Guidelines for Vaccination During Pulse Dose Steroid Therapy
Non-live vaccines can be administered to patients on pulse dose steroids, but live-attenuated vaccines should be withheld until at least 1 month after cessation of high-dose steroid therapy (≥20 mg/day of prednisone or equivalent for ≥14 days). 1, 2
Classification of Steroid Dosing and Immunosuppression
- High-dose steroid therapy is defined as prednisone ≥20 mg/day (or equivalent) for ≥14 days, or ≥2 mg/kg/day for ≥14 days 1, 3
- Moderate to severe immunosuppression is considered with prednisone doses ≥20 mg/day (or equivalent) for >2 weeks 3
- Lower doses of steroids (short-term therapy <14 days, alternate-day therapy, maintenance physiologic doses, or topical/inhaled steroids) are not considered significantly immunosuppressive 1
Guidelines for Non-Live Vaccines
- Non-live vaccines (inactivated, recombinant, subunit) can be administered to patients on any dose of steroids, including pulse dose therapy 1, 2
- For patients taking prednisone >10 mg daily but <20 mg daily, administering any non-live vaccines is conditionally recommended 1
- For patients taking prednisone ≥20 mg daily, influenza vaccination is conditionally recommended regardless of steroid dose 1, 4
- For other non-live vaccines (besides influenza), deferring vaccination until glucocorticoids are tapered to <20 mg daily is conditionally recommended 1
- Antibody response to vaccines may be suboptimal in patients on high-dose steroids 1, 2
Guidelines for Live-Attenuated Vaccines
- Live-attenuated vaccines (MMR, varicella, yellow fever, oral polio) should be withheld in patients on high-dose steroids (≥20 mg/day of prednisone or equivalent for ≥14 days) 1
- Patients should avoid live-attenuated vaccines for at least 1 month after cessation of high-dose steroid therapy 1, 2
- Live vaccines can be considered in patients on lower doses of steroids (prednisone <20 mg/day or <2 mg/kg/day) 1
- MMR and yellow fever boosters were found to be safe in patients on methotrexate <15 mg/m² 1
Special Considerations
- Patients who receive corticosteroid doses equivalent to ≥20 mg/day of prednisone for <14 days can generally receive live vaccines immediately after cessation of treatment, although some experts prefer waiting 2 weeks 1
- For patients exposed to varicella or measles while on immunosuppressive steroid therapy, prophylaxis with immunoglobulin may be indicated 2
- Patients vaccinated while on immunosuppressive therapy should be considered unimmunized and should be revaccinated at least 3 months after therapy is discontinued 1
- Consider measuring pathogen-specific antibody concentrations after vaccination in patients on high-dose glucocorticoids (≥2 mg/kg or ≥20 mg/day for ≥2 weeks) 1
Common Pitfalls and Caveats
- Do not administer live-attenuated vaccines to patients on high-dose steroids due to risk of vaccine-associated illness 5, 6
- Do not assume that topical, inhaled, or short-term steroid use contraindicate vaccination - these routes/durations are generally considered safe for all vaccines 1
- Remember that antibody response may be suboptimal in patients on high-dose steroids, so consider revaccination after discontinuation of therapy 1, 7
- Be aware that even low-dose prednisone (7.5-20 mg daily) has been associated with increased risk of severe wild-type varicella-zoster virus infections, suggesting caution with live zoster vaccines even at lower steroid doses 5