Vaccination Guidelines for Patients on Steroids and Immunosuppressive Therapy
Core Principle: Steroid Dose Determines Vaccination Strategy
For patients on steroids, the critical threshold is prednisone ≥20 mg/day (or equivalent) for ≥14 days—below this dose, all non-live vaccines can be administered without delay, while above this dose, most non-live vaccines (except influenza) should be deferred until the dose is tapered below 20 mg/day. 1, 2
Non-Live Vaccines: Dose-Based Algorithm
Prednisone ≤10 mg/day
- Administer all non-live vaccines immediately without delay 1
- This includes influenza, pneumococcal (Prevnar 20, Pneumovax 23), RSV, hepatitis vaccines, Tdap, and COVID-19 1, 2
- Good immunogenicity is expected at this dose range 2
Prednisone >10 mg but <20 mg/day
- Administer all non-live vaccines without delay 1, 2
- Vaccine efficacy remains acceptable in this dose range 2, 3
- No need to hold or adjust steroid dosing around vaccination 3
Prednisone ≥20 mg/day
- Influenza vaccine: Give immediately regardless of dose—never defer 1, 2, 3
- All other non-live vaccines (pneumococcal, RSV, hepatitis, etc.): Defer until prednisone is tapered below 20 mg/day 1, 2, 3
- High-dose steroids significantly blunt vaccine immunogenicity, particularly for pneumococcal vaccines 2, 3
- If vaccines are given at ≥20 mg/day, patients should be considered unimmunized and revaccinated at least 3 months after therapy is discontinued or dose reduced below 20 mg/day 2, 3
Live Vaccines: Strict Contraindications
When Live Vaccines Are Contraindicated
- Prednisone ≥20 mg/day (or ≥2 mg/kg/day for patients <10 kg) for ≥14 days 4, 5
- Live vaccines include MMR, varicella, intranasal influenza, yellow fever, oral typhoid, BCG, and live zoster vaccine (Zostavax) 4
- The FDA label for prednisone explicitly states that "administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids" 5
Timing After Steroid Discontinuation
- Wait at least 1 month after cessation of high-dose steroid therapy before administering live vaccines 2, 4
- Some experts prefer waiting 3 months for maximum safety 4
- For short courses (<14 days) of prednisone ≥20 mg/day, live vaccines can generally be given immediately after cessation, though some experts prefer waiting 2 weeks 2
Important Exception: Low-Dose Steroids
- Patients on prednisone <20 mg/day or <2 mg/kg/day can receive live vaccines 1, 2
- Physiologic replacement doses (e.g., for Addison's disease or congenital adrenal hyperplasia) do not suppress immune response and allow all vaccinations including live vaccines 4, 5
Special Considerations for Specific Immunosuppressive Agents
Conventional DMARDs (Methotrexate, Azathioprine)
- Do not hold these medications around the time of non-live vaccines 1, 3
- Low-level immunosuppression is defined as methotrexate ≤0.4 mg/kg/week or azathioprine ≤3 mg/kg/day 1
- Live vaccines may be considered in patients on low-dose conventional DMARDs when combined with prednisone <20 mg/day 1
Biologic DMARDs (TNF Inhibitors, Rituximab, etc.)
- For non-live vaccines: Continue biologics without interruption 1
- For live vaccines: Defer while on any biologic therapy 1
- Anti-CD20 agents (rituximab, ocrelizumab): Delay vaccination for at least 6 months after the last dose, or ideally vaccinate 4-6 weeks before starting therapy 1
- TNF inhibitors significantly reduce vaccine response; consider timing vaccines before initiating therapy when possible 1
Timing Vaccination Around Initiation of Immunosuppressive Therapy
Ideal Scenario: Vaccinate Before Starting Therapy
- Administer all indicated vaccines at least 2-4 weeks before initiating immunosuppressive therapy 1
- This maximizes vaccine immunogenicity before immune suppression occurs 1
- For live vaccines, administer at least 4 weeks before starting immunosuppressive therapy 1
If Therapy Cannot Be Delayed
- Prioritize disease control over vaccination—active disease takes precedence 1
- Administer non-live vaccines even if immunosuppression must start immediately 1
- Plan to revaccinate 3 months after therapy is discontinued or dose reduced 2, 3
Disease Activity Considerations
- Disease activity itself does not contraindicate vaccination with non-live vaccines 1, 2
- The concern is purely pharmacologic (steroid/immunosuppressant dose) rather than disease-related 2
- Most studies fail to show increased disease flare rates after vaccination, though patient concerns about flares are common and warrant shared decision-making 1
Post-Vaccination Monitoring
When to Check Antibody Titers
- Consider measuring pathogen-specific antibody concentrations after vaccination in patients on prednisone ≥20 mg/day for ≥2 weeks 2, 3
- Routine antibody measurement is not necessary at doses <20 mg/day 2
If Inadequate Response Documented
- Revaccinate at least 3 months after immunosuppressive therapy is discontinued or dose reduced below threshold 2, 3
Common Pitfalls to Avoid
- Never defer influenza vaccination while waiting for steroid taper, even at doses ≥20 mg/day—timely influenza protection outweighs concerns about reduced antibody response 2, 3
- Do not use live attenuated influenza vaccine (intranasal) in any patient on immunosuppressive therapy—only inactivated (injectable) influenza vaccine is safe 2, 4
- Do not assume physiologic replacement doses of steroids contraindicate live vaccines—patients on replacement therapy for adrenal insufficiency can receive all vaccines 4, 5
- Do not forget to counsel patients about exposure risks—varicella and measles can have serious or fatal courses in non-immune patients on corticosteroids 5