What vaccines are recommended for patients on long-term corticosteroids (steroids)?

Vaccination Recommendations for Patients on Long-Term Steroids

Patients on long-term corticosteroids should receive annual inactivated influenza vaccine, pneumococcal vaccines (PCV13 followed by PPSV23), and COVID-19 vaccines, while strictly avoiding all live vaccines. 1

Critical Principle: Live Vaccines Are Contraindicated

All live vaccines must be avoided in patients receiving immunosuppressive doses of corticosteroids (≥2 mg/kg/day or ≥20 mg/day prednisone equivalent for ≥2 weeks). 1 This includes:

• Live attenuated influenza vaccine (nasal spray) 1
• MMR (measles, mumps, rubella) 1
• Varicella 1
• Oral polio vaccine 2
• BCG 1
• Oral typhoid 1

The rationale is prevention of vaccine-strain viral disease in immunocompromised hosts. 2 Wait >1 month after discontinuing high-dose corticosteroids before administering live vaccines. 1

Essential Vaccines for Steroid-Treated Patients

Influenza Vaccine (Annual)

• Use only inactivated (subcutaneous/intramuscular) influenza vaccine annually 1
• The nasal spray formulation is live-attenuated and absolutely contraindicated 1
• Annual vaccination reduces respiratory infection risk, which is particularly important given increased susceptibility on steroids 1

Pneumococcal Vaccines

Administer pneumococcal conjugate vaccine (PCV13/Prevenar13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23): 1

• Ideally give PPSV23 prior to initiating corticosteroid therapy when possible 1
• If already on steroids, give PCV13 first, then PPSV23 at least 8 weeks later 3
• Patients on immunosuppressive therapy are at increased risk for invasive pneumococcal disease 1
• Continue according to national guidance for revaccination intervals 1

Important caveat: Prior receipt of PPSV23 may blunt antibody response to subsequent PCV13, so sequence matters. 4, 5 However, most patients still achieve adequate protection levels despite reduced antibody titers. 1

COVID-19 Vaccines

• Administer according to current recommendations for immunocompromised individuals and those on long-term steroids 1
• All currently available COVID-19 vaccines are non-live and safe for immunosuppressed patients 1

Tetanus-Diphtheria-Pertussis (Tdap/Td)

• Inactivated vaccines like Tdap can and should be administered on the routine schedule 2
• These pose no safety risk in immunosuppressed patients 2
• Maintain routine Td boosters every 10 years 1

Recombinant Zoster Vaccine (Shingrix)

Shingrix is the preferred herpes zoster vaccine for patients on corticosteroids: 6

• Administered as 2-dose series (0 and 2-6 months) 6
• Non-live recombinant vaccine, safe for immunocompromised patients 6
• Concomitant low-dose glucocorticoids (<10 mg/day prednisone) do not adversely impact vaccine response 6
• Studies show only mild disease flares (4-17%) with no serious adverse events 6

Timing Considerations for Optimal Response

Antibody response may be suboptimal in patients on high-dose corticosteroids (≥10 mg/day prednisone equivalent): 1

• For high-dose steroids (≥2 mg/kg or ≥20 mg/day for ≥2 weeks), consider measuring post-vaccination antibody titers to confirm adequate response 1
• If possible, administer vaccines before initiating immunosuppressive therapy for optimal immunogenicity 1
• Vaccination during active disease or high-dose therapy may result in reduced antibody concentrations, though most patients still achieve protective levels 1

Special Populations

Patients on Multiple Immunosuppressants

• If receiving corticosteroid-sparing agents (methotrexate, azathioprine, etc.) in addition to steroids, live vaccines remain absolutely contraindicated regardless of steroid dose 2
• Non-live vaccines remain safe but may have further reduced immunogenicity 7

Short-Term or Low-Dose Steroids

The following do NOT contraindicate live vaccines: 1

• Short-term therapy (<2 weeks) 1
• Low to moderate doses 1
• Alternate-day treatment with short-acting preparations 1
• Maintenance physiologic (replacement) doses 1
• Topical application (skin, eyes) 1
• Intra-articular, bursal, or tendon injections 1
• Inhaled corticosteroids 1

Common Pitfalls to Avoid

1. Never administer live influenza vaccine (nasal spray) to steroid-treated patients - this is the most common error 1

2. Do not assume all pneumococcal vaccines are the same - the sequence of PCV13 before PPSV23 matters for optimal protection 1, 3

3. Do not delay inactivated vaccines - waiting for lower steroid doses is unnecessary and leaves patients unprotected 1, 2

4. Do not forget household contacts - they should receive all recommended vaccines, including live vaccines, to create a protective cocoon 2

5. Avoid giving PPSV23 first if possible - this can induce hyporesponsiveness to subsequent PCV13, reducing its effectiveness 4, 5