Is the flu shot safe for patients with ulcerative colitis (UC)?

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Last updated: October 2, 2025 • View editorial policy

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Influenza Vaccination in Patients with Ulcerative Colitis

Annual inactivated influenza vaccination is strongly recommended for all patients with ulcerative colitis, including those on immunosuppressive therapy. 1

Safety and Efficacy

The inactivated influenza vaccine is considered safe and effective for patients with ulcerative colitis (UC), regardless of their immunosuppression status:

  • Patients with inflammatory bowel disease (IBD), including UC, are at increased risk of influenza compared to the general population and are more likely to require hospitalization when infected 1
  • Annual vaccination provides protection against influenza and its potential complications 1
  • The inactivated (injectable) influenza vaccine is safe for patients on immunosuppressive therapy 1

Important Considerations

Vaccine Type Selection

  • Only use inactivated (injectable) influenza vaccines for UC patients on immunosuppressive therapy 1
  • Avoid live attenuated (nasal spray) influenza vaccines in immunosuppressed patients 1
  • High-dose influenza vaccines may be beneficial for patients on anti-TNF monotherapy, as they produce significantly higher post-immunization antibody levels 1

Timing Considerations

  • Ideally administer vaccines before starting immunosuppressive therapy when possible 1
  • The timing of vaccination relative to infliximab infusion does not affect serological protection 1

Immune Response Factors

  • Patients on immunosuppressive therapy may have a reduced immune response to vaccination, particularly those on:
    • Combination therapy (anti-TNF agent + azathioprine) 1
    • Anti-TNF monotherapy 1
  • Despite potentially reduced efficacy, the immune response remains sufficient to warrant annual vaccination 1

Potential Concerns and Pitfalls

Disease Flares

While there is a single case report of UC exacerbation following influenza vaccination 2, multiple guidelines and larger studies indicate that influenza vaccination is generally safe and not associated with disease flares 1. The benefits of vaccination in preventing potentially severe influenza infection outweigh the minimal risk of disease exacerbation.

Vaccine Uptake

Despite recommendations, vaccination rates among UC patients are consistently lower than recommended 3. Healthcare providers should actively promote annual influenza vaccination for all UC patients.

Special Populations

  • Patients aged 65 and older should receive high-dose, recombinant, or adjuvanted influenza vaccines 1
  • Patients on anti-TNF monotherapy may benefit from high-dose influenza vaccines 1

Vaccination Algorithm for UC Patients

  1. Assess immunosuppression status
  2. Select appropriate vaccine:
    • For all UC patients: Use inactivated (injectable) influenza vaccine
    • For patients on anti-TNF monotherapy: Consider high-dose influenza vaccine
    • For patients ≥65 years: Use high-dose, recombinant, or adjuvanted influenza vaccine
  3. NEVER use live attenuated (nasal spray) influenza vaccines in immunosuppressed patients
  4. Administer annually, preferably before flu season begins
  5. Educate patients about the importance of vaccination despite potentially reduced immune response

By following these recommendations, healthcare providers can help protect UC patients from influenza and its complications, which is particularly important given their increased risk of infection and complications.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

[A case of ulcerative colitis relapsed by influenza vaccination].

The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi, 2007

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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