Can Hepatitis B (HB) vaccine be administered concurrently with steroid pulse therapy?

From the Guidelines

It is generally safe to administer the Hepatitis B vaccine during steroid pulse therapy, but the immune response may be suboptimal. According to the most recent and highest quality study available, 1, non-live vaccines, such as the Hepatitis B vaccine, can be administered to patients using glucocorticosteroids, and the vaccine does not aggravate disease or cause serious adverse events. However, the study also notes that high-dose glucocorticosteroids (≥2 mg/kg or a total dose of ≥20 mg/day for 2 weeks or more) may reduce the immune response to the vaccine.

Key Considerations

• If possible, it's preferable to schedule the vaccination either before starting steroid therapy or 3-6 months after completing it to ensure maximum effectiveness.
• For patients already on high-dose steroids, the vaccine can still be given if protection against Hepatitis B is urgently needed, but consider checking antibody titers 1-2 months after completing the vaccination series to confirm adequate protection.
• The standard Hepatitis B vaccination schedule consists of three doses given at 0,1, and 6 months.
• The concern with administering vaccines during high-dose steroid therapy is that corticosteroids suppress T-cell function and antibody production, potentially reducing the immune response to the vaccine.

Recommendations

• Check antibody titers 1-2 months after completing the vaccination series to confirm adequate protection.
• If titers are insufficient, a booster dose may be necessary.
• Consider the risk of Hepatitis B infection in an unprotected individual, which may outweigh the risk of reduced vaccine efficacy in certain clinical situations, as noted in 1 and 1.

Additional Information

• The safety of the Hepatitis B vaccine has been established in various studies, including 1, which reported that hepatitis B vaccines have been shown to be safe when administered to both adults and children.
• However, the immune response to the vaccine may be reduced in patients on high-dose steroids, as noted in 1.

From the Research

Hepatitis B Vaccine and Steroid Pulse Therapy

• The administration of Hepatitis B vaccine with steroid pulse therapy is a complex issue, and the decision to do so should be based on individual patient circumstances and medical history.
• Studies have shown that corticosteroids can cause hepatitis B virus (HBV) reactivation in patients with resolved HBV infection 2, 3.
• The risk of HBV reactivation is higher in patients receiving high-dose corticosteroids, particularly those with a cumulative dose of prednisone greater than 1506 mg or a time-weighted average dose greater than 20 mg/day 2.
• In patients with chronic hepatitis B, high-dose corticosteroids (>40 mg prednisolone equivalents) increase the risk of hepatitis flare, even with short courses of treatment (<7 days) 4.
• The effectiveness of the Hepatitis B vaccine may be reduced in patients receiving steroid therapy, particularly those with steroid-sensitive nephrotic syndrome 5.
• Prophylactic anti-HBV therapy may be necessary for patients receiving high-dose corticosteroids, especially those with a history of HBV infection or resolved HBV infection 6.

Considerations for Vaccination

• The decision to administer the Hepatitis B vaccine with steroid pulse therapy should be based on the individual patient's risk factors, medical history, and current health status.
• Patients with a history of HBV infection or resolved HBV infection should be carefully evaluated for the risk of HBV reactivation before receiving corticosteroids 2, 3.
• The vaccine's effectiveness may be reduced in patients receiving steroid therapy, and alternative vaccination strategies may be necessary 5.
• Regular monitoring of HBV DNA levels and liver function tests may be necessary for patients receiving corticosteroids, particularly those with a history of HBV infection or resolved HBV infection 6, 4.