From the Guidelines
Caution is needed when administering live vaccines to individuals on oral steroids, and live vaccines should be avoided in patients taking high-dose oral steroids (prednisone ≥20mg daily or equivalent) for two weeks or longer. This is because these medications suppress the immune system and may reduce vaccine effectiveness while increasing the risk of vaccine-related infection, as noted in the 2023 guideline for vaccinations in patients with rheumatic and musculoskeletal diseases 1. The evidence suggests that patients should wait at least one month after stopping high-dose steroids before receiving live vaccines. However, low-dose steroids (prednisone <20mg daily or equivalent), short courses (less than two weeks), or non-systemic steroids (topical, inhaled, or local injections) typically don't significantly compromise immunity and don't contraindicate live vaccines, as supported by the 2023 american college of rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases 1. Conversely, there are no restrictions on giving oral steroids to someone who has recently received a live vaccine. The timing concern only applies when steroids precede vaccination, not when they follow it. This guidance reflects the understanding that steroids can impair the immune response needed to safely process live attenuated organisms in vaccines, potentially allowing these weakened pathogens to replicate excessively and cause disease, as discussed in the general recommendations on immunization by the advisory committee on immunization practices (acip) and the american academy of family physicians (aafp) 1. Some key points to consider include:
- The exact amount of systemically absorbed corticosteroids and the duration of administration needed to suppress the immune system are not well-defined, as noted in the 1994 general recommendations on immunization 1.
- Most experts agree that steroid therapy usually does not contraindicate administration of live virus vaccines when it is short-term, low to moderate dose, or administered topically, as stated in the 1997 immunization of health-care workers recommendations 1.
- The immunosuppressive effects of steroid treatment vary, but many clinicians consider a dose equivalent to or greater than a prednisone dose of 20 mg per day sufficiently immunosuppressive to cause concern about the safety of administering live virus vaccines, as mentioned in the 2002 general recommendations on immunization 1. Overall, the decision to administer live vaccines to individuals on oral steroids should be made on a case-by-case basis, taking into account the specific circumstances and the potential risks and benefits, as recommended by the 2023 american college of rheumatology guideline for vaccinations in patients with rheumatic and musculoskeletal diseases 1.
From the FDA Drug Label
Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids. Killed or inactivated vaccines may be administered. However, the response to such vaccines may be diminished and cannot be predicted Indicated immunization procedures may be undertaken in patients receiving nonimmunosuppressive doses of corticosteroids as replacement therapy (e.g., for Addison’s disease). Patients on corticosteroid therapy may exhibit a diminished response to toxoids and live or inactivated vaccines due to inhibition of antibody response. Corticosteroids may also potentiate the replication of some organisms contained in live attenuated vaccines Routine administration of vaccines or toxoids should be deferred until corticosteroid therapy is discontinued if possible (see WARNINGS: Infection: Vaccination).
Key Points:
- Live vaccines are contraindicated in patients receiving immunosuppressive doses of corticosteroids.
- Killed or inactivated vaccines may be administered, but the response may be diminished.
- Nonimmunosuppressive doses of corticosteroids may allow for vaccination.
- Corticosteroid therapy may inhibit antibody response to vaccines and potentiate replication of live attenuated vaccine organisms.
- Vaccination should be deferred until corticosteroid therapy is discontinued if possible. 2 2
From the Research
Oral Steroids and Live Vaccines
- The administration of live vaccines to individuals taking oral steroids is generally contraindicated, as it may lead to adverse events and exacerbate the underlying condition 3.
- However, a prospective study found that live attenuated vaccines can be effective and safe for patients receiving immunosuppressive agents, including oral steroids, if their cellular and humoral immunological parameters are within normal levels 4.
- The study found that patients with CD4 cell counts ≥ 500/mm3, stimulation index of lymphocyte blast transformation by PHA ≥ 101.6, serum IgG level ≥ 300 mg/dl, and no steroid use or prednisolone < 1 mg/kg/day or < 2 mg/kg/2 days, can receive live attenuated vaccines safely 4.
Live Vaccines and Oral Steroids
- Live vaccines should be avoided in individuals taking oral steroids, especially if they are immunocompromised, as it may carry the risk of infecting the patient 5.
- Inactivated vaccines, on the other hand, are safe and recommended for immunocompromised patients, including those taking oral steroids 5, 6.
- The timing of vaccination is crucial, and vaccines should preferably be administered prior to the planned immunosuppressive therapies, including oral steroids 3.
Special Considerations
- Household contacts of immunocompromised patients, including those taking oral steroids, should receive vaccines to protect the patient 5, 3.
- Clinicians should have sufficient and updated information concerning the safety, efficacy, and contraindications to vaccination of immunocompromised patients, including those taking oral steroids 3.
- The effectiveness of influenza vaccines may be reduced in individuals taking oral steroids, and alternative vaccination strategies, such as high-dose vaccines, may be considered 7.