Be Ready to Vaccinate Patients on Immunosuppressants

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.

Expect some specialists to recommend a high-dose or adjuvanted flu vaccine for adults on immunosuppressive meds...but there’s not much evidence they’re more effective.

Encourage immunocompromised patients to get at least 1 dose of a 2024-2025 COVID-19 vaccine...or three doses if it’s their primary series, with 4 to 8 weeks between doses.

Recommend a single dose of any RSV vaccine for immunocompromised patients age 75 and older...or age 60 to 74 residing in a nursing home...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 18 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...instead of 1 dose like in immunocompetent patients age 9 to 20.

Continue to recommend pneumococcal vaccines for immunocompromised patients. Use Health Canada’s website to guide dosing 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 don’t delay giving a vaccine...consult with specialists afterward if needed.

For more med-specific guidance...and considerations with household contacts...see our chart, Vaccinating Immunocompromised Patients.

• FAQ: Vaccinating Immunocompromised Patients
• Chart: Flu Vaccines for 2024-25 (Canada)
  
• Chart: COVID-19 Vaccines 2024-25 (Canada)
  
• Chart: Preventing RSV
• FAQ: Shingles Vaccine: FAQs
• FAQ: HPV Vaccination
• Chart: Comparison of Pneumococcal Vaccines