Vaccination Timing with Immunosuppressive Therapy

Introduction to Vaccination Timing

The American College of Rheumatology recommends deferring non-live attenuated vaccines, including pneumococcal vaccines like Prevnar 20, until prednisone is tapered below 20mg daily because high-dose steroids significantly blunt vaccine immunogenicity 1
The American College of Rheumatology conditionally recommends deferring pneumococcal vaccination until glucocorticoids are tapered to less than 20mg daily, based on low-quality evidence showing that high-dose steroids may significantly impair the immune response to pneumococcal vaccines 1

The same principles apply to all non-live vaccines, including RSV vaccination, although specific data on RSV vaccine response in steroid-treated patients is limited 1
The RSV vaccine is relatively new, and its effectiveness in immunosuppressed patients remains unknown 2, 3

If vaccines are administered while on prednisone ≥20mg daily, the immune response will likely be blunted, potentially resulting in inadequate protective antibody levels 1
Patients vaccinated while on immunosuppressive therapy (≥20mg/day prednisone for ≥2 weeks) should be considered unimmunized and should be revaccinated at least 3 months after therapy is discontinued, according to CDC guidance 1
The American College of Rheumatology recommends considering measurement of pathogen-specific antibody concentrations after vaccination in patients on high-dose glucocorticoids (≥20mg/day for ≥2 weeks) to determine if adequate immunity was achieved 1

Revaccination is likely necessary if vaccines are given at current doses ≥20mg daily, and patients should be revaccinated at least 3 months after immunosuppressive therapy is discontinued or reduced below the threshold, according to CDC guidance 1

At doses between 10-20mg daily, the American College of Rheumatology conditionally recommends proceeding with non-live vaccines without delay, as vaccine efficacy is acceptable in this dose range 1
Glucocorticoids do not need to be held around the time of non-live vaccines—patients can continue their prednisone without interruption before or after vaccination 1

If influenza vaccine is also needed, it should be given immediately without waiting for steroid taper, as the American College of Rheumatology explicitly prioritizes timely influenza vaccination over concerns about steroid-induced immunosuppression 1, 4
This recommendation applies even to patients on ≥20mg prednisone daily, and the American College of Rheumatology advises against deferring influenza vaccination while waiting for steroid taper 4