Herpes Zoster Vaccine Allergic Reactions and Side Effects in a Patient Starting Upadacitinib
Recombinant zoster vaccine (RZV, Shingrix) is the preferred herpes zoster vaccine in immunocompromised or immunosuppressed adults because it is a non-live subunit vaccine. [1]
RZV adverse effects are usually injection-site pain, redness, swelling, and systemic reactogenicity such as myalgia, fatigue, headache, shivering, fever, and gastrointestinal symptoms. [2]
Clinically significant allergic reactions are rare, and vaccination should not proceed after a history of severe allergic reaction (e.g., anaphylaxis) to a vaccine component or following a prior dose. [1], [2]
Vaccine-Related Allergic Reactions
Severe allergic reaction (including anaphylaxis) to herpes zoster vaccines is uncommon, but it is a recognized risk for both RZV and live zoster vaccine (ZVL). [1], [3], [4]
RZV should not be administered to persons with a history of severe allergic reaction such as anaphylaxis to any component of the vaccine. [1]
RZV postmarketing hypersensitivity events include angioedema, rash, and urticaria. [2]
For ZVL (Zostavax), hypersensitivity reactions including anaphylaxis have occurred. [4]
For ZVL (Zostavax), contraindications include a history of anaphylactic/anaphylactoid reaction to gelatin, neomycin, or any other component. [3]
Common RZV (Shingrix) Side Effects
Local (solicited) adverse reactions within 7 days (both doses combined, age ≥50 years) include injection-site pain (78%), redness (38%), and swelling (26%). [2]
Systemic (solicited) adverse reactions within 7 days (age ≥50 years) include myalgia (45%), fatigue (45%), headache (38%), shivering (27%), fever (21%), and gastrointestinal symptoms (17%). [2]
Severe (grade 3) solicited reactions are less common and include grade 3 pain, myalgia, fatigue, headache, shivering, and gastrointestinal symptoms reported as preventing normal activity. [2]
After dose 2, headache and shivering are reported more frequently than after dose 1. [2]
Syncope (fainting) can occur with injectable vaccines, including RZV, and procedures should be in place to avoid injury and restore perfusion after syncope. [5]
Other Clinically Important Adverse Events With RZV
Guillain-Barré syndrome (GBS) has been reported very rarely after RZV, and an increased risk was identified in post-licensure analyses in older adults. [2]
RZV postmarketing observational evidence indicates an association between RZV and GBS risk in adults aged 65 years and older, with estimated excess cases in a risk window of 1–42 days after vaccination. [2]
Common ZVL (Zostavax) Side Effects (When It Is Considered Contraindicated)
ZVL (Zostavax) most frequent adverse reactions (reported in ≥1% of subjects) include headache and injection-site reactions. [4]
ZVL is not recommended for immunosuppressed patients because it is a live vaccine. [1]
ZVL is contraindicated in immunosuppression or immunodeficiency. [3]
Monotherapy Versus Combination Considerations for Vaccination Timing
RZV is administered as a 2-dose series. [1]
RZV is recommended for immunocompromised adults aged ≥19 years who are or will be immunodeficient or immunosuppressed due to disease or therapy. [6]
CDC vaccine-precautions guidance for immunocompromised adults supports completing the RZV series even after non-anaphylactic grade 1–3 reactions after dose 1. [6]
Initiation Thresholds and Contraindications Relevant to Upadacitinib Initiation
RZV should be deferred in acute illness with fever when feasible. [1]
RZV should not be administered with a history of severe allergic reaction (including anaphylaxis) to any component or following a prior dose. [1], [2]
ZVL should not be used in immunosuppressed patients such as those receiving JAK inhibitors because ZVL is contraindicated in immunosuppression or immunodeficiency. [3]
Common Pitfalls to Avoid
Using ZVL (live zoster vaccine) in an immunosuppressed patient should be avoided because of the immunosuppression contraindication. [3], [1]
Proceeding with additional doses after severe allergic reaction to a prior dose should be avoided. [1]
Attribution bias should be avoided because injection-site pain and systemic symptoms after RZV are common and expected reactogenicity within 7 days in controlled trials. [2]
Failure to plan for post-injection syncope safety should be avoided. [5]
Targets and Goals of Therapy With Vaccination
Vaccination with RZV is intended to reduce the incidence of herpes zoster and related complications in adults who are immunocompromised or immunosuppressed due to disease or therapy. [6]
RZV remains preferred over ZVL due to higher efficacy and stronger overall benefit in practice recommendations for adults, including immunocompromised populations. [1]
Medication-Specific Interaction Point for Upadacitinib Context
Upadacitinib therapy represents immunosuppression, which supports selection of RZV rather than ZVL for herpes zoster prevention. [1], [3]
No routine dose modification of upadacitinib is specified in the available vaccine allergy and adverse-reaction labeling for RZV in the cited sources. [2]