Questions are coming up about how to vaccinate adults who are using immunosuppressive meds...in the midst of another busy vaccine season.
Live vaccines (MMR, varicella, intranasal FluMist, etc) are best given at least 4 weeks before starting an immunosuppressive med...to minimize any risks from uninhibited replication of the vaccine virus.
It’s okay to give live vaccines to patients on any dose of an oral steroid for less than 14 days...using topical or inhaled steroids...or after a recent steroid injection.
And some patients can get live vaccines if they take LOW-level immunosuppressants...such as prednisone under 20 mg/day or a max methotrexate dose of 0.4 mg/kg/week. Weigh risks and benefits.
But avoid live vaccines for patients on HIGH-level immunosuppressants...such as certain biologics (adalimumab, natalizumab, etc) or prednisone doses of at least 20 mg/day for 14 days or longer.
Non-live vaccines (hep B, HPV, Tdap, etc) are ideally given at least 2 weeks before starting immunosuppressants...for the best immune response.
But don’t withhold them if a patient is already immunocompromised.
For flu vaccination, use any age-appropriate INJECTABLE product.
CDC now says a high-dose or adjuvanted flu vaccine is an option for adults 18 to 64 who’ve received a solid organ transplant and are taking immunosuppressants (tacrolimus, etc).
Expect some specialists to recommend a high-dose or adjuvanted flu vaccine for adults on other immunosuppressive meds. But there’s not much evidence it’s more effective...and it may not be covered or authorized under standing orders.
Encourage immunocompromised patients to get at least 1 dose of a 2024-2025 COVID-19 vaccine. Follow CDC’s Interim Clinical Considerations for specifics on additional doses, timing, etc.
Recommend a single dose of any RSV vaccine for immunocompromised patients age 60 and older...if they haven’t had one yet. There’s not enough evidence for use in younger patients...or for booster doses.
Give 2 IM doses of recombinant zoster vaccine (Shingrix) 2 to 6 months apart to most immunocompromised adults 19 and up. It’s okay to give the doses a minimum of 4 weeks apart if needed.
Use a 3-dose series of human papillomavirus vaccine (Gardasil 9) in immunocompromised patients who need the vaccine.
Continue to recommend pneumococcal vaccines for immunocompromised adults 19 and up. Use CDC’s PneumoRecs VaxAdvisor app or website to guide recommendations based on prior vaccines.
Be aware, there’s some evidence that holding methotrexate for 2 weeks after some non-live vaccines may boost immune response. But avoid a missed opportunity...and consult with specialists afterward if needed.
For more med-specific guidance...and considerations with household contacts...see our chart, Vaccinating Immunocompromised Patients.
- CDC. Altered immunocompetence. General best practices for immunization: Updated August 1, 2023. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html (Accessed October 14, 2024).
- CDC. Adult Immunization Schedule by Medical Condition and Other Indication. Updated November 16, 2023. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-medical-condition.html (Accessed October 14, 2024).
- Chat VS, Ellebrecht CT, Kingston P, et al. Vaccination recommendations for adults receiving biologics and oral therapies for psoriasis and psoriatic arthritis: Delphi consensus from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2024 Jun;90(6):1170-1181.
- Bass AR, Chakravarty E, Akl EA, et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken). 2023 Mar;75(3):449-464.
- Kamboj M, Bohlke K, Baptiste DM, et al. Vaccination of Adults With Cancer: ASCO Guideline. J Clin Oncol. 2024 May 10;42(14):1699-1721.