Vaccination Timing with Prednisone: Clarification and Consequences
Yes, I confirm that waiting until the prednisone dose is below 20mg daily is recommended before administering RSV and Prevnar 20 vaccines, with the exception of influenza vaccine which should be given immediately regardless of steroid dose. 1
Why Wait Until Below 20mg?
The American College of Rheumatology specifically recommends deferring non-live attenuated vaccines (including pneumococcal vaccines like Prevnar 20) until prednisone is tapered below 20mg daily because high-dose steroids (≥20mg) significantly blunt vaccine immunogenicity. 1 This threshold is based on evidence showing a dose-response relationship between prednisone and vaccine antibody responses. 1
For pneumococcal vaccination specifically: The American College of Rheumatology conditionally recommends deferring until glucocorticoids are tapered to less than 20mg daily, based on low-quality evidence showing that high-dose steroids may significantly impair the immune response to pneumococcal vaccines. 1
For RSV vaccination: While specific data on RSV vaccine response in steroid-treated patients is limited, the same principles apply to all non-live vaccines. 1 The RSV vaccine is relatively new, and its effectiveness in immunosuppressed patients remains unknown. 2
What Happens If You Vaccinate Now?
If vaccines are administered while on prednisone ≥20mg daily:
Suboptimal antibody response: The immune response will likely be blunted, potentially resulting in inadequate protective antibody levels. 1
CDC guidance on revaccination: Patients vaccinated while on immunosuppressive therapy (≥20mg/day prednisone for ≥2 weeks) should be considered unimmunized and should be revaccinated at least 3 months after therapy is discontinued. 1
Antibody testing consideration: The American College of Rheumatology recommends considering measurement of pathogen-specific antibody concentrations after vaccination in patients on high-dose glucocorticoids (≥20mg/day for ≥2 weeks) to determine if adequate immunity was achieved. 1
Is Dose Repeat Necessary?
Yes, revaccination is likely necessary if vaccines are given at current doses ≥20mg daily. 1
According to CDC guidance, patients should be revaccinated at least 3 months after immunosuppressive therapy is discontinued or reduced below the threshold. 1
This means you would need to wait until prednisone has been discontinued or maintained at <20mg daily for at least 3 months before revaccinating. 1
Practical Timeline
Since the patient would likely be at 15mg in a couple of weeks:
Optimal approach: Wait 2 weeks until prednisone reaches 15mg, then administer both RSV and Prevnar 20 vaccines. 1 At doses between 10-20mg daily, the American College of Rheumatology conditionally recommends proceeding with non-live vaccines without delay, as vaccine efficacy is acceptable in this dose range. 1
No need to hold steroids: Glucocorticoids do not need to be held around the time of non-live vaccines—patients can continue their prednisone without interruption before or after vaccination. 1
Important Exception: Influenza Vaccine
If influenza vaccine is also needed, give it immediately without waiting for steroid taper. 1, 3
The American College of Rheumatology explicitly prioritizes timely influenza vaccination over concerns about steroid-induced immunosuppression and advises against deferring influenza vaccination while waiting for steroid taper. 3
This recommendation applies even to patients on ≥20mg prednisone daily. 3