Should patients on immunosuppressive medications be vaccinated

Should patients on immunosuppressive medications be vaccinated?

Yes. However, depending on the medication and dose, there are special considerations. It is important to know if the vaccine is live or inactivated. Patients on prednisone or on immunosuppressive medications can receive any of the inactivated vaccines. They can receive these vaccinations without an increased chance of flaring their underlying disease. However, their protective antibody titers following vaccination may be blunted because of immunosuppressive medications (especially prednisone).

Patients on prednisone ≥20 mg/day, and/or medications should not receive live attenuated virus vaccines. Furthermore, they should avoid contact with children recently vaccinated with oral polio vaccine, smallpox or rotavirus because the virus is shed in their stool. They should avoid contact with patients who received the live influenza virus intranasally and those who develop a rash following the live herpes zoster vaccine.

Inactivated vaccines:

  • • Influenza A/B/H1N1 vaccine: give yearly.
    • Patients on MTX should skip one weekly dose immediately after they receive the flu vaccine to maximize its protective response.
  • • Pneumococcal vaccine:
    • Pneumococcal polysaccharide 23-valent vaccine (PPSV23) to all immunosuppressed patients aged over 19 years at the start of therapy and 5 years later. They should receive an additional dose at age of 65 years if it has been >5 years since the previous two doses of PPSV23.
    • Pneumococcal conjugate 13-valent vaccine (PCV13) has recently been advised to be given to immunosuppressed patients aged over 19 years. If the patient has not previously received PPSV23, they should get one dose of PCV13 followed by 8 weeks later with a dose of PPSV23. If the high-risk patient has received PPSV23 previously, they should get one dose of PCV13 given at least 1 year after the PPSV23 vaccination.
  • • Hepatitis B vaccine: at-risk patients on MTX or leflunomide.
  • • Age-appropriate vaccinations: tetanus diphtheria/acellular pertussis, meningococcal, Haemophilus influenzae B.
  • • Other inactivated vaccines as appropriate: inactivated polio, rabies, hepatitis A, hepatitis B, human papilloma virus, typhoid polysaccharide.
  • • Zoster Vaccine Recombinant, Adjuvanted (Shingrix): This newer inactivated vaccine was approved by the FDA in October of 2017 and is now recommended by the Center for Disease Control for those on “low-dose prednisone”. Initial recommendations of the FDA favor this over the live herpes zoster vaccine (Zostavax). However, it has not been tested in those on more significant immunosuppression at this time.

Live vaccines.

  • • Live vaccines currently available: mumps/measles/rubella, zoster vaccine live (zostavax), live attenuated influenza (nasal), varicella zoster, yellow fever, oral typhoid, Bacillus Calmette–Guérin, rotavirus, oral adenovirus, smallpox.
  • • At the doses used in rheumatology, patients on low-dose prednisone (<20 mg/day) and csDMARDs can receive live vaccines. If initially on higher doses, patient must be on the lower dose (e.g., prednisone <20 mg/day) for at least 1 month before receiving the live vaccine.
  • • Patients on biologics should be off the biologic for at least three half-lives before receiving a live vaccine and not restart the biologic until 1 month after administration of the live vaccine.
  • • Zoster vaccine live (Zostavax) is a live subcutaneous zoster vaccine. This is the “older” zoster vaccine and was the only option prior to late 2017. See earlier for recommendations.

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