Influenza Vaccination in Patients on Corticosteroids

General Recommendations

For patients taking the equivalent of prednisone ≤10 mg daily, administering any non-live influenza vaccination is strongly recommended without delay, according to the American College of Rheumatology 1
For patients taking the equivalent of prednisone >10 mg daily but <20 mg daily, administering any non-live attenuated influenza vaccination is still conditionally recommended, according to the American College of Rheumatology 1
For patients taking higher doses (equivalent of prednisone ≥20 mg daily), administering influenza vaccination is conditionally recommended without delay, according to the American College of Rheumatology 1

For adults aged 66 years, the inactivated influenza vaccine (IIV) is the preferred option, as live attenuated influenza vaccine (LAIV) is contraindicated in persons aged ≥50 years, according to the Centers for Disease Control and Prevention (CDC) 2
Timely influenza vaccination is particularly important for older adults, who are at higher risk for influenza complications, according to the CDC 3

If the patient has a moderate or severe acute illness with fever, consider deferring vaccination until symptoms resolve, according to the CDC 2
For patients with a history of Guillain-Barré syndrome within 6 weeks following a previous dose of influenza vaccine, caution is warranted, according to the CDC 2
Ensure the patient understands that inactivated influenza vaccines cannot cause influenza illness, according to the CDC 4
Avoid missing the opportunity to vaccinate during the current healthcare encounter, as this may lead to the patient remaining unvaccinated during influenza season, according to the CDC 4

The Advisory Committee on Immunization Practices (ACIP) does not list concurrent corticosteroid therapy as a contraindication or precaution for influenza vaccination 5, 6
Contraindications for influenza vaccines are primarily related to history of severe allergic reaction to vaccine components 5, 7
Contraindications for influenza vaccines also include moderate to severe acute febrile illness, with vaccination deferred until symptoms resolve 7

The Centers for Disease Control and Prevention (CDC) recommends that for inactivated influenza vaccines (IIVs), the standard administration is intramuscular injection in the deltoid muscle for adults 5
If receiving both injections on the same day, they should be administered at different anatomical sites to minimize local reactions 6
Complete vaccination at least 2 weeks before initiation of immunosuppressive therapy when possible, although this typically applies to more significant immunosuppression than typical corticosteroid injections 6

For optimal protection, influenza vaccination should be completed by the end of October, regardless of corticosteroid treatment status 6, 8
For children requiring two doses of influenza vaccine, these should be administered at least 4 weeks apart 6, 8

The American Academy of Pediatrics and the CDC agree that live attenuated influenza vaccine (LAIV) has more contraindications than inactivated vaccines, but is still not contraindicated solely due to corticosteroid injections 7, 9

The Centers for Disease Control and Prevention, as reported in MMWR Recommendations and Reports, notes that live attenuated influenza vaccines have more contraindications and should be used with caution in immunosuppressed patients, whereas inactivated vaccines like Fluad are preferred 10
According to MMWR Recommendations and Reports, live attenuated influenza vaccines should not be administered to persons receiving immunosuppressive therapies, highlighting the importance of choosing inactivated vaccines for these patients 11

The guideline recommends that live attenuated influenza vaccines should not be administered to patients on immunosuppressive doses of corticosteroids, emphasizing the need for inactivated vaccines like Fluad for this population 10, 11