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Herpes zoster prevention before JAK inhibitor therapy — SCE Rheumatology MCQ

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ModeratePreventionHerpes zoster prevention before JAK inhibitor therapySCE Rheumatology

A 43-year-old woman with seropositive rheumatoid arthritis has persistent high disease activity despite methotrexate 20 mg once weekly. Following appropriate screening, upadacitinib is planned in 21 days. There is no clinical indication to start it sooner, but prolonged postponement would leave her inflammatory disease inadequately controlled. She had chickenpox in childhood but has never received a shingles vaccine and has no history of herpes zoster. She is systemically well, is not pregnant and has no vaccine allergy. Which is the most appropriate strategy to prevent herpes zoster?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Give Shingrix now, start upadacitinib in 21 days and give the second Shingrix dose 8 weeks after the first

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · A = shown as D · B = shown as E

Upadacitinib is a JAK inhibitor and therefore constitutes targeted therapy for autoimmune disease within the UK definition of severe immunosuppression. Since 1 September 2025, severely immunosuppressed adults are eligible for Shingrix from 18 years of age, so her age does not exclude vaccination. For an eligible person anticipating immunosuppressive therapy, Shingrix should preferably begin one month before treatment, but an interval of at least 14 days is acceptable when one month is not possible. Giving the first dose now provides 21 days before upadacitinib. The second dose should be administered 8 weeks to 6 months later; treatment may commence after the first dose, so completing both doses beforehand is unnecessary. A applies an obsolete lower age threshold and ignores the expanded programme. C unnecessarily postpones effective rheumatoid arthritis treatment because Shingrix is non-live and the full course need not precede immunosuppression. D is less appropriate because there is an adequate opportunity to vaccinate before treatment, when this is specifically preferred. E is incorrect because the current UK programme uses the recombinant, non-live Shingrix vaccine; a live zoster vaccine is inappropriate around clinically significant immunosuppression and is no longer used in the routine programme.

Reference: Immunisation against infectious disease: Shingles (herpes zoster) (12 August 2025) — https://assets.publishing.service.gov.uk/media/689cba1b1c63de6de5bb12a9/Green-book-chapter-Shingles_12_8_24.pdf