Varivax Vaccine

Drug overview for VARIVAX VACCINE (varicella virus vaccine live/pf):

Generic name: VARICELLA VIRUS VACCINE LIVE/PF (VAR-i-SEL-a)
Drug class: Varicella Vaccines
Therapeutic class: Biologicals

Varicella virus vaccine is a live, attenuated virus vaccine that contains varicella zoster virus (VZV) of the Oka/Merck strain

No enhanced Uses information available for this drug.

DRUG IMAGES

VARIVAX VACCINE WITH DILUENT

The following indications for VARIVAX VACCINE (varicella virus vaccine live/pf) have been approved by the FDA:

Indications:
Varicella vaccination

Professional Synonyms:
Active immunization against varicella-zoster virus
Vaccination to prevent chickenpox
Vaccination to prevent varicella

The following dosing information is available for VARIVAX VACCINE (varicella virus vaccine live/pf):

Dosing
Administration
VARIVAX VACCINE
Generic

Single-antigen varicella virus vaccine live (Varivax(R)) is administered in 0.5-mL doses.

When the single-antigen varicella vaccine (Varivax(R)) is administered within 30 minutes following reconstitution as specified, each 0.5-mL dose contains at least 1350 plaque-forming units (PFU) of Oka/Merck varicella virus.

Varicella virus vaccine live (Varivax(R)) is administered by subcutaneous or IM injection. A fixed-combination vaccine preparation containing measles, mumps, rubella, and varicella vaccine (ProQuad(R)) is also commercially available for use when such vaccines are indicated in children 12 months through 12 years of age; consult the prescribing information for ProQuad(R) for additional details. Varicella virus vaccine live (Varivax(R)) is supplied as a single-dose vial of lyophilized vaccine that must be reconstituted with the accompanying sterile diluent (supplied in a vial or prefilled syringe) prior to administration.

If the diluent is supplied in a vial, withdraw the entire volume of diluent from the vial and slowly inject into the lyophilized vaccine vial; gently agitate to dissolve completely. If the diluent is supplied as a prefilled syringe, reconstitute the vaccine by slowly injecting the entire contents of the prefilled syringe into the lyophilized vaccine vial; gently agitate to dissolve completely. A single dose of varicella virus vaccine live is approximately 0.5

mL. See the manufacturer's prescribing information for additional details on preparation of individual vaccine preparations. After reconstitution, withdraw and administer the entire volume immediately after reconstitution; discard if not used within 30 minutes after reconstitution..

Store the lyophilized vaccine component of varicella virus vaccine live between -50degreesC and -15degreesC prior to use. Before reconstitution, the lyophilized vaccine component may be stored at 2-8degreesC for up to 72 continuous hours; protect from light. Varicella vaccine may be given simultaneously with other age appropriate vaccines.

When multiple vaccines are administered during a single health-care visit, each vaccine should be given with a different syringe and at different injection sites. Injection sites should be separated by at least 1 inch, if possible. If multiple vaccines must be given into a single limb, the deltoid may be used in older children and adults, but the anterolateral thigh is preferred in infants and younger children.

Dosing information for VARIVAX VACCINE
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
VARIVAX VACCINE WITH DILUENT	Maintenance	Adults inject 0.5 milliliter (1,350 unit) by subcutaneous route once
VARIVAX VACCINE VIAL	Maintenance	Adults inject 0.5 milliliter (1,350 unit) by subcutaneous route once

No generic dosing information available.

The following drug interaction information is available for VARIVAX VACCINE (varicella virus vaccine live/pf):

Contraindicated
Severe
Moderate

There are 5 contraindications. These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.

Drug Interaction	Drug Names
Selected Live Viral Vaccines/Selected Immunoglobulins SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Immune globulin(IG) products may prevent the immune system from properly responding to the vaccine.(1-19) CLINICAL EFFECTS: Administration of selected live viral vaccines after immunoglobulins may impair the efficacy of the vaccine.(1-19) Administration of immunoglobulins within 2-4 weeks after selected live viral vaccines impair the efficacy of the vaccine.(1-4,15) PREDISPOSING FACTORS: The amount of antigen-specific antibody present in the administered immunoglobulin product determines the duration of this interaction.(15) PATIENT MANAGEMENT: The recommendations regarding this interaction are conflicting. The Centers for Disease Control and Prevention(CDC) immunization recommendations for spacing of live vaccines and antibody-containing products include the following(15): - Live attenuated influenza vaccine, rotavirus, zoster and Ty21a typhoid vaccines may be given any time before, concurrent, with, or after administration of any immune globulin. Yellow fever vaccine may also be given in areas where donor blood products are unlikely to contain a substantial quantity of yellow fever antibody. - Administration of measles or varicella containing vaccines should be postponed for the following intervals after immunoglobulin therapy: Hepatitis B IG, Tetanus IG - 3 months Rabies IG - 4 months Varicella IG - 5 months Measles prophylaxis IG - 6 months if nonimmunocompromised Botulinum IG Intravenous, CMV IG Intravenous, Hepatitis A IG - 6 months Intravenous Immune Globulin(IVIG) - 8 to 11 months depending upon the dose Monoclonal antibody to RSV F protein (palivizumab) - none - Administration of antibody-containing products should be delayed 2 weeks after administration of live vaccines, except for influenza, rotavirus, zoster and typhoid vaccines as noted above. CDC guidelines state that in circumstances where there is high-risk of vaccine-preventable disease, it is acceptable to administer a dose of vaccine prior to completion of these intervals.(16) Manufacturer recommendations are as follows: Administration of a live viral vaccine should be postponed for at least three months in patients who have received the following immunoglobulin therapy: anthrax immunoglobulin,(19) cytomegalovirus immunoglobulin,(1) hepatitis B immunoglobulin,(5,6) rabies immunoglobulin,(7) tetanus immunoglobulin,(8-11) vaccinia immunoglobulin,(18) and zoster immunoglobulin.(2) Administration of a live viral vaccine should be postponed for at least six months in patients who have received the following immunoglobulin therapy: botulinum neurotoxin a/b immune globulin.(17) The US manufacturer of human immunoglobulin states that live viral vaccines should be postponed for three months in patients who have received human immunoglobulin. The Australian and Canadian manufacturers of human immunoglobulin advise postponing live viral vaccines for 3-6 months in patients who have received human immunoglobulin.(6,12,13,18) The UK manufacturer states that vaccines may be compromised for one year and vaccines should be postponed in children for at least seven months.(14) The US manufacturer of immune globulin-hyaluronidase states that immune response to live attenuated vaccines may be impaired for up to 6 months, or for a year or more in the case of measles vaccine.(15) Cytomegalovirus immunoglobulin(1) or human immunoglobulin(3) should not be administered to patients who have received a live vaccine in the previous two weeks. If a live viral vaccine is given within two weeks of zoster immunoglobulin,(1) repetition of the vaccination three months after the completion of immunoglobulin should be considered. DISCUSSION: CDC Immunization Recommendations(15)provide discussion, charts, and further details regarding appropriate use and timing of vaccine therapy.(16)	ALYGLO, ANTHRASIL (NATIONAL STOCKPILE), ASCENIV, BABYBIG, BIVIGAM, CNJ-016 (NATIONAL STOCKPILE), CUTAQUIG, CUVITRU, CYTOGAM, FLEBOGAMMA DIF, GAMASTAN, GAMMAGARD LIQUID, GAMMAGARD LIQUID ERC, GAMMAGARD S-D, GAMMAKED, GAMMAPLEX, GAMUNEX-C, HEPAGAM B, HIZENTRA, HYPERHEP B, HYPERRAB, HYPERTET, HYQVIA, HYQVIA IG COMPONENT, IMOGAM RABIES-HT, KEDRAB, NABI-HB, OCTAGAM, PANZYGA, PRIVIGEN, QIVIGY, VARIZIG, XEMBIFY, YIMMUGO
Live Vaccines; Live BCG/Selected Immunosuppressive Agents SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: A variety of disease modifying agents suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(2) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1) Patients who receive anti-B cell therapies should not receive live vaccines for at least 6 months after such therapies due to a prolonged duration of immunosuppression. An exception is the Zoster vaccine, which can be given at least 1 month after receipt of anti-B cell therapies.(1) The US manufacturer of abatacept states live vaccines should not be given during or for up to 3 months after discontinuation of abatacept.(2) The US manufacturer of live BCG for intravesicular treatment of bladder cancer states use is contraindicated in immunosuppressed patients.(3) The US manufacturer of daclizumab states live vaccines are not recommended during and for up to 4 months after discontinuation of treatment.(4) The US manufacturer of guselkumab states that live vaccines should be avoided during treatment with guselkumab.(5) The US manufacturer of inebilizumab-cdon states that live vaccines are not recommended during treatment and after discontinuation until B-cell repletion. Administer all live vaccinations at least 4 weeks prior to initiation of inebilizumab-cdon.(6) The US manufacturer of ocrelizumab states that live vaccines are not recommended during treatment and until B-cell repletion occurs after discontinuation of therapy. Administer all live vaccines at least 4 weeks prior to initiation of ocrelizumab.(7) The US manufacturer of ozanimod states that live vaccines should be avoided during and for up to 3 months after discontinuation of ozanimod.(8) The US manufacturer of siponimod states that live vaccines are not recommended during treatment and for up to 4 weeks after discontinuation of treatment.(9) The US manufacturer of ustekinumab states BCG vaccines should not be given in the year prior to, during, or the year after ustekinumab therapy.(10) The US manufacturer of satralizumab-mwge states that live vaccines are not recommended during treatment and should be administered at least four weeks prior to initiation of satralizumab-mwge.(11) The US manufacturer of ublituximab-xiiy states that live vaccines are not recommended during treatment and until B-cell recovery. Live vaccines should be administered at least 4 weeks prior to initiation of ublituximab-xiiy.(12) The US manufacturer of etrasimod states that live vaccines should be avoided during and for 5 weeks after treatment. Live vaccines should be administered at least 4 weeks prior to initiation of etrasimod.(13) The US manufacturer of emapalumab-lzsg states that live vaccines should not be administered to patients receiving emapalumab-lzsg and for at least 4 weeks after the last dose of emapalumab-lzsg. The safety of immunization with live vaccines during or following emapalumab-lzsg therapy has not been studied.(14) The US manufacturer of sibeprenlimab-szsi states live vaccines should not be given within 30 days prior to initiation or during treatment with sibeprenlimab-szsi.(15) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)	ABECMA, ABRAXANE, ABRILADA(CF), ABRILADA(CF) PEN, ABRILADA(CF) PEN (2 PACK), ACTEMRA, ACTEMRA ACTPEN, ACTIMMUNE, ADALIMUMAB-AACF(CF), ADALIMUMAB-AACF(CF) (2 PK), ADALIMUMAB-AACF(CF) PEN (2 PK), ADALIMUMAB-AACF(CF) PEN CROHNS, ADALIMUMAB-AACF(CF) PEN PS-UV, ADALIMUMAB-AATY(CF), ADALIMUMAB-AATY(CF) AI CROHNS, ADALIMUMAB-AATY(CF) AUTOINJECT, ADALIMUMAB-ADAZ(CF), ADALIMUMAB-ADAZ(CF) PEN, ADALIMUMAB-ADBM(CF), ADALIMUMAB-ADBM(CF) PEN, ADALIMUMAB-ADBM(CF)PEN, ADALIMUMAB-BWWD(CF), ADALIMUMAB-BWWD(CF) AUTOINJECT, ADALIMUMAB-FKJP(CF), ADALIMUMAB-FKJP(CF) PEN, ADALIMUMAB-RYVK(CF), ADALIMUMAB-RYVK(CF) AUTOINJECT, ADBRY, ADBRY AUTOINJECTOR, ADCETRIS, ADRIAMYCIN, ADRUCIL, AFINITOR, AFINITOR DISPERZ, AKEEGA, ALFERON N, ALIQOPA, ALKERAN, ALUNBRIG, AMJEVITA(CF), AMJEVITA(CF) AUTOINJECTOR, AMTAGVI, ARAVA, ARCALYST, ARRANON, ARSENIC TRIOXIDE, ARZERRA, ASPARLAS, ASTAGRAF XL, ATGAM, AUBAGIO, AUCATZYL, AUGTYRO, AVGEMSI, AVONEX, AVONEX (4 PACK), AVONEX PEN, AVONEX PEN (4 PACK), AVSOLA, AVTOZMA, AVTOZMA AUTOINJECTOR, AXTLE, AZACITIDINE, AZASAN, AZATHIOPRINE, AZATHIOPRINE SODIUM, BAFIERTAM, BAVENCIO, BEIZRAY, BEIZRAY-ALBUMIN, BELEODAQ, BELRAPZO, BENDAMUSTINE HCL, BENDEKA, BENLYSTA, BESPONSA, BESREMI, BETASERON, BEXAROTENE, BICNU, BIMZELX, BIMZELX AUTOINJECTOR, BLEOMYCIN SULFATE, BLINCYTO, BORTEZOMIB, BORUZU, BOSULIF, BRAFTOVI, BREYANZI, BREYANZI CD4 COMPONENT, BREYANZI CD8 COMPONENT, BRIUMVI, BRUKINSA, BUSULFAN, BUSULFEX, CABOMETYX, CAELYX, CALQUENCE, CAMPTOSAR, CAPECITABINE, CAPRELSA, CARBOPLATIN, CARMUSTINE, CARVYKTI, CELLCEPT, CHLORAMBUCIL, CIBINQO, CIMZIA, CIMZIA (2 PACK), CISPLATIN, CLADRIBINE, CLOFARABINE, COLUMVI, COMETRIQ, COPIKTRA, COSENTYX, COSENTYX (2 SYRINGES), COSENTYX SENSOREADY (2 PENS), COSENTYX SENSOREADY PEN, COSENTYX SYRINGE, COSENTYX UNOREADY PEN, COSMEGEN, CYCLOPHOSPHAMIDE, CYCLOPHOSPHAMIDE MONOHYDRATE, CYCLOSPORINE, CYCLOSPORINE MODIFIED, CYLTEZO(CF), CYLTEZO(CF) PEN, CYTARABINE, DACARBAZINE, DACTINOMYCIN, DANZITEN, DARAPRIM, DARZALEX, DARZALEX FASPRO, DASATINIB, DAUNORUBICIN HCL, DAURISMO, DECITABINE, DEXRAZOXANE, DIMETHYL FUMARATE, DOCETAXEL, DOCIVYX, DOXIL, DOXORUBICIN HCL, DOXORUBICIN HCL LIPOSOME, DUPIXENT PEN, DUPIXENT SYRINGE, EBGLYSS PEN, EBGLYSS SYRINGE, EFLORNITHINE HCL, ELAHERE, ELLENCE, ELREXFIO, ENBREL, ENBREL MINI, ENBREL SURECLICK, ENHERTU, ENSPRYNG, ENTYVIO, ENTYVIO PEN, ENVARSUS XR, EPIRUBICIN HCL, EPKINLY, ERBITUX, ERLOTINIB HCL, ETOPOPHOS, ETOPOSIDE, EVEROLIMUS, EVOMELA, FARESTON, FARYDAK, FINGOLIMOD, FLOXURIDINE, FLUDARABINE PHOSPHATE, FLUOROURACIL, FOLOTYN, FRINDOVYX, FYARRO, GAMIFANT, GAVRETO, GAZYVA, GEFITINIB, GEMCITABINE HCL, GENGRAF, GILENYA, GLEEVEC, GLEOSTINE, GLIADEL, GRAFAPEX, HADLIMA, HADLIMA PUSHTOUCH, HADLIMA(CF), HADLIMA(CF) PUSHTOUCH, HEPZATO, HERCEPTIN, HERCEPTIN HYLECTA, HERCESSI, HERZUMA, HICON, HULIO(CF), HULIO(CF) PEN, HUMIRA, HUMIRA PEN, HUMIRA(CF), HUMIRA(CF) PEN, HUMIRA(CF) PEN CROHN'S-UC-HS, HUMIRA(CF) PEN PSOR-UV-ADOL HS, HYCAMTIN, HYRIMOZ(CF), HYRIMOZ(CF) PEDIATRIC CROHN'S, HYRIMOZ(CF) PEN, HYRIMOZ(CF) PEN CROHN-UC START, HYRIMOZ(CF) PEN PSORIASIS, ICLUSIG, ICOTYDE, IDAMYCIN PFS, IDARUBICIN HCL, IFEX, IFOSFAMIDE, ILARIS, ILUMYA, IMAAVY, IMATINIB MESYLATE, IMBRUVICA, IMDELLTRA, IMFINZI, IMKELDI, IMULDOSA, IMURAN, INFLECTRA, INFLIXIMAB, INFUGEM, INQOVI, INREBIC, IRESSA, IRINOTECAN HCL, ISTODAX, IVRA, IWILFIN, IXEMPRA, JAKAFI, JAYPIRCA, JEMPERLI, JEVTANA, KADCYLA, KANJINTI, KEMOPLAT, KESIMPTA PEN, KEVZARA, KEYTRUDA, KEYTRUDA QLEX, KINERET, KISQALI, KOMZIFTI, KYMRIAH, KYXATA, LEFLUNICLO, LEFLUNOMIDE, LEMTRADA, LENALIDOMIDE, LEQSELVI, LEUKERAN, LEVAMISOLE HCL, LITFULO, LOMUSTINE, LONSURF, LOQTORZI, LUNSUMIO, LUNSUMIO VELO, LUPKYNIS, LUTATHERA, LYMPHIR, LYNOZYFIC, LYNPARZA, MATULANE, MAVENCLAD, MAYZENT, MECHLORETHAMINE HCL, MEKINIST, MEKTOVI, MELPHALAN HCL, MERCAPTOPURINE, METHOTREXATE, METHOTREXATE SODIUM, METHOTREXATE-NACL, MITOMYCIN, MITOXANTRONE HCL, MONJUVI, MUTAMYCIN, MYCOPHENOLATE MOFETIL, MYCOPHENOLIC ACID, MYFORTIC, MYHIBBIN, MYLERAN, MYLOTARG, NELARABINE, NEMLUVIO, NEORAL, NEXAVAR, NILOTINIB D-TARTRATE, NILOTINIB HCL, NIPENT, NULOJIX, OCREVUS, OCREVUS ZUNOVO, OGIVRI, OJJAARA, OLUMIANT, OMVOH, OMVOH PEN, ONCASPAR, ONIVYDE, ONTRUZANT, ONUREG, OPDIVO, OPDIVO QVANTIG, OPDUALAG, ORENCIA, ORENCIA CLICKJECT, OTULFI, OXALIPLATIN, PACLITAXEL, PACLITAXEL PROTEIN-BOUND, PAZOPANIB HCL, PEGASYS, PEMETREXED, PEMETREXED DISODIUM, PEMFEXY, PEMRYDI RTU, PERJETA, PHESGO, PHYRAGO, PLEGRIDY, PLEGRIDY PEN, PLUVICTO, POLIVY, POMALIDOMIDE, POMALYST, PONVORY, POTELIGEO, PRALATREXATE, PROCARBAZINE HCL, PROGRAF, PROLEUKIN, PURIXAN, PYRIMETHAMINE, PYZCHIVA, PYZCHIVA AUTOINJECTOR, QUALAQUIN, QUININE HCL, QUININE SULFATE, REBIF, REBIF REBIDOSE, REMICADE, RENFLEXIS, REVLIMID, REVUFORJ, REZUROCK, RHAPSIDO, RIABNI, RINVOQ, RINVOQ LQ, RITUXAN, RITUXAN HYCELA, ROMIDEPSIN, RUBRACA, RUXIENCE, RYDAPT, RYLAZE, RYSTIGGO, RYTELO, SANDIMMUNE, SAPHNELO, SARCLISA, SCEMBLIX, SELARSDI, SILIQ, SIMLANDI(CF), SIMLANDI(CF) AUTOINJECTOR, SIMPONI, SIMPONI ARIA, SIMULECT, SIROLIMUS, SKYRIZI, SKYRIZI ON-BODY, SKYRIZI PEN, SODIUM IODIDE I-131, SORAFENIB, SOTYKTU, SPEVIGO, SPRYCEL, STARJEMZA, STELARA, STEQEYMA, STIVARGA, STRONTIUM-89 CHLORIDE, SUNITINIB MALATE, SUTENT, SYLVANT, TABLOID, TACROLIMUS, TACROLIMUS XL, TALTZ AUTOINJECTOR, TALTZ AUTOINJECTOR (2 PACK), TALTZ AUTOINJECTOR (3 PACK), TALTZ SYRINGE, TALVEY, TALZENNA, TARGRETIN, TASCENSO ODT, TASIGNA, TECARTUS, TECELRA, TECENTRIQ, TECENTRIQ HYBREZA, TECFIDERA, TECVAYLI, TEMODAR, TEMOZOLOMIDE, TEMSIROLIMUS, TEPADINA, TEPYLUTE, TERIFLUNOMIDE, TEVIMBRA, TEZSPIRE, THALOMID, THIOGUANINE, THIOTEPA, THYMOGLOBULIN, TOFACITINIB CITRATE, TOFIDENCE, TOPOTECAN HCL, TOREMIFENE CITRATE, TORISEL, TORPENZ, TRAMETINIB, TRAZIMERA, TREANDA, TREMFYA, TREMFYA ONE-PRESS, TREMFYA PEN, TREMFYA PEN INDUCTION (2 PEN), TRIFLURIDINE, TRISENOX, TRUQAP, TRUXIMA, TYENNE, TYENNE AUTOINJECTOR, TYRUKO, TYSABRI, UNITUXIN, UNLOXCYT, UPLIZNA, USTEKINUMAB, USTEKINUMAB-AAUZ, USTEKINUMAB-AEKN, USTEKINUMAB-TTWE, VALRUBICIN, VALSTAR, VANFLYTA, VELCADE, VELSIPITY, VENCLEXTA, VENCLEXTA STARTING PACK, VERZENIO, VIDAZA, VINBLASTINE SULFATE, VINCASAR PFS, VINCRISTINE SULFATE, VINORELBINE TARTRATE, VITRAKVI, VIVIMUSTA, VOTRIENT, VOYXACT, VYVGART, VYVGART HYTRULO, VYXEOS, WAYRILZ, WEZLANA, XALKORI, XELJANZ, XELJANZ XR, XOFIGO, XPOVIO, YESCARTA, YESINTEK, YONDELIS, YUFLYMA(CF), YUFLYMA(CF) AI CROHN'S-UC-HS, YUFLYMA(CF) AUTOINJECTOR, YUSIMRY(CF) PEN, ZANOSAR, ZEJULA, ZEPOSIA, ZEPZELCA, ZEVALIN, ZOKINVY, ZORTRESS, ZYDELIG, ZYMFENTRA, ZYMFENTRA PEN, ZYNYZ
Selected Live Viral Vaccines/Rho Immunoglobulin SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Immune globulin products may prevent the immune system from properly responding to the vaccine.(1-6) CLINICAL EFFECTS: Administration of a live viral vaccine after immunoglobulins may impair the efficacy of the vaccine.(1-6) Administration of immunoglobulins within 2-4 weeks after a live viral vaccine impair the efficacy of the vaccine.(1-6) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Administration of a live viral vaccine should be postponed for three months in patients who have received immunoglobulin therapy, including Rho immunoglobulin.(1-6) If a live viral vaccine is given within two to four weeks of rho immunoglobulin, then repeat vaccination three months after the completion of immunoglobulin should be considered.(2-4) DISCUSSION: Administration of a live viral vaccine after immunoglobulins(1-6) or administration of immunoglobulins after a live vaccine(3) may impair the efficacy of the vaccine.	HYPERRHO, RHOGAM ULTRA-FILTERED PLUS, RHOPHYLAC, WINRHO SDF
Varicella; Zoster Live Vaccine/Acyclovir; Famciclovir; Valacyclovir SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Acyclovir, famciclovir, and valacyclovir inhibit varicella zoster virus activity and may prevent the body from developing an immune response to the live vaccine. CLINICAL EFFECTS: Administration of antiviral agents active against varicella zoster virus may decrease the efficacy of live, attenuated varicella or zoster vaccines.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: CDC immunization guidelines recommend acyclovir, famciclovir or valacyclovir discontinuation at least 24 hours prior to administration of varicella or zoster vaccines, if possible. Delay use or resumption of antiviral therapy for 14 days after vaccination.(1) DISCUSSION: Acyclovir, famciclovir, valacyclovir inhibit varicella zoster virus activity and may prevent the body from developing an immune response to the live vaccine, decreasing the efficacy of efficacy of live, attenuated varicella or zoster vaccines.(1)	ACYCLOVIR, ACYCLOVIR SODIUM, ACYCLOVIR SODIUM-0.9% NACL, FAMCICLOVIR, VALACYCLOVIR, VALACYCLOVIR HCL, VALTREX, ZOVIRAX
Live Vaccines/Bevacizumab SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Systemic bevacizumab suppresses the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. Intravitreal injections of small doses of bevacizumab for macular degeneration or macular edema are not expected to suppress immune function. PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) Intravitreal injections of small doses of bevacizumab for macular degeneration or macular edema are not expected to suppress immune function. For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)	ALYMSYS, AVASTIN, JOBEVNE, MVASI, VEGZELMA, ZIRABEV

There are 9 severe interactions. These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.

Drug Interaction	Drug Names
Systemic Corticosteroids; Corticotropin (ACTH)/Live Vaccines SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Corticosteroids and corticotropin suppress the immune system. In severely immunocompromised patients, virus replication after administration of live, attenuated-virus vaccines can be enhanced and/or the immune response to the vaccine may be decreased.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) PREDISPOSING FACTORS: Patients receiving immunosuppressive doses of corticosteroids or corticotropin for equal to or greater than 14 consecutive days.(1) PATIENT MANAGEMENT: The Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are severely immunosuppressed, including those who are receiving or have received high-dose, systemic steroids for greater than or equal to 14 consecutive days. Live vaccines should be deferred for at least 1 month after discontinuation of high-dose systemic steroids administered for 14 consecutive days. When initiating immunosuppressives doses of corticosteroids, wait 4 weeks after a live vaccines is administered. However, if patients require therapy for chronic inflammatory conditions, do not delay therapy due to past vaccines. Patients who are vaccinated within the 14 days prior to initiating immunosuppressive therapy should be considered unvaccinated and should be revaccinated at least 3 months after immunosuppressive therapy is discontinued.(1) The US manufacturer of corticotropin(2) and triamcinolone(3) and the Australian manufacturer of dexamethasone(4) state that administration of live or live-attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids or corticotropin. The manufacturer of deflazacort states that live or live-attenuated vaccines should be administered at least 4 to 6 weeks prior to initiation of therapy with deflazacort.(5) DISCUSSION: Many clinicians consider a dose equivalent to either 2 mg/kg of body weight or a total of 20 mg/day of prednisone as sufficiently immunosuppressive to raise safety concerns about live-virus vaccines.(1) Immunization procedures may be undertaken in patients receiving corticosteroids when the therapy is short term (less than 2 weeks); low to moderate dose; long-term, alternate-day treatment with short-acting preparations; maintenance physiologic doses (replacement therapy); or administered topically (skin or eyes), by aerosol, or by intra-articular, bursal, or tendon injection.(1) Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)	ACTHAR, ACTHAR SELFJECT, ADRENOCORTICOTROPHIC HORMONE, AGAMREE, ALDOSTERONE, ALKINDI SPRINKLE, ANUCORT-HC, ANUSOL-HC, BECLOMETHASONE DIPROPIONATE, BETALOAN SUIK, BETAMETHASONE ACETATE MICRO, BETAMETHASONE ACETATE-SOD PHOS, BETAMETHASONE DIPROPIONATE, BETAMETHASONE SOD PHOS-ACETATE, BETAMETHASONE SOD PHOS-WATER, BETAMETHASONE SODIUM PHOSPHATE, BETAMETHASONE VALERATE, BUDESONIDE, BUDESONIDE DR, BUDESONIDE EC, BUDESONIDE ER, BUDESONIDE MICRONIZED, BUPIVACAINE-DEXAMETH-EPINEPHRN, CELESTONE, CLOBETASOL PROPIONATE MICRO, CORTEF, CORTENEMA, CORTICOTROPHIN, CORTIFOAM, CORTISONE ACETATE, CORTROPHIN, DEFLAZACORT, DEPO-MEDROL, DESONIDE MICRONIZED, DESOXIMETASONE, DESOXYCORTICOSTERONE ACETATE, DEXABLISS, DEXAMETHASONE, DEXAMETHASONE ACETATE, DEXAMETHASONE ACETATE MICRO, DEXAMETHASONE INTENSOL, DEXAMETHASONE ISONICOTINATE, DEXAMETHASONE MICRONIZED, DEXAMETHASONE SOD PHOS-WATER, DEXAMETHASONE SODIUM PHOSPHATE, DEXAMETHASONE-0.9% NACL, DMT SUIK, DOUBLEDEX, EMFLAZA, EOHILIA, FLUDROCORTISONE ACETATE, FLUNISOLIDE, FLUOCINOLONE ACETONIDE, FLUOCINOLONE ACETONIDE MICRO, FLUOCINONIDE MICRONIZED, FLUTICASONE PROPIONATE, FLUTICASONE PROPIONATE MICRO, HEMADY, HEMMOREX-HC, HEXATRIONE, HYDROCORTISONE, HYDROCORTISONE ACETATE, HYDROCORTISONE SOD SUCCINATE, JAYTHARI, KENALOG-10, KENALOG-40, KENALOG-80, KHINDIVI, KYMBEE, LIDOCIDEX-I, MAS CARE-PAK, MEDROL, MEDROLOAN II SUIK, MEDROLOAN SUIK, METHYLPREDNISOLONE, METHYLPREDNISOLONE AC MICRO, METHYLPREDNISOLONE ACETATE, METHYLPREDNISOLONE SODIUM SUCC, MILLIPRED, MILLIPRED DP, MOMETASONE FUROATE, ORAPRED ODT, P-PACK PREDNISONE, PREDNISOLONE, PREDNISOLONE ACETATE MICRONIZE, PREDNISOLONE MICRONIZED, PREDNISOLONE SODIUM PHOS ODT, PREDNISOLONE SODIUM PHOSPHATE, PREDNISONE, PREDNISONE INTENSOL, PREDNISONE MICRONIZED, PROCTOCORT, PYQUVI, SOLU-CORTEF, SOLU-MEDROL, TAPERDEX, TARPEYO, TRIAMCINOLONE, TRIAMCINOLONE ACETONIDE, TRIAMCINOLONE DIACETATE, TRIAMCINOLONE DIACETATE MICRO, TRILOAN II SUIK, TRILOAN SUIK, UCERIS, VERIPRED 20, ZCORT
Varicella Virus Vaccine Live/Salicylates SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Use of salicylates during natural varicella infection has been associated with Reye's Syndrome.(1-4) CLINICAL EFFECTS: Use of the live varicella virus vaccine in patients receiving salicylate therapy or use of salicylates within 6 weeks after vaccination with the live varicella virus vaccine may increase the risk of Reye's Syndrome.(1-4) Symptoms of Reye's syndrome include drowsiness, confusion, seizures, coma. In severe cases, Reye's syndrome can result in death. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The Canadian, UK, and US manufacturers of live varicella virus vaccine indicated for the prevention of chicken pox state that vaccine recipients should avoid the use of salicylates for 6 weeks after vaccination.(1-4) There is no such restriction in the labeling for live varicella virus vaccine indicated for the prevention of shingles, which is only indicated for patients age 60 and older.(5) DISCUSSION: Because the use of salicylates during natural varicella infection has been associated with Reye's Syndrome, the use of salicylates for 6 weeks following vaccination with live varicella virus vaccine should be avoided.(1-4)	ACETYL SALICYLIC ACID, ASA-BUTALB-CAFFEINE-CODEINE, ASCOMP WITH CODEINE, ASPIRIN, ASPIRIN-DIPYRIDAMOLE ER, BISMUTH SUBSALICYLATE, BUTALBITAL-ASPIRIN-CAFFEINE, CARISOPRODOL-ASPIRIN, CARISOPRODOL-ASPIRIN-CODEINE, CHOLINE MAGNESIUM TRISALICYLAT, DIFLUNISAL, DOLOBID, DURLAZA, MB CAPS, NORGESIC, NORGESIC FORTE, ORPHENADRINE-ASPIRIN-CAFFEINE, ORPHENGESIC FORTE, PHENYL SALICYLATE, SALSALATE, SODIUM SALICYLATE, URELLE, URETRON D-S, URIBEL TABS, URIMAR-T, URNEVA, URO-MP, URO-SP, YOSPRALA
Live Vaccines/Live Vaccines SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: The immune response to an injectable or nasally administered live vaccine may be impaired if it is administered within 28 days of another injectable or nasally administered live vaccine.(1) CLINICAL EFFECTS: Non-simultaneous administration (i.e. given on different days) of an injectable or nasally administered live vaccine to an individual who has received another injectable or nasally administered live vaccine in the previous 28 days may result in the second vaccine being ineffective.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The CDC states that multiple injectable or nasal live vaccines (e.g. MMR and varicella) may be administered on the same day. However, injectable or nasally administered live vaccines not administered on the same day should be administered at least 4 weeks apart whenever possible. If injectable or nasal live vaccines are administered less than 4 weeks apart and not on the same day, the vaccine administered second should be considered invalid and be repeated at least 4 weeks after the last, invalid dose.(1) DISCUSSION: The immune response to a live vaccine may be impaired if it is administered within 28 days of another live vaccine. In a study, patients who received varicella vaccine less than 28 days after MMR vaccination had an increased risk for varicella vaccine failure (i.e., varicella disease in a vaccinated person) of 2.5-fold compared with those who received varicella vaccine before or more than 28 days after MMR.(1)	ACAM2000 (NATIONAL STOCKPILE), BCG VACCINE (TICE STRAIN), DENGVAXIA, ERVEBO (NATIONAL STOCKPILE), STAMARIL, YF-VAX
Live Vaccines/Methotrexate (low strength injection, oral) SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: A variety of disease modifying agents such as methotrexate suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) CDC recommendations for zoster vaccine state it may be administered to patients receiving methotrexate if the dose is < or = to 0.4 mg/kg/week for treatment of rheumatoid arthritis, psoriasis, inflammatory bowel disease or other conditions.(1) For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)	METHOTREXATE, RASUVO, TREXALL, XATMEP
Tuberculin Testing/Live Vaccines SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Measles infection and severe acute and chronic infections may induce an anergic state resulting in a false-negative tuberculin test. The live measles vaccine, as well as other live vaccines (e.g. smallpox, varicella, yellow fever) theoretically may also suppress response to tuberculin testing, though the degree of suppression may be less than that expected from acute infection with wild-type virus.(1-4) CLINICAL EFFECTS: Tuberculin testing that is performed more than one day but less than 28 days after administration of a live vaccine may result in a false negative tuberculin response. Tuberculin testing may be administered simultaneously with live vaccines.(1-4) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The CDC states that live vaccines (e.g. MMR and varicella) and tuberculin testing may be administered within one day of each other at separate administration sites. If it has been more than one day since tuberculin testing has been administered, the live vaccine can be given at any interval after the tuberculin test. However, if the live vaccine has been administered more than one day previously and tuberculin testing is indicated, tuberculin testing should be deferred for at least 4-6 weeks.(1-4) DISCUSSION: Suppression of response to tuberculin testing has been observed following measles infection, live measles vaccination, and live smallpox vaccination. The degree of suppression after live virus vaccination is likely to be less than that from an acute infection with wild-type virus. There is no data on suppression of response to tuberculin testing with other live vaccines. In the absence of data, the CDC recommends tuberculin testing within one day that a live vaccine is administered. Otherwise the tuberculin test should be deferred for at least 4-6 weeks.(1-4)	APLISOL, TUBERSOL
Live Vaccines; Live BCG/Hydroxyurea SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Hydroxyurea may suppress the immune system.(1) Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(2) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(2) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(3) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies), treatments (e.g. radiation) and cytotoxic drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: Recommendations for administration of live vaccines in patients on hydroxyurea are dependent on the indication. The US manufacturers of hydroxyurea recommend avoiding live vaccine use in patients taking hydroxyurea. Evaluate hematologic status prior to and during treatment with hydroxyurea. Provide supportive care and modify the dose or discontinue hydroxyurea as needed.(1) The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician. Patients who are vaccinated within the 14 days prior to initiating immunosuppressive therapy should be considered unvaccinated and should be revaccinated at least 3 months after immunosuppressive therapy is discontinued.(2) The ACIP recommendations state that routine vaccinations patients with secondary immunodeficiency such as sickle cell disease are likely effective. Live viral and bacterial vaccines are contraindicated in patients with generalized malignant neoplasm, immunosuppressive, or radiation therapy, depending on immune status.(4) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(2) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(2) A multicenter, randomized, double-blind, placebo-controlled trial in infants and young children with sickle cell disease (BABY HUG) studied the response to pneumococcal and measles, mumps, and rubella vaccines in patients using hydroxyurea. The authors concluded that hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with sickle cell disease. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.(5)	DROXIA, HYDREA, HYDROXYUREA, SIKLOS, XROMI
Live Vaccines; Live BCG/Teplizumab SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Teplizumab may cause lymphopenia and suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(1,2) CLINICAL EFFECTS: The expected serum antibody response may not be obtained. The vaccine may result in illness.(1,2) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(3) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live-attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) Vaccination should ideally precede the initiation of teplizumab therapy by 8 weeks. Live vaccines are not recommended within the 8 weeks prior to, during, or for 52 weeks after stopping teplizumab therapy.(2) DISCUSSION: Vaccinations may be less effective if administered within 8 weeks before, during, and for 52 weeks following teplizumab therapy.(2) Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)	TZIELD
Live Vaccines/Leniolisib SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Leniolisib modifies the immune system. Immune response to live vaccines may be decreased during treatment with leniolisib.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained.(1) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The manufacturer of leniolisib states live, attenuated vaccinations may be less effective if administered during leniolisib treatment.(1) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)	JOENJA
Live Vaccines/Brensocatib SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Brensocatib may suppress the immune system by inhibiting dipeptidyl peptidase-1 (DPP-1). Brensocatib prevents the activation of neutrophil serine proteases (NSPs) during neutrophil maturation in the bone marrow.(1) Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(2) CLINICAL EFFECTS: The expected serum antibody response may not be obtained. The vaccine may result in illness. Immune response to live vaccines may be decreased during periods of immunocompromise.(2) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The coadministration of live vaccines and brensocatib should be avoided.(1) The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live-attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(2) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(2) The concomitant use of live attenuated vaccines and brensocatib has not been evaluated. Brensocatib may suppress the immune system by inhibiting dipeptidyl peptidase-1 (DPP-1).(1)	BRINSUPRI

There are 1 moderate interactions. The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.

Drug Interaction	Drug Names
Zoster Vaccine Live/Pneumococcal Vaccine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Concurrent administration of pneumococcal and zoster vaccines may decrease the immune response to the zoster vaccine. The mechanism is not clear.(1,2) CLINICAL EFFECTS: Concurrent administration of pneumococcal vaccine may decrease antibody titers and possibly the effectiveness of the zoster vaccine.(1,2) The safety profile of the vaccines is unaffected.(3) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The CDC states that to avoid potential barriers to vaccination posed by separation of vaccine administration, zoster and pneumovax vaccines may be administered during the same visit.(3,4) A large observational study did not find an increased risk for herpes zoster in patients who received pneumococcal and zoster vaccines on the same day compared with patients who received pneumococcal vaccine 30 to 265 days prior to zoster vaccine administration.(5) The US manufacturer of zoster vaccine states providers should consider separating administration of pneumococcal and zoster vaccines by 4 weeks.(1) DISCUSSION: In a manufacturer sponsored double-blind controlled trial, 473 adults who received concurrent administration of zoster and Pneumovax(r) had significantly lower varicella zoster virus antibody titers compared with individuals who had vaccine administration separated by 4 weeks. Based upon this trial result the manufacturer recommends consideration of a 4 week separation between zoster and pneumococcal vaccine administration.(1-2) A retrospective cohort study compared the incidence of herpes zoster in 7,187 patients who received pneumococcal and zoster vaccines on the same day with 7,179 patients who received pneumococcal vaccine 30 - 365 days prior to zoster vaccination. Patients were followed for up to 3.5 years. The estimated incidence of herpes zoster in the concomitant vaccination cohort was 4.54 per 1000 person-years, and in the nonconcomitant cohort was 4.51 per 1000 person-years. The hazard ratio for concomitant vaccination compared with noncomitant vaccination was 1.19 (95% CI, 0.81 - 1.74), not statistically significant.(5)	PNEUMOVAX 23

Drug Interaction

Drug Names

Zoster Vaccine Live/Pneumococcal Vaccine

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Concurrent administration of pneumococcal and zoster vaccines may decrease the immune response to the zoster vaccine. The mechanism is not clear.(1,2)

CLINICAL EFFECTS: Concurrent administration of pneumococcal vaccine may decrease antibody titers and possibly the effectiveness of the zoster vaccine.(1,2) The safety profile of the vaccines is unaffected.(3)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The CDC states that to avoid potential barriers to vaccination posed by separation of vaccine administration, zoster and pneumovax vaccines may be administered during the same visit.(3,4) A large observational study did not find an increased risk for herpes zoster in patients who received pneumococcal and zoster vaccines on the same day compared with patients who received pneumococcal vaccine 30 to 265 days prior to zoster vaccine administration.(5) The US manufacturer of zoster vaccine states providers should consider separating administration of pneumococcal and zoster vaccines by 4 weeks.(1)

DISCUSSION: In a manufacturer sponsored double-blind controlled trial, 473 adults who received concurrent administration of zoster and Pneumovax(r) had significantly lower varicella zoster virus antibody titers compared with individuals who had vaccine administration separated by 4 weeks. Based upon this trial result the manufacturer recommends consideration of a 4 week separation between zoster and pneumococcal vaccine administration.(1-2) A retrospective cohort study compared the incidence of herpes zoster in 7,187 patients who received pneumococcal and zoster vaccines on the same day with 7,179 patients who received pneumococcal vaccine 30 - 365 days prior to zoster vaccination.

Patients were followed for up to 3.5 years. The estimated incidence of herpes zoster in the concomitant vaccination cohort was 4.54

per 1000 person-years, and in the nonconcomitant cohort was 4.51 per 1000 person-years. The hazard ratio for concomitant vaccination compared with noncomitant vaccination was 1.19

(95% CI, 0.81 - 1.74), not statistically significant.(5)

PNEUMOVAX 23

The following contraindication information is available for VARIVAX VACCINE (varicella virus vaccine live/pf):

Overview
Contraindicated
Severe
Moderate

Drug contraindication overview.

*History of severe allergic reaction to any component of the varicella virus live vaccine (including neomycin and gelatin) or to a previous dose of varicella vaccine. *Immunosuppression. *Moderate or severe febrile illness (>38.5degreesC).

*Active untreated tuberculosis. *Individuals who are pregnant or who are planning on becoming pregnant within the next 3 months.

There are 10 contraindications. Absolute contraindication.

Contraindication List
HIV infection
Hodgkin's lymphoma
Immunosuppression
Leukemia
Malignant neoplasm of bone marrow
Multiple myeloma
Non-hodgkin's lymphoma
Pregnancy
Secondary malignant neoplasm of bone marrow
Untreated active tuberculosis

There are 0 severe contraindications.

There are 1 moderate contraindications. Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.

Moderate List
High fever >101 degrees fahrenheit

The following adverse reaction information is available for VARIVAX VACCINE (varicella virus vaccine live/pf):

Overview
Severe
Less Severe

Adverse reaction overview.

Common adverse effects reported in individuals 1-12 years of age receiving Varivax(R) included fever >=38.9degreesC (oral) and injection site complaints. Common adverse effects reported in individuals >=13 years of age receiving Varivax(R) included fever >=37.8degreesC

(oral) and injection site complaints. Common adverse effects reported in all individuals receiving Varivax(R) included varicella-like rash at the injection site and generalized varicella-like rash.

There are 30 severe adverse reactions.

More Frequent	Less Frequent
High fever >101 degrees fahrenheit	Arthralgia Fatigue Lymphadenopathy Skin rash

Rare/Very Rare
Acute retinal necrosis Anaphylaxis Angioedema Aplastic anemia Bell's palsy Cellulitis Dyspnea Encephalitis Erythema Erythema multiforme Guillain-barre syndrome Headache disorder IgA vasculitis Impetigo Interstitial pneumonitis Myalgia Myelitis Neck stiffness Nervousness Non-infective meningitis Pneumonia Seizure disorder Stevens-johnson syndrome Thrombocytopenic disorder Urticaria

There are 19 less severe adverse reactions.

More Frequent	Less Frequent
Acute bacterial otitis media Fever Injection site sequelae Rhinorrhea	Abdominal pain with cramps Anorexia Constipation Cough Diarrhea Eczema Irritability Malaise Nausea Pruritus of skin Upper respiratory infection Vomiting

Rare/Very Rare
Dizziness Paresthesia Pharyngitis

The following precautions are available for VARIVAX VACCINE (varicella virus vaccine live/pf):

Pediatric
Pregnant
Lactation
Geriatric

Safety and efficacy of varicella virus vaccine live (Varivax(R)) in pediatric patients younger than 12 months of age have not been established.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Varicella virus vaccine live is contraindicated in pregnant women; infection during pregnancy with the wild-type varicella virus has been associated with adverse outcomes, including congenital varicella syndrome.

It is not known whether varicella virus vaccine live is secreted in human milk. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for the varicella virus vaccine live and any potential adverse effects on the breast-fed child from the vaccine or from susceptibility to varicella.

Clinical studies of varicella virus vaccine live did not include sufficient numbers of seronegative adults 65 years of age and older to determine whether geriatric adults respond differently than younger individuals.