient who has chickenpox or shingles, particularly for immunocompromised individuals who are VZV-seronegative 10

Early recognition and prompt treatment are critical to prevent complications, with antiviral therapy initiation within 72 hours of rash onset being crucial 10
The American Academy of Ophthalmology recommends prompt ophthalmological evaluation for any symptoms suggesting eye involvement, such as rash near the eye, eye pain, or visual changes, with special precautions for herpes zoster ophthalmicus necessary to prevent vision loss 6, 7
The American College of Rheumatology recommends considering routine antiviral prophylaxis against reactivation of herpes zoster in specific situations, such as for patients with a history of recurrent herpes zoster infections, especially those affecting the eyes 9