What are the implications of prednisone (corticosteroid) therapy on receiving immunizations (vaccinations)?

From the Guidelines

Patients on prednisone therapy should receive non-live attenuated vaccinations, with the specific approach depending on the daily dose of prednisone. For patients taking the equivalent of prednisone ≤10 mg daily, administering any non–live vaccinations is strongly recommended 1. This is because the immunosuppressive effects of prednisone are less pronounced at lower doses, and the benefits of vaccination outweigh the risks. Key considerations include:

• The type of vaccine: non-live attenuated vaccines are preferred over live vaccines for patients on prednisone therapy, as they do not carry the risk of causing the infection they are intended to prevent.
• The dose of prednisone: patients taking higher doses of prednisone (≥20 mg daily) may need to defer non-live attenuated vaccinations, other than influenza vaccination, until their prednisone dose is reduced to <20 mg daily 1.
• The timing of vaccination: ideally, vaccines should be administered before starting prednisone therapy, but if this is not possible, they can be given during therapy, taking into account the potential reduced efficacy due to immunosuppression. Some studies have shown that higher doses of prednisone can reduce the immunogenicity of vaccines, such as the influenza vaccine 1. However, the most recent and highest quality study, published in 2023, provides clear guidance on the administration of non-live attenuated vaccinations to patients taking prednisone 1. In general, inactivated vaccines like the flu shot, pneumococcal vaccine, COVID-19 vaccines, and Tdap are safe during prednisone therapy, though they may be less effective due to the immunosuppressive effects of steroids. It is essential to weigh the benefits and risks of vaccination in patients on prednisone therapy, considering factors such as the specific vaccine, the dose of prednisone, and the individual patient's health status. Ultimately, the decision to administer vaccines to patients on prednisone therapy should be made on a case-by-case basis, taking into account the latest evidence and guidelines, such as those provided by the American College of Rheumatology 1.

From the FDA Drug Label

Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids. Killed or inactivated vaccines may be administered. However, the response to such vaccines may be diminished and cannot be predicted Indicated immunization procedures may be undertaken in patients receiving nonimmunosuppressive doses of corticosteroids as replacement therapy (e.g., for Addison’s disease). Patients on corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response.

Prednisone therapy and receiving immunizations:

• Live or live, attenuated vaccines are contraindicated in patients receiving immunosuppressive doses of prednisone.
• Killed or inactivated vaccines may be administered, but the response to such vaccines may be diminished.
• Nonimmunosuppressive doses of prednisone may allow for indicated immunization procedures. 2 2

From the Research

Prednisone Therapy and Receiving Immunizations

• Patients on prednisone therapy may have impaired immune responses to vaccinations due to the immunosuppressive effects of the medication 3, 4.
• Influenza vaccination is recommended for all individuals, including those on immunosuppressive therapy, as they are at higher risk of severe illness and complications from influenza infection 5, 6, 4.
• The use of high-dose trivalent, inactivated, split-virus influenza vaccine (IIV3-HD) may be considered for immunocompromised patients, including those on prednisone therapy, as it has been shown to elicit stronger humoral responses compared to standard-dose trivalent vaccine 3.
• Live attenuated influenza vaccines are generally contraindicated in patients under immunosuppressive therapy, including those on prednisone, due to the risk of vaccine-related complications 4.
• Inactivated influenza vaccines, on the other hand, are considered safe for use in immunocompromised patients, including those on prednisone therapy, and are recommended for annual vaccination 5, 6, 4, 7.

Vaccination Strategies for Immunocompromised Patients

• Immunocompromised patients, including those on prednisone therapy, may require special consideration when it comes to vaccination, including the use of adjuvanted vaccines, high-dose vaccines, and booster doses 3.
• The timing of vaccination is also important, with some studies suggesting that vaccination soon after vaccine becomes available can be considered for pregnant women in the third trimester, while others recommend avoiding vaccination in July and August unless there is concern that later vaccination might not be possible 6.
• Healthcare providers should consult current guidelines and recommendations for vaccination in immunocompromised patients, including those on prednisone therapy, to ensure optimal protection against influenza and other vaccine-preventable diseases 6, 4.