Vaccination Guidelines for Patients on Pulse Dose Steroid Therapy

Classification of Steroid Dosing and Immunosuppression

High-dose steroid therapy is defined as prednisone ≥20 mg/day (or equivalent) for ≥14 days, or ≥2 mg/kg/day for ≥14 days, according to the American College of Rheumatology 1, 2
Moderate to severe immunosuppression is considered with prednisone doses ≥20 mg/day (or equivalent) for >2 weeks, as stated by the Centers for Disease Control and Prevention 3
Lower doses of steroids (short-term therapy <14 days, alternate-day therapy, maintenance physiologic doses, or topical/inhaled steroids) are not considered significantly immunosuppressive, as reported by the Centers for Disease Control and Prevention 4, 5

Guidelines for Non-Live Vaccines

Non-live vaccines (inactivated, recombinant, subunit) can be administered to patients on any dose of steroids, including pulse dose therapy, according to the American College of Rheumatology 1
For patients taking prednisone >10 mg daily but <20 mg daily, administering any non-live vaccines is conditionally recommended by the American College of Rheumatology 6
For patients taking prednisone ≥20 mg daily, influenza vaccination is conditionally recommended regardless of steroid dose, as stated by the American College of Rheumatology 6
Antibody response to vaccines may be suboptimal in patients on high-dose steroids, as reported by the Centers for Disease Control and Prevention 2

Guidelines for Live-Attenuated Vaccines

Live-attenuated vaccines (MMR, varicella, yellow fever, oral polio) should be withheld in patients on high-dose steroids (≥20 mg/day of prednisone or equivalent for ≥14 days), according to the Centers for Disease Control and Prevention 7, 4
Patients should avoid live-attenuated vaccines for at least 1 month after cessation of high-dose steroid therapy, as recommended by the Centers for Disease Control and Prevention 7
Live vaccines can be considered in patients on lower doses of steroids (prednisone <20 mg/day or <2 mg/kg/day), as stated by the American College of Rheumatology 1, 5

Special Considerations

Patients who receive corticosteroid doses equivalent to ≥20 mg/day of prednisone for <14 days can generally receive live vaccines immediately after cessation of treatment, although some experts prefer waiting 2 weeks, as reported by the Centers for Disease Control and Prevention 7
Patients vaccinated while on immunosuppressive therapy should be considered unimmunized and should be revaccinated at least 3 months after therapy is discontinued, according to the Centers for Disease Control and Prevention 2, 5
Consider measuring pathogen-specific antibody concentrations after vaccination in patients on high-dose glucocorticoids (≥2 mg/kg or ≥20 mg/day for ≥2 weeks), as recommended by the American College of Rheumatology 1

Vaccination Recommendations for Patients with Pneumonia on Steroids

Influenza Vaccination Recommendations

The American College of Rheumatology conditionally recommends influenza vaccination for patients taking prednisone ≥20 mg daily (or equivalent) regardless of the current pneumonia treatment, with a strength of evidence based on moderate-quality data 8, 9
Administering influenza vaccination on schedule is recommended rather than deferring vaccination, even in patients on high-dose steroids, as supported by the American College of Rheumatology 10

Pneumococcal Vaccination Recommendations

The American College of Rheumatology conditionally recommends deferring pneumococcal vaccination until glucocorticoids are tapered to less than 20 mg daily for patients on prednisone ≥20 mg daily (or equivalent), based on low-quality evidence showing that high-dose steroids may significantly impair the immune response to pneumococcal vaccines 8, 9, 11
For patients on moderate doses of prednisone (>10 mg but <20 mg daily), pneumococcal vaccination can be administered without deferral, as recommended by the American College of Rheumatology 12

Practical Approach to Vaccination in These Patients

For influenza vaccination, the American College of Rheumatology recommends administering as soon as clinically appropriate, regardless of steroid dose, and not delaying vaccination even if the patient is on high-dose steroids 8, 9
For pneumococcal vaccination, the American College of Rheumatology recommends deferring until steroid dose is tapered below 20 mg daily if on prednisone ≥20 mg daily, and administering without delay if on prednisone <20 mg daily 8, 9, 12
For patients on other immunosuppressants in addition to steroids, the American College of Rheumatology recommends continuing most immunosuppressive medications around the time of vaccination, and considering deferring pneumococcal vaccination until just before the next rituximab dose 8, 10, 11, 13

Vaccination Timing for Patients on Glucocorticoids

Rationale Based on Current Guidelines

The American College of Rheumatology recommends deferring non-live attenuated vaccines, including RSV and Prevnar 20, until the prednisone dose is tapered below 20mg daily, with the exception of influenza vaccine, which should be given regardless of steroid dose 14, 15
High-dose steroids (≥20mg prednisone) significantly blunt vaccine immunogenicity, particularly for pneumococcal vaccines, based on low-quality evidence 14, 15
The American College of Rheumatology provides conditional recommendations for administering non-live attenuated vaccines without delay when the prednisone dose is between 10mg and 20mg daily, as vaccine efficacy is acceptable at this dose range 14, 16

Practical Considerations

Waiting until the prednisone dose is below 20mg daily can substantially improve the antibody response to non-live vaccines, such as RSV and Prevnar 20, due to a dose-response relationship between prednisone and vaccine responses 14, 15
The American College of Rheumatology suggests that glucocorticoids do not need to be held around the time of non-live vaccines, and patients can continue their prednisone without interruption before or after vaccination 14, 16

Disease Activity Considerations

The American College of Rheumatology states that PMR disease activity itself does not contraindicate vaccination, and vaccines can be given regardless of disease activity, with the concern being purely pharmacologic (steroid dose) rather than disease-related 14, 17, 18

Influenza Vaccination in Patients on Oral Steroids

Recommendation by Steroid Dose

The American College of Rheumatology recommends administering the influenza vaccine to patients taking prednisone ≤10 mg daily or equivalent, without delay, due to the strong evidence supporting its effectiveness 19
The American College of Rheumatology recommends administering the influenza vaccine to patients taking prednisone >10 mg but <20 mg daily, as the benefits of vaccination outweigh the potential risks 19
No delay or deferral is needed for influenza vaccination at prednisone doses ≤20 mg daily, according to the American College of Rheumatology 19
The American College of Rheumatology still recommends administering the influenza vaccine even at doses ≥20 mg prednisone daily, as timely influenza protection outweighs concerns about potentially reduced antibody response 19

Vaccine Type Matters

The American Gastroenterological Association and the National Comprehensive Cancer Network recommend using only inactivated (killed) influenza vaccine in patients on any dose of oral steroids, due to the risk of live attenuated vaccines in immunosuppressed individuals 20, 21
The American Gastroenterological Association and the National Comprehensive Cancer Network recommend never using live attenuated influenza vaccine in patients receiving immunosuppressive steroid therapy, due to the risk of vaccine-related complications 20, 21

Special Populations

The American Gastroenterological Association recommends annual inactivated influenza vaccine for all adult IBD patients, due to their increased risk of influenza-related complications 20
The American Gastroenterological Association recommends considering high-dose influenza vaccine for patients on anti-TNF monotherapy, as it produces higher antibody levels than standard-dose vaccine 20
The National Comprehensive Cancer Network recommends annual inactivated influenza vaccine for all immunosuppressed cancer patients, due to their increased risk of influenza-related complications 21
The National Comprehensive Cancer Network states that insufficient data currently exists to routinely recommend high-dose over standard-dose vaccine in cancer patients, and therefore recommends using standard-dose vaccine 21

Common Pitfalls to Avoid

The American College of Rheumatology recommends not deferring influenza vaccination while waiting for steroid taper, even at doses ≥20 mg daily, as this can leave patients unprotected against influenza 19

Vaccination Guidance for Patients on Immunosuppressive Therapy

Expected Immune Response and Vaccine Administration

Good immunogenicity is expected for influenza and pneumococcal vaccines at prednisone doses <20mg daily, with studies demonstrating adequate antibody responses to vaccines in patients on low-dose glucocorticosteroids (<10mg/day) and acceptable responses at moderate doses (10-20mg/day), according to the American College of Rheumatology 22, 23
Chronic prednisone treatment at doses below 20mg does not significantly affect specific antibody responses to pneumococcal or influenza immunization, as evidenced by research published in reputable medical journals 23
Routine measurement of post-vaccination antibody titers is not necessary at 15mg daily, unless patients are on high-dose glucocorticosteroids (≥20mg/day for ≥2 weeks), as recommended by guideline societies 22, 23

Vaccine-Specific Considerations

Live vaccines (MMR, varicella, intranasal influenza, yellow fever) should be avoided as a general precaution in patients on chronic immunosuppressive therapy, even at doses below 20mg daily, due to potential risks and contraindications 22