Meds & Biologics
If you have ulcerative colitis and take immunosuppressive medication, vaccines can feel like a minefield. Your pharmacist asks if you're immunocompromised. Your GI says to "check before getting any live vaccines." And the information you find online rarely accounts for which specific medication you're on. The reality is that most vaccines are safe and recommended for people with UC, but a small category of live vaccines requires careful timing, and one vaccine in particular, the shingles vaccine, has a confusing history that still trips people up.
Why Vaccination Matters More on Immunosuppressive Therapy
UC medications work by dialing down parts of your immune system that drive inflammation. That same suppression also reduces your body's ability to fight off infections. This makes staying current on vaccines more important for people with UC than for the general population, not less.
The Crohn's and Colitis Foundation notes that individuals with inflammatory bowel disease who are on immunosuppressive therapies face a higher risk of serious complications from preventable infections like influenza. Vaccines are one of the most straightforward tools you have to reduce that risk. The key is knowing which vaccines you can safely receive while on your current medication, and which ones need to wait.
The Core Rule: Live vs. Inactivated Vaccines
The single most important distinction in vaccine safety for UC patients on immunosuppressants is whether a vaccine is live or inactivated.
Inactivated vaccines use killed pathogens or pieces of a pathogen. They cannot cause infection, even in someone with a suppressed immune system. These are safe to receive at any time, regardless of what UC medication you're taking. Your immune response to these vaccines may be somewhat weaker than someone who is not immunosuppressed, but you still gain meaningful protection.
Live vaccines use a weakened but still active version of the virus. In a healthy immune system, the weakened virus stimulates an immune response without causing disease. But if your immune system is significantly suppressed, that weakened virus could potentially replicate in an uncontrolled way and cause the very infection the vaccine is meant to prevent. This is why live vaccines are contraindicated while you're on most UC immunosuppressants.
Common inactivated vaccines that are safe on immunosuppressive therapy include the annual flu shot (the injected version), COVID-19 vaccines from Pfizer, Moderna, and Novavax, the pneumococcal vaccine, hepatitis A and B vaccines, HPV vaccine, and the Tdap/tetanus vaccine. Common live vaccines to avoid while immunosuppressed include MMR (measles, mumps, rubella), the live nasal spray flu vaccine (FluMist), varicella (chickenpox), and yellow fever.
Which UC Medications Count as Immunosuppressive?
Not every UC medication suppresses the immune system enough to affect vaccine decisions. Aminosalicylates like mesalamine (Asacol, Lialda, Pentasa) are not considered immunosuppressive and do not restrict which vaccines you can receive.
The medications that do carry vaccine restrictions include thiopurines like azathioprine (Imuran) and 6-mercaptopurine, methotrexate, biologic therapies such as infliximab (Remicade), adalimumab (Humira), vedolizumab (Entyvio), and ustekinumab (Stelara), JAK inhibitors like tofacitinib (Xeljanz) and upadacitinib (Rinvoq), and calcineurin inhibitors like cyclosporine and tacrolimus. Systemic corticosteroids like prednisone also count when used at high doses (generally 20 mg or more daily for two weeks or longer), according to CDC guidelines on altered immunocompetence.
If you're on combination therapy, such as a biologic plus a thiopurine, the same rules apply: avoid live vaccines while on treatment.
The Shingles Vaccine Confusion
The shingles vaccine is the single most confusing vaccine topic for UC patients, and for good reason. There are two completely different shingles vaccines, and they have opposite safety profiles.
The old vaccine, Zostavax, was a live vaccine. It was contraindicated for anyone on immunosuppressive therapy. Zostavax has been discontinued in the United States and is no longer available, but many patients and even some healthcare providers still associate "shingles vaccine" with the old live version.
The current vaccine, Shingrix, is a recombinant (non-live) vaccine. It is safe for immunosuppressed patients and is specifically recommended for them. The CDC's Advisory Committee on Immunization Practices updated its recommendation in 2021 to include any immunosuppressed patient aged 19 and older as eligible for Shingrix, lowering the age threshold from 50 specifically because immunosuppressed individuals face a higher risk of shingles.
This matters for UC patients in particular. Thiopurines and JAK inhibitors have been associated with increased herpes zoster risk. Clinical trials have evaluated Shingrix specifically in UC patients on tofacitinib, confirming both its safety and effectiveness in this population. If you're 19 or older and on any immunosuppressive UC therapy, ask your doctor about Shingrix. You do not need to stop your medication to receive it.
The Flu Shot: Safe, Recommended, and Worth Asking About High-Dose
The injectable flu vaccine is inactivated and safe for UC patients on any medication. You should get one every year. What's worth knowing is that your immune response may be somewhat blunted by immunosuppressive therapy, particularly if you're on combination regimens.
A high-dose flu vaccine option exists and may produce a stronger immune response in immunosuppressed individuals. Some gastroenterology guidelines suggest it as a preferred option for immunocompromised patients. Ask your GI or pharmacist whether the high-dose version is appropriate for you. One important note: always choose the injected flu vaccine. The nasal spray version (FluMist) is a live vaccine and should be avoided.
COVID-19 Vaccines: Safe and Still Relevant
All currently available COVID-19 vaccines in the United States, including the updated formulations from Pfizer, Moderna, and Novavax, are non-live vaccines. They are safe for UC patients on immunosuppressive therapy. Large studies of IBD patients who received COVID-19 vaccines found that flares were infrequent and that the vaccine did not worsen disease activity in the vast majority of patients.
As with the flu vaccine, immunosuppressive medications may reduce the strength of your immune response to COVID-19 vaccination. The CDC recommends additional doses for moderately or severely immunocompromised individuals, and your GI can help you determine the right schedule.
Timing Vaccines Around Starting or Stopping Treatment
The ideal time to review your vaccine status is before you start a new immunosuppressive medication. If you need any live vaccines, they should be administered at least four to six weeks before beginning therapy. Once you're on treatment, live vaccines should be deferred until at least three months after stopping the medication, depending on the specific drug.
Inactivated vaccines can be given at any point during treatment. However, administering them before starting immunosuppression, when possible, gives you the best chance of mounting a full immune response. If you're already on medication, you should still get recommended inactivated vaccines on schedule, as partial protection is better than none.
What to Bring to Your Next Vaccination Appointment
Knowing exactly which UC medications you take, including dosages, makes it easier for your pharmacist or healthcare provider to confirm which vaccines are safe for you. Many pharmacies check for immunosuppressive medications before administering vaccines, but the screening questions are often broad. You may be asked something generic like "are you immunocompromised?" when the real question is whether you're on a specific medication that contraindicates live vaccines.
Track your vaccination schedule alongside your medications in Aidy. Knowing exactly which immunosuppressants you're on helps you and your pharmacist make safe vaccine decisions.