Can patients taking oral steroids, such as prednisone, receive the influenza vaccine?

Can Patients on Oral Steroids Receive the Influenza Vaccine?

Yes, patients taking oral steroids at any dose should receive the inactivated influenza vaccine without delay, regardless of their prednisone dose. 1, 2

Recommendation by Steroid Dose

The approach to influenza vaccination differs from other vaccines based on steroid dosing:

Low to Moderate Dose Steroids (≤20 mg prednisone daily)

• Strongly administer the influenza vaccine to all patients taking prednisone ≤10 mg daily or equivalent 1
• Administer the influenza vaccine to patients taking prednisone >10 mg but <20 mg daily 1
• No delay or deferral is needed at these doses 1

High-Dose Steroids (≥20 mg prednisone daily)

• Still administer the influenza vaccine even at doses ≥20 mg prednisone daily 1, 2
• Influenza vaccination is specifically exempted from the general recommendation to defer other non-live vaccines at high steroid doses 1, 2
• The rationale is that timely influenza protection outweighs concerns about potentially reduced antibody response 1

Key Distinction: Influenza vs. Other Vaccines

This is a critical point that distinguishes influenza vaccination from other non-live vaccines:

• Influenza vaccine: Give immediately at any steroid dose 1, 2
• Other non-live vaccines (pneumococcal, RSV, etc.): Defer until prednisone <20 mg daily 1, 2

The American College of Rheumatology explicitly prioritizes timely influenza vaccination over concerns about steroid-induced immunosuppression, even when prednisone doses are ≥20 mg daily 1, 2

Vaccine Type Matters

• Use only inactivated (killed) influenza vaccine (standard injection) in patients on any dose of oral steroids 1, 3
• Never use live attenuated influenza vaccine (nasal spray) in patients receiving immunosuppressive steroid therapy 1, 3
• Live attenuated vaccines should be avoided in patients on prednisone ≥20 mg daily for ≥14 days 2

Evidence on Vaccine Response

While high-dose steroids may blunt antibody response to influenza vaccine, the clinical data is reassuring:

• Most studies show patients on oral corticosteroids can still mount adequate antibody responses to influenza vaccine 4, 5, 6, 7
• One study in elderly COPD patients found no difference in seroconversion rates (56-89%) or seroprotection rates (64-93%) between patients on systemic steroids versus controls 7
• Another study showed 84% of corticosteroid-treated pulmonary patients developed fourfold antibody rise, similar to 79% in non-steroid patients 6
• High-dose inhaled corticosteroids may slightly diminish response to influenza B antigen, but not A antigens 5

Timing Considerations

• No need to time vaccination around steroid administration 3
• Do not hold or adjust steroids before or after influenza vaccination 2, 8
• Vaccinate during routine visits beginning in September through the influenza season 3
• Optimal timing for organized campaigns is October through mid-November 3

Special Populations

Patients with IBD

• Annual inactivated influenza vaccine is recommended for all adult IBD patients 1
• Consider high-dose influenza vaccine for patients on anti-TNF monotherapy, as it produces higher antibody levels than standard-dose vaccine 1

Cancer Patients

• Annual inactivated influenza vaccine is recommended for all immunosuppressed cancer patients 1
• Insufficient data currently exists to routinely recommend high-dose over standard-dose vaccine in cancer patients 1

Common Pitfalls to Avoid

• Do not defer influenza vaccination while waiting for steroid taper, even at doses ≥20 mg daily 1, 2
• Do not use nasal spray vaccine in any patient on immunosuppressive steroids 1, 3
• Do not confuse influenza vaccine guidelines with those for other vaccines (pneumococcal, RSV), which should be deferred at high steroid doses 1, 2
• Do not hold steroids around the time of influenza vaccination 2, 8