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Shingrix After Zoster — SCE Rheumatology MCQ

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EasyRheumatology PharmacologyShingrix After ZosterSCE Rheumatology

A 50-year-old woman with rheumatoid arthritis has been taking methotrexate 25 mg once weekly for 6 months. She recently developed localised herpes zoster, which was treated appropriately. At review, the rash has completely resolved and there are no active vesicles. Which preventive strategy is most appropriate?

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Correct answer: A — Offer a two-dose course of recombinant zoster vaccine (Shingrix)

The correct answer is A. Methotrexate above 20 mg weekly meets the UKHSA definition of severe immunosuppression. Such adults are eligible for two doses of the non-live recombinant vaccine Shingrix, with the second dose given 8 weeks to 6 months later. Previous shingles does not remove eligibility; vaccination can proceed after the acute illness has resolved and there are no active vesicles. Continuous aciclovir is not routinely indicated after a single episode. Prior infection does not provide reliable durable protection against recurrence. A live attenuated zoster vaccine is inappropriate in severe immunosuppression and is no longer used in the UK national programme. Increasing methotrexate would not prevent zoster and could increase infection risk.

Reference: UK Health Security Agency. Immunisation against infectious disease: Shingles (herpes zoster), Green Book chapter 28a, Box 1 and recommendations for severe immunosuppression, updated 12 August 2025. https://assets.publishing.service.gov.uk/media/689cba1b1c63de6de5bb12a9/Green-book-chapter-Shingles_12_8_24.pdf