Recombinant zoster vaccine in patients with inflammatory rheumatic diseases: efficacy, long-term protection and safety under immunosuppression

Patients with inflammatory rheumatic diseases (IRDs) have a substantially increased risk of herpes zoster (HZ), driven by underlying immune dysregulation and immunosuppressive therapy, particularly high-dose glucocorticoids, biologic disease-modifying antirheumatic drugs and Janus kinase inhibitors. The adjuvanted recombinant zoster vaccine (RZV) has shown high efficacy in preventing HZ in older adults and durable protection for at least 10 years. Emerging data in immunocompromised populations, including rheumatology cohorts, support clinically meaningful protection with an acceptable safety profile.Recent evidence includes randomised controlled trials demonstrating non-inferiority of RZV vs placebo for short-term flare risk in adults with IRDs on stable immunosuppression. Real-world cohort data also showed a marked reduction in HZ relapse after vaccination (approximately 95%), with very few flares and no serious vaccine-related events. In contrast, a pharmacovigilance analysis of 920 autoimmune patients identified an 8.5% flare incidence and a threefold increased reporting OR for post-RZV flares, particularly in systemic lupus erythematosus, underscoring the need for short-term monitoring and clear counselling rather than avoidance of vaccination.Updated recommendations from the European Alliance of Associations for Rheumatology, the American College of Rheumatology, the Advisory Committee on Immunisation Practices/Centers for Disease Control and Prevention and national bodies now support two doses of RZV for adults with IRD at increased HZ risk, including many receiving potent immunosuppression. This review summarises current evidence on the efficacy, effectiveness, durability and safety of RZV in IRD and interprets new data on vaccination-related autoimmune flares. It also proposes a practical vaccination strategy for rheumatology care and highlights key research gaps.