decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Use Caution/Monitor. Avoid administration of live attenuated influenza vaccine intranasal within 2 weeks before or 48 hours after administration of oseltamivir, unless medically indicated.oxaliplatinMonitor Closely (1)oxaliplatin decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Coadministration with immunosuppressant therapy reduced efficacy of the vaccine may occur. If possible, complete all age-appropriate vaccinations at least 2 weeks prior to initiation of immunosuppressant therapy. Patients vaccinated <14 days before initiation or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued. .ozanimodMinor (1)ozanimod decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Minor/Significance Unknown. No clinical data are available on the efficacy and safety of vaccinations in patients taking ozanimod. Vaccinations may be less effective if coadministered with ozanimod.phenytoinMinor (1)influenza virus vaccine quadrivalent, phenytoin. Mechanism: unknown. Minor/Significance Unknown. Vaccine administration may incr or decr phenytoin levels.ponesimodMonitor Closely (1)ponesimod decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Use Caution/Monitor. If possible, complete all age-appropriate vaccinations at least 4 weeks before initiating ponesimod.prednisoloneSerious - Use Alternative (1)prednisolone decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Corticosteroids also increase risk of infection with concomitant live vaccines.prednisoneSerious - Use Alternative (1)prednisone decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Corticosteroids also increase risk of infection with concomitant live vaccines.procarbazineMonitor Closely (1)procarbazine decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Coadministration with immunosuppressant therapy reduced efficacy of the vaccine may occur. If possible, complete all age-appropriate vaccinations at least 2 weeks prior to initiation of immunosuppressant therapy. Patients vaccinated <14 days before initiation or during immunosuppressive therapy should be revaccinated at least 3 months after therapy is discontinued. .rilonaceptSerious - Use Alternative (1)rilonacept decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.rituximabMonitor Closely (1)rituximab, influenza virus vaccine quadrivalent. immunosuppressive effects; risk of infection. Use Caution/Monitor. When used for rheumatoid arthritis, follow current immunization guidelines and administer non-live vaccines at least 4 weeks prior to a course of rituximab.rituximab-hyaluronidaseMonitor Closely (1)rituximab-hyaluronidase, influenza virus vaccine quadrivalent. immunosuppressive effects; risk of infection. Use Caution/Monitor. When used for rheumatoid arthritis, follow current immunization guidelines and administer non-live vaccines at least 4 weeks prior to a course of rituximab.satralizumabMonitor Closely (1)satralizumab decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Administer all immunizations according to immunization guidelines. At least 2 weeks before initiating for non-live vaccines. .secukinumabSerious - Use Alternative (1)secukinumab decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Prior to initiating secukinumab, complete all age appropriate immunizations; non-live vaccinations received during treatment with secukinumab may not elicit an immune response sufficient to prevent disease.siponimodSerious - Use Alternative (1)siponimod decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Avoid or Use Alternate Drug. Pause vaccinations beginning 1 week before initiating siponimod and for 4 weeks after stopping treatment. Coadministration with live attenuated vaccines may increase infection risk.sirolimusSerious - Use Alternative (1)sirolimus decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.tacrolimusSerious - Use Alternative (1)tacrolimus decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.temsirolimusSerious - Use Alternative (1)temsirolimus decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.teplizumabSerious - Use Alternative (1)teplizumab decreases effects of influenza virus vaccine quadrivalent by Other (see comment). Avoid or Use Alternate Drug. Comment: Administer all age-appropriate vaccinations before starting teplizumab. Inactivated or mRNA vaccines are not recommended within 2 weeks before teplizumab treatment, during treatment, or 6 weeks after completion of treatment.tocilizumabSerious - Use Alternative (1)tocilizumab decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Immunosuppressants also increase risk of infection with concomitant live vaccines.tralokinumabMonitor Closely (1)tralokinumab will decrease the level or effect of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Use Caution/Monitor. Limited data are available regarding coadministration with non-live vaccines.triamcinolone acetonide injectable suspensionSerious - Use Alternative (1)triamcinolone acetonide injectable suspension decreases effects of influenza virus vaccine quadrivalent by pharmacodynamic antagonism. Contraindicated. Corticosteroids also increase risk of infection with concomitant live vaccines.ublituximabMonitor Closely (1)ublituximab decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Administer all immunizations according to immunization guidelines at least 4 weeks before initiating ublituximab for live or live-attenuated vaccines and, whenever possible, at least 2 weeks before initiating for non-live vaccines. Vaccination with live virus vaccines is not recommended during treatment and until B-cell repletion. Do not administer live or live-attenuated vaccines to infants of mothers exposed to ublituximab during pregnancy, before confirming recovery of B-cell counts as measured by CD19+ B cells.voclosporinMonitor Closely (1)voclosporin decreases effects of influenza virus vaccine quadrivalent by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Inactivated vaccines noted to be safe for administration may not be sufficiently immunogenic during treatment. >10% Afluria Quadrivalent Pain (61-68%) Myalgia (8-40%) Headache (10-27%) Redness (17-24%) Malaise (8-24%) Irritability (16-18%) Induration (15-17%) Swelling (13-17%) Any fever (5-16%) Nausea/vomiting (3-12%) Fluarix Quadrivalent Pain (43.7%) Redness (23%) Fatigue (19.7%) Swelling (18.5%) Muscle aches (17.5%) Drowsiness (17.2%) Irritability (16.8%) Headache (16.3%) Loss of appetite (15.5%) Flucelvax Quadrivalent Injection site erythema (11.9-13.4%) Injection site induration (8.7-11.6%) FluLaval Quadrivalent Pain (59.5%) Muscle aches (26.3%) Headaches (21.5%) Fatigue (21.5%) Arthralgia (14.8%) Fluzone High-Dose Quadrivalent Injection site pain (41.3%) Myalgia (22.7%) Headache (14.4%) Malaise (13.2%) 1-10% Afluria Quadrivalent Diarrhea (2-8%) Loss of appetite (4-5%) Fluarix Quadrivalent Arthralgia (9.8%) Gastrointestinal symptoms (9.8%) Fever (8.9%) Shivering (6.4%) Fever (6%) Pain, Grade 3 (1.6%) Fatigue, Grade 3 (1.5%) Headache, Grade 3 (1.3%) Fever, Grade 3 (1.1%) Redness, Grade 3 (1%) Drowsiness, Grade 3 (1%) Gastrointestinal symptoms, Grade 3 (1%) FluLaval Quadrivalent Gastrointestinal symptoms (9.3%) Shivering (8.8%) Pain, Grade 3 (1.7%) Fever (1.3%) <1% Fluarix Quadrivalent Swelling, Grade 3 (0.8%) Irritability, Grade 3 (0.7%) Muscle aches, Grade 3 (0.7%) Shivering, Grade 3 (0.5%) Loss of appetite (0.3%) Fever (0.3%) Flucelvax Quadrivalent Headache (0.3-0.9%) Fatigue (0.6-0.8%) Myalgia (0.3-0.8%) Diarrhea (0.5-0.6%) Arthralgia (0.3-0.5%) Injection site pain (0.5%) Chills (0.2-0.3%) Nausea (0.2-0.3%) Loss of appetite (0.2-0.3%) Vomiting (0.2%) FluLaval Quadrivalent Headache, Grade 3 (0.9%) Muscle aches, Grade 3 (0.8%) Fatigue, Grade 3 (0.8%) Arthralgia, Grade 3 (0.8%) Gastrointestinal symptoms, Grade 3 (0.8%) Shivering, Grade 3 (0.6%) Fever, Grade 3 (0.4%) Postmarketing Reports Afluria Quadrivalent Blood and lymphatic disorders: Thrombocytopenia Immune system disorders: Allergic or immediate hypersensitivity reactions, including anaphylactic shock and serum sickness Nervous system disorders: Neuralgia, paresthesia, convulsions (eg, febrile seizures), encephalomyelitis, encephalopathy, neuritis or neuropathy, transverse myelitis, and Guillain-Barré syndrome Vascular disorders: Vasculitis Skin and subcutaneous tissue disorders: Pruritus, urticaria, and rash General disorders and administration site conditions: Cellulitis, large injection site swelling, influenzalike illness Fluarix Quadrivalent Blood and lymphatic disorders: Lymphadenopathy Cardiac disorders: Tachycardia Ear and labyrinth disorders: Vertigo Eye disorders: Conjunctivitis, eye irritation, eye pain, eye redness, eye swelling, eyelid swelling Gastrointestinal disorders: Abdominal pain or discomfort; swelling of the mouth, throat, and/or tongue General disorders and administration site conditions: Asthenia, chest pain, feeling hot, injection site mass, injection site reaction, injection site warmth, body aches Immune system disorders: Anaphylactic reaction (eg, shock), anaphylactoid reaction, hypersensitivity, serum sickness Infections and infestations: Injection site abscess, injection site cellulitis, pharyngitis, rhinitis, tonsillitis Nervous system disorders: Convulsion, encephalomyelitis, facial palsy, facial paresis, Guillain-Barré syndrome, hypoesthesia, myelitis, neuritis, neuropathy, paresthesia, syncope Respiratory, thoracic, and mediastinal disorders: Asthma, bronchospasm, dyspnea, respiratory distress, stridor Skin and subcutaneous tissue disorders: Angioedema, erythema, erythema multiforme, facial swelling, pruritus, Stevens-Johnson syndrome, sweating, urticaria Vascular disorders: Henoch-Schönlein purpura, vasculitis Flucelvax Quadrivalent Immune system disorders: Allergic or immediate hypersensitivity reactions (eg, anaphylactic shock) Nervous systems disorders: Syncope, presyncope, paresthesia Skin and subcutaneous tissue disorders: Generalized skin reactions (eg, pruritus, urticaria, nonspecific rash) General disorders and administration site conditions: Extensive swelling of injected limb FluLaval Quadrivalent Blood and lymphatic disorders: Lymphadenopathy Eye disorders: Eye pain, photophobia Gastrointestinal disorders: Dysphagia, vomiting General disorders and administration site conditions: Chest pain, injection site inflammation, asthenia, injection site rash, influenzalike symptoms, abnormal gait, injection site bruising, injection site sterile abscess Immune system disorders: Allergic reactions (including anaphylaxis), angioedema Infections and infestations: Rhinitis, laryngitis, cellulitis Musculoskeletal and connective-tissue disorders: Muscle weakness, arthritis Nervous system disorders: Dizziness, paresthesia, hypoesthesia, hypokinesia, tremor, somnolence, syncope, Guillain-Barré syndrome, convulsions/seizures, facial or cranial nerve paralysis, encephalopathy, limb paralysis Psychiatric disorders: Insomnia Respiratory, thoracic, and mediastinal disorders: Dyspnea, dysphonia, bronchospasm, throat tightness Skin and subcutaneous tissue disorders: Urticaria, localized or generalized rash, pruritus, sweating Vascular disorders: Flushing, pallor Contraindications Severe hypersensitivity (eg, anaphylaxis) to any component of the vaccine, including egg protein, or following a previous administration of any influenza vaccine Cautions Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of vaccine Use split or purified surface antigen in children Defer vaccine with febrile illnesses until illness is resolved; may administer vaccine with minor illnesses without fever (eg, upper respiratory tract infections) Expected immune response may not be obtained in immunocompromised individuals, including those receiving immunosuppressive therapy Guillain-Barré syndrome has been reported within 6 weeks of receipt of influenza vaccines Tip of syringe may contain natural rubber latex Syncope reported with injectable vaccines IM injections may cause hematoma in individuals with bleeding disorders (eg, hemophilia, anticoagulant therapy) Before administration, review immunization history for possible vaccine sensitivity and previous vaccination-related adverse reactions Vaccination may not protect all susceptible individuals Drug interaction overview Coadministration with other vaccines Do not mix with any other vaccine in the same syringe or vial There are insufficient data to assess the coadministration of influenza vaccine with other vaccines When concomitant administration of other vaccines is required, administer at different injection sites Immunosuppressive therapies Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune response to influenza vaccine Pregnancy There are insufficient data on influenza vaccine in pregnant women to inform vaccine-associated risk Pregnancy exposure registry Monitors pregnancy outcomes in women exposed to influenza vaccine during pregnancy Healthcare providers are encouraged to register women by calling the following: H5 FluLaval Quadrivalent, Fluarix Quadrivalent: 1-888-452-9622 Afluria Quadrivalent: 1-855-358-8966 or sending an email to Seqirus at us.medicalinformation@seqirus.com Fluzone Intradermal Quadrivalent or Fluzone Quadrivalent: 1-800-822-2463 Animal data No adverse effects observed on preweaning or vaccine-related fetal malformations when administered to female rabbits before pregnancy or during pregnancy Clinical considerations Pregnant women are at increased risk of complications associated with influenza infection compared with nonpregnant women The CDC recommends pregnant women be immunized with influenza vaccine by injection and not the live-attenuated influenza vaccine (LAIV; intranasal influenza vaccine) Vaccination has been shown to reduce the risk of flu-associated acute respiratory infection in pregnant women by up to 50%; immunization also confers some immunity to infants for the first several months after their birth, when they are too young to be vaccinated Lactation Unknown if distributed in human breast milk Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for the drug, and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal conditionPregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available. Mechanism of Action Inactivated influenza virus types A & B subunits Conveys active immunity via stimulation of production of endogenously produced antibodies Pharmacokinetics Onset: ~2 weeks Duration: Several months Effectiveness: Varies seasonally, depending on viral strain and mutations; lower antibody response in patients aged >65 yr or immunosuppressed individuals IM Administration Do not administer IV, intradermally (ID), or SC