Can steroids be given after rabies (Rabies virus) vaccinations?

Steroids and Rabies Vaccination: Guidelines for Administration

Steroids should not be administered during rabies vaccination unless essential for the treatment of other conditions, as they can interfere with the development of active immunity after vaccination and potentially predispose the patient to rabies. 1

Effect of Steroids on Rabies Vaccine Efficacy

• Corticosteroids and other immunosuppressive agents can interfere with the development of active immunity after rabies vaccination 1
• Immunosuppressive medications may predispose patients to rabies by reducing the protective immune response to vaccination 1
• When steroids must be used concurrently with rabies vaccination, antibody testing becomes essential to ensure adequate protection 1

Clinical Decision Algorithm

For Post-Exposure Prophylaxis (PEP):

1. Primary consideration: Do not administer steroids during rabies PEP unless absolutely essential for treating other conditions 1
2. If steroids are medically necessary:
   • Proceed with standard rabies vaccination schedule 1
   • Obtain serum samples to test for rabies antibody to ensure an acceptable antibody response has developed 1
   • If inadequate antibody response is detected, consult with appropriate public health officials for additional guidance 1

For Pre-Exposure Prophylaxis:

• Patients on immunosuppressive medications should consider postponing pre-exposure vaccinations if possible 1
• If vaccination is necessary while on steroids, use the intramuscular route rather than intradermal administration 1
• Check antibody titers after completing the pre-exposure series to confirm adequate response 1

Special Situations

Management of Allergic Reactions to Rabies Vaccine

• For patients with history of serious hypersensitivity to rabies vaccine who must be revaccinated, antihistamines can be administered 1
• In rare cases of anaphylactic reactions to rabies vaccine where continued vaccination is essential, short-term use of corticosteroids with antihistamines may be considered under close medical supervision 2
• A case report demonstrated successful completion of rabies vaccination using prophylactic high-dose corticosteroids and antihistamines in a patient who had previously experienced anaphylaxis to the vaccine 2

Serum Sickness-like Reactions

• Serum sickness-like reactions, particularly to equine rabies immunoglobulin, may require treatment with antihistamines and a short course of steroids 3
• These reactions typically occur 5-10 days after administration of rabies immunoglobulin 3

Important Caveats

• When rabies PEP is administered to an immunosuppressed person (including those on steroids), antibody testing is critical to ensure adequate protection 1
• Rabies is nearly 100% fatal once clinical symptoms develop, making adequate immune response to vaccination essential 4
• For patients with established rabies infection, corticosteroids should not be used as part of treatment 5
• The risk of developing rabies must be carefully weighed against the risk of adverse reactions when considering any modification to the standard vaccination protocol 1

Monitoring Recommendations

• For patients requiring concurrent steroid therapy and rabies vaccination, closely monitor for:
  • Development of adequate antibody titers (≥0.5 IU/mL) 6
  • Potential vaccine-related adverse events 6, 7
  • Signs of inadequate immune response requiring additional vaccine doses 1