What medications can cause you to be considered immunocompromised?

The recommendations for COVID-19 vaccines are different for patients who are immunocompromised. Medications can impact your body's ability to protect its self.

People taking any of the following categories of medications are considered severely immunocompromised:

High-dose corticosteroids—Most clinicians consider a dose of either >2 mg/kg of body weight or ≥20 mg per day of prednisone or equivalent in people who weigh >10 kg, when administered for ≥2 weeks, as sufficiently immunosuppressive to raise concern about the safety of vaccination with live vaccines. Furthermore, the immune response to vaccines may be impaired. Clinicians should wait ≥1 month after discontinuation of high-dose systemic corticosteroid therapy before administering a live-virus vaccine.
Alkylating agents (such as cyclophosphamide).
Antimetabolites (such as azathioprine, 6-mercaptopurine, methotrexate). However, low-dose monotherapy (methotrexate ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine ≤1.5 mg/kg/day) with these drugs does not preclude administration of either zoster vaccine.
Transplant-related immunosuppressive drugs (such as cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, and mycophenolate mofetil).
Cancer chemotherapeutic agents are classified as severely immunosuppressive, as evidenced by increased rates of opportunistic infections and blunting of responses to certain vaccines among patient groups.¹ Vaccination following immunomodulatory therapies, such as checkpoint inhibitors, and CAR-T cell treatments have not been well studied, and until additional data are available, live attenuated vaccine should be avoided for many months after treatment.
Tumor necrosis factor (TNF) blockers such as etanercept, adalimumab, certolizumab pegol, golimumab, and infliximab blunt the immune response to certain vaccines and certain chronic infections. When used alone or in combination regimens with other disease-modifying agents to treat rheumatoid disease, TNF blockers were associated with an impaired response to hepatitis A, influenza, and pneumococcal vaccines.
- Despite measurable impairment of the immune response, postvaccination antibody titers were often sufficient to provide protection for most people; therefore, treatment with TNF blockers does not preclude immunization against hepatitis A, influenza, and pneumococcal disease. When possible, all doses in the hepatitis A and pneumococcal series should be given before travel.
- The use of live vaccines is contraindicated according to the prescribing information for most of these therapies.
Other biologic agents that are immunosuppressive or immunomodulatory may result in significant immunocompromise as outlined in Table 5-02. In particular, lymphocyte-depleting agents (thymoglobulin or alemtuzumab) and B cell–depleting agents (rituximab) are more significantly immunosuppressive. Consideration of the clinical context in which these were given is important, especially in hematologic malignancies.

¹ Some of these agents are less immunosuppressive than others, such as tamoxifen or trastuzumab given to breast cancer patients, but clinical data to support safety with live vaccines are lacking.

The information above is adapted from CDC’s Traveler’s Health: Immunocompromised Travelers