Is it safe to administer a vaccination to a patient on prednisone (corticosteroid) therapy?

Vaccination in Patients on Prednisone

Yes, it is safe to give vaccinations to patients on prednisone, but the type of vaccine and prednisone dose determine the specific approach: inactivated vaccines can be given at any dose, while live vaccines should be avoided if the patient is on high-dose therapy (≥20 mg/day for ≥14 days). 1

Inactivated Vaccines: Safe at Any Dose

Inactivated vaccines (including influenza, pneumococcal, COVID-19, hepatitis, Tdap) can be administered to patients on any dose of prednisone without delay or contraindication. 1, 2

• The FDA label for prednisone states that killed or inactivated vaccines may be administered to patients on corticosteroids, though the response may be diminished 3
• The ACIP guidelines confirm that inactivated vaccines are safe regardless of steroid dose, though antibody response may be suboptimal in patients on high-dose steroids 1
• For influenza vaccination specifically, the American College of Rheumatology recommends administering the vaccine without delay even at doses ≥20 mg/day, as timely protection outweighs concerns about potentially reduced antibody response 2
• Use only inactivated influenza vaccine, never live attenuated (intranasal) formulations in patients on any dose of steroids 2

Expected Vaccine Response by Dose

• Low-dose prednisone (<7 mg/day): Vaccine responses are maintained with good immunogenicity 4
• Moderate-dose prednisone (7-20 mg/day): Generally adequate antibody responses, though data is somewhat inconclusive 4, 5
• High-dose prednisone (≥20 mg/day): Antibody titers and seropositivity are reduced, but vaccination is still recommended for critical vaccines like influenza 1, 2, 4

Live Vaccines: Dose and Duration Matter

Live vaccines are contraindicated in patients receiving prednisone ≥20 mg/day (or ≥2 mg/kg/day in children >10 kg) for ≥14 days. 1, 6

When Live Vaccines Are Safe

Corticosteroid therapy is not a contraindication to live vaccines when: 1

• Short-term therapy: <2 weeks duration regardless of dose
• Low-to-moderate dose: <20 mg/day prednisone equivalent
• Alternate-day treatment with short-acting preparations
• Physiologic replacement doses (e.g., for adrenal insufficiency)
• Topical, inhaled, or intra-articular administration

When to Defer Live Vaccines

• Wait at least 1 month after discontinuation of high-dose steroid therapy (≥20 mg/day for ≥14 days) before administering live vaccines 1, 6
• Some experts recommend waiting 3 months for maximum safety 6
• The FDA label explicitly contraindicates live or live-attenuated vaccines in patients receiving immunosuppressive doses of corticosteroids 3

Live Vaccines Affected

Live vaccines that require caution include: MMR, varicella, live attenuated influenza (intranasal), yellow fever, oral typhoid, BCG, and live zoster vaccine (Zostavax) 6

Important exception: Recombinant zoster vaccine (Shingrix) is NOT a live vaccine and can be given to patients on any dose of steroids 6

Practical Algorithm for Vaccination Decision

Step 1: Identify Vaccine Type

• Inactivated vaccine → Proceed with vaccination at any prednisone dose 1, 2
• Live vaccine → Proceed to Step 2

Step 2: Assess Prednisone Dose and Duration

• <20 mg/day → Live vaccines are generally safe 1
• ≥20 mg/day for <14 days → Live vaccines can be given immediately after cessation (some experts prefer waiting 2 weeks) 7
• ≥20 mg/day for ≥14 days → Live vaccines are contraindicated; wait at least 1 month after discontinuation 1, 6

Step 3: Special Considerations for Specific Vaccines

Influenza: Always give inactivated formulation without delay, regardless of steroid dose 2

Pneumococcal: Can be given at any dose, but the American College of Rheumatology suggests deferring until prednisone is tapered to <20 mg/day for optimal response 2

COVID-19: Administer without steroid dose adjustment 2

Common Pitfalls to Avoid

• Do not defer influenza vaccination while waiting for steroid taper, even at high doses—this leaves patients unprotected during flu season 2
• Do not use live attenuated (intranasal) influenza vaccine in any patient on chronic steroids 2
• Do not assume physiologic replacement doses (e.g., for adrenal insufficiency) are immunosuppressive—these patients can receive all vaccines including live vaccines 2, 6
• Do not routinely measure antibody titers after vaccination unless the patient is on high-dose glucocorticoids (≥20 mg/day for ≥2 weeks) 2
• Remember that patients on combination immunosuppression require greater caution, even if steroid dose alone is below the threshold 6

Safety Considerations

• Serious adverse events following live vaccines have been documented in patients on corticosteroids, including deaths in children receiving corticosteroids who were given varicella vaccine, and in adults on low-dose prednisone (10 mg/day) who received live zoster vaccine 8
• The FDA warns that varicella and measles can have serious or fatal courses in non-immune patients taking corticosteroids 3
• Inactivated vaccines are well tolerated with no serious adverse events reported in patients on immunosuppressive therapy 9