Vaccines and medications: timing, immunosuppressants and interactions

Ahead of the autumn and flu season, many people ask: can I get vaccinated if I take medication long term — and is there anything to keep in mind about timing? Planning is especially worthwhile with immunomodulating drugs such as methotrexate, corticosteroids or biologics. This guide gives you an easy-to-understand overview, but it never replaces a conversation with the specialist practice treating you.

1. Why timing matters with some medications

A vaccine works by training the immune system: the body gets to know a pathogen and builds up protection. This is exactly where immunomodulating medications come in — they deliberately dampen the immune system, for example in rheumatism, psoriasis or Crohn's disease. This effect is intended in these conditions, but it can weaken the response to a vaccination.

That is why timing is about two goals. First, the vaccination should build up the best possible protective effect. Second, the underlying condition should stay stable — so the medication must not be paused carelessly. This trade-off is made by the practice treating you — usually rheumatology, gastroenterology or dermatology — together with you. Your job is to make sure the information is complete and to schedule appointments in good time.

Important to understand: there is no blanket rule of "always pause" or "never vaccinate". One and the same medication may carry on unchanged for one vaccination and require a different approach for another. It also matters whether it is an inactivated (killed) vaccine or a live vaccine. That is why the individual guidance from your specialist practice cannot be replaced by anything — not even by this guide.

2. Inactivated vaccine or live vaccine — the crucial difference

For people with a dampened immune system, the most important distinction is between inactivated and live vaccines. It determines whether a vaccination is possible at all.

3. Methotrexate: a short pause can help

Methotrexate is one of the most commonly used disease-modifying drugs for rheumatism and psoriasis. With inactivated vaccines such as the flu jab, an interesting effect appears: if methotrexate is paused briefly around the vaccination, the protective effect can be measurably better — usually without the underlying condition flaring up straight away.

Professional bodies such as the German Society for Rheumatology (DGRh, the national rheumatology association) therefore discuss briefly pausing methotrexate for something like a few weeks after the vaccination. Whether this makes sense for you, however, depends on your disease activity — with an unstable condition, the benefit of continuous treatment often outweighs it. You make this decision together with your rheumatology team, never on your own.

4. Corticosteroids and prednisolone: the dose decides

With prednisolone and other corticosteroid preparations, the size of the dose matters a great deal. High-dose therapy noticeably weakens the vaccine response, whereas a low maintenance dose usually barely does.

• Low dose (roughly below the equivalent of about 20 mg of prednisolone per day, depending on duration): inactivated vaccines are usually possible without any problem.
• High dose over a longer period: the vaccine response can turn out weaker. Where possible, an inactivated vaccination is scheduled for a phase with a lower dose.
• Live vaccines: under higher-dose corticosteroids, avoid them as a rule — the same caution applies here as with other immunosuppressants.

A short course of corticosteroids, say a few days during an infection, is by contrast usually not a problem for vaccination timing. Here too: the precise assessment is made by your practice, which knows your dose and treatment duration.

5. Biologics: plan vaccinations with your specialist practice

Biologics and modern targeted drugs (such as TNF inhibitors or other antibody therapies) are widely used in rheumatism, psoriasis and Crohn's disease. Two points are important for vaccination planning:

• Inactivated vaccines are usually possible under biologics and are explicitly recommended — though the protective effect may be somewhat weaker depending on the drug.
• Live vaccines are fundamentally not permitted while biologic therapy is ongoing.
• Some drugs have fixed infusion or injection intervals. An inactivated vaccination is then often scheduled to fit the cycle, so that the immune response is as good as possible.

Because the details differ from one preparation to another, planning with the specialist practice treating you is especially important here. Ideally, any outstanding vaccinations should be completed before starting biologic therapy — above all any necessary live vaccinations.

6. Blood thinners and the injection into the muscle

Many vaccines are injected into the upper-arm muscle (intramuscularly). Anyone taking blood thinners understandably worries about bruising — the good news: an intramuscular vaccination is generally no problem even under anticoagulation, provided a few simple steps are followed.

• Use a thin needle to irritate the tissue as little as possible.
• After the vaccination, press firmly on the injection site for a few minutes — do not rub it.
• With phenprocoumon (Marcumar), ideally schedule the appointment for a period with a stable, well-controlled INR (the blood-clotting measurement).

Do not stop your blood thinner on your own for a vaccination. If you are unsure, mention the anticoagulation just before the injection — then the person vaccinating you can adjust their technique accordingly.

7. Flu and other routine vaccinations

People with a dampened immune system in particular benefit especially from the recommended routine vaccinations, because infections can take a more severe course in them. Germany's Standing Committee on Vaccination (STIKO, the national vaccination advisory body) recommends the following for this group, among others:

• Flu vaccination every year, ideally in autumn before the season starts — as an inactivated vaccine (not as a nasal spray, which is a live vaccine). You can read more on the topic in the guide to flu.
• Pneumococcus to protect against pneumonia.
• COVID-19 according to the current recommendation.
• Boosters for tetanus, diphtheria and whooping cough as scheduled.

All of these vaccinations are inactivated vaccines and are therefore generally possible even under immunosuppression. The best time for the flu vaccination is usually October or November — early enough for protection to be in place at the peak of the wave, and matched to the timing of your medications.

8. Your checklist before the vaccination

• Draw up a complete list of medications — including immunosuppressants, corticosteroids, biologics and blood thinners.
• Plan the timing in good time — arrange vaccination appointments early with the specialist practice treating you, not only in the middle of the season.
• Clarify inactivated or live vaccine — under immunosuppression, live vaccines are generally off-limits.
• Don't stop anything on your own — any pausing of methotrexate & co. only on medical advice.

How to pause and restart medications safely in general is also covered in the guides to prednisolone and methotrexate.

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