(MEE zels, mumpz, roo BEL a, & var i SEL a VYE rus vak SEEN)
Measles, mumps, rubella, and varicella vaccination: To provide active immunization for the prevention of measles, mumps, rubella, and varicella in children 12 months to 12 years of age.
The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination against measles, mumps, rubella, and varicella in healthy children; the first dose should be given at 12 to 15 months of age and the second dose at 4 to 6 years of age. For children receiving their first dose at 12 to 47 months of age, either the MMRV combination vaccine or separate MMR and varicella vaccines can be used. The ACIP prefers administration of separate MMR and varicella vaccines as the first dose in this age group unless the parent or caregiver expresses preference for the MMRV combination. For children receiving the first dose at ≥48 months or their second dose at any age, use of MMRV is preferred. For children with a personal or family history of seizures, the ACIP recommends vaccination with separate MMR and varicella vaccines, as opposed to the MMRV combination vaccine (CDC/ACIP [Marin 2010]).
Canadian labeling (not in US labeling): MMRV combination vaccine is approved for use in healthy children (Priorix-Tetra: 9 months to 6 years; ProQuad: 12 months to 6 years); may consider use in healthy children ≤12 years of age based upon prior experience with the separate component (live-attenuated MMR or live-attenuated varicella [OKA-strain]) vaccines.
US labeling: Hypersensitivity to this vaccine, measles-, mumps-, rubella-, and/or varicella-containing vaccines, or any component of the formulation, including gelatin; history of anaphylactic reactions to neomycin; individuals with blood dyscrasias, leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic systems; those receiving immunosuppressive therapy (including high-dose systemic corticosteroids); primary and acquired immunodeficiency states (including AIDs or symptomatic HIV; cellular immune deficiencies; hypogammaglobulinemic and dysgammaglobulinemic states); family history of congenital or hereditary immunodeficiency (until immune competence in the vaccine recipient is demonstrated); active untreated tuberculosis; current febrile illness with fever >38.5 ‚ °C (>101.3 ‚ °F); pregnancy
Canadian labeling: Priorix-Tetra: Hypersensitivity to this vaccine, measles-, mumps-, rubella-, and/or varicella-containing vaccines, or any component of the formulation, including neomycin; pregnancy; severe humoral or cellular (primary or acquired) immunodeficiency.
Immunization:
US labeling: Children 12 months to 12 years: SubQ: One dose (0.5 mL). The first dose is usually administered at 12 to 15 months of age. If a second dose of measles, mumps, rubella, and varicella vaccine is needed, ProQuad can be used with the second dose usually administered at 4 to 6 years of age.
At least 1 month should elapse between a previous dose of a measles-containing vaccine (eg, MMR) and at least 3 months should elapse between a dose of varicella-containing vaccine.
ACIP recommendations: Administer the first dose at 12 to 15 months of age and the second dose at 4 to 6 years of age. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. For children receiving their first dose at 12 to 47 months of age, either the MMRV combination vaccine or separate MMR and varicella vaccines can be used. (The ACIP prefers administration of separate MMR and varicella vaccines as the first dose in this age group unless the parent or caregiver expresses preference for the MMRV combination.) For children receiving the first dose at ≥48 months or their second dose at any age, use of MMRV is preferred. The ACIP recommends that children with a personal or family history of seizures be vaccinated with separate MMR and varicella vaccines, as opposed to the MMRV combination vaccine (CDC/ACIP [Marin 2010]).
Canadian labeling:
Priorix-Tetra: SubQ or IM: Infants ≥9 months and Children ≤6 years: Two doses (0.5 mL each dose) administered at least 4 to 6 weeks apart (minimum interval between doses: 4 weeks)
ProQuad: SubQ: Children 12 months to 6 years: Two doses (0.5 mL each dose) administered at least 4 weeks apart
There are no dosage adjustments provided in the manufacturer 's labeling.
There are no dosage adjustments provided in the manufacturer 's labeling.
Use the total volume of the provided diluent to reconstitute vaccine. Gently agitate to dissolve powder. Use only sterile syringes that are free of preservatives, antiseptics, detergents, or other antiviral substances.
Disinfectants (eg, alcohol) may inactivate the attenuated viruses in the vaccine. Allow disinfectant adequate time to evaporate from skin prior to administration. To prevent syncope related injuries, adolescents and adults should be vaccinated while seated or lying down (NCIRD/ACIP 2011). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering persons name, title, and address be entered into the patient's permanent medical record.
US labeling: For SubQ injection only; inject in the outer aspect of the deltoid region of the upper arm or in the higher anterolateral area of the thigh.
Canadian labeling: For SubQ (ProQuad or Priorix-Tetra) or IM (Priorix-Tetra) injection only; inject in the deltoid region of upper arm. Do not administer by IM injection in patients with bleeding disorders.
Note: The Canadian labeling states that Priorix-Tetra (MMRV) may be given simultaneously (at different injection sites) with the combination vaccine Infanrix-hexa (contains diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio virus-Haemophilus influenzae type B [DTaP-HBV-IPV/Hib]) and with monovalent vaccines DTaP, Hib, IPV, HBV.
Powder for injection: Before reconstitution, store the lyophilized vaccine between -50 ‚ °C and -15 ‚ °C (-58 ‚ °F and 5 ‚ °F) in a reliably maintained freezer (eg, chest, frost-free) for up to 18 months. Use of dry ice may subject the vaccine to temperatures colder than -50 ‚ °C (-58 ‚ °F).
May store refrigerated at 2 ‚ °C to 8 ‚ °C (36 ‚ °F to 46 ‚ °F) for up to 72 hours prior to reconstitution. Discard any vaccine stored at 2 ‚ °C to 8 ‚ °C (36 ‚ °F to 46 ‚ °F) that is not used within 72 hours of removal from -15 ‚ °C (5 ‚ °F) storage.
Protect the vaccine from light at all times.
Canadian products:
ProQuad: During shipment, vaccine must be maintained at a temperature between -50 ‚ °C and +8 ‚ °C (-58 ‚ °F and 46 ‚ °F). Use of dry ice may subject the vaccine to temperatures colder than -50 ‚ °C. Before reconstitution, store refrigerated at a temperature of 2 ‚ °C to 8 ‚ °C (36 ‚ °F to 46 ‚ °F) or in a freezer at temperatures above -50 ‚ °C (-58 ‚ °F); if subsequently transferred to a refrigerator, the vaccine may be placed back in the freezer. May administered provided total (cumulative multiple excursions) time out of refrigeration (prior to reconstitution, at temperatures between 8 ‚ °C and 25 ‚ °C) does not exceed 14 hours. These are not, however, recommendations for storage. Protect the vaccine from light at all times.
Priorix-Tetra: Store refrigerated at 2 ‚ °C to 8 ‚ °C (36 ‚ °F to 46 ‚ °F). Do not freeze. Store in the original packaging in order to protect from light.
Reconstituted vaccine: Discard reconstituted vaccine if it is not used within 30 minutes. Do not freeze reconstituted vaccine. Protect from light at all times.
Canadian products:
ProQuad: Use as soon as possible after reconstitution. Discard if not used within 30 minutes. Store reconstituted vaccine in the vaccine vial in a dark place at room temperature. Do not freeze reconstituted vaccine.
Priorix-Tetra: Administer as soon as possible. May be refrigerated (2 ‚ °C to 8 ‚ °C; 36 ‚ °F to 46 ‚ °F) for up to 8 hours.
Diluent: Store diluent separately at room temperature (20 ‚ °C to 25 ‚ °C [68 ‚ °F to 77 ‚ °F]), or in a refrigerator (2 ‚ °C to 8 ‚ °C [36 ‚ °F to 46 ‚ °F]).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, powder for reconstitution [preservative free]:
ProQuad: Measles virus ≥3.00 log10 TCID50, mumps virus ≥4.3 log10 TCID50, rubella virus ≥3.00 log10 TCID50, and varicella virus ≥3.99 log10 PFU [contains albumin (human), bovine serum, chicken egg protein, gelatin, neomycin, sorbitol, and sucrose ( ≤21 mg/vial)]
ProQuad: Measles virus ≥3.00 log10 TCID50, mumps virus ≥4.3 log10 TCID50, rubella virus ≥3.00 log10 TCID50, and varicella virus ≥3.99 log10 PFU [contains recombinant albumin (human), bovine serum, chicken egg protein, gelatin, neomycin, sorbitol, and sucrose ( ≤21 mg/vial)]
Do not mix with other vaccines or injections. Separate needles and syringes should be used for each injection.
5-ASA Derivatives: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. The primary concern is the potential development of Reyes Syndrome, a condition that has been associated with the use of salicylates in children with varicella infections. Consider therapy modification
AzaTHIOprine: May enhance the adverse/toxic effect of Vaccines (Live). AzaTHIOprine may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose azathioprine (3 mg/kg/day or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns and is not a contraindication for administration of zoster vaccine. Higher doses of azathioprine should be avoided. Consider therapy modification
Belimumab: May enhance the adverse/toxic effect of Vaccines (Live). Avoid combination
Corticosteroids (Systemic): May enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided. Consider therapy modification
Daclizumab: May enhance the adverse/toxic effect of Vaccines (Live). Daclizumab may diminish the therapeutic effect of Vaccines (Live). Avoid combination
Dimethyl Fumarate: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, Dimethyl Fumarate may increase the risk of vaccinal infection. Dimethyl Fumarate may diminish the therapeutic effect of Vaccines (Live). Management: Canadian labeling for dimethyl fumarate states that live attenuated vaccine administration is not recommended during treatment. U.S. labeling does not mention this. Consider therapy modification
Fingolimod: May enhance the adverse/toxic effect of Vaccines (Live). Vaccinal infections may develop. Fingolimod may diminish the therapeutic effect of Vaccines (Live). Avoid combination
Immune Globulins: May diminish the therapeutic effect of Vaccines (Live). Management: Consult full interaction monograph for dose interval recommendations. This interaction does not apply to oral Ty21a typhoid vaccine or others listed as exceptions. Consider therapy modification
Immunosuppressants: May enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Exceptions: AzaTHIOprine; Beclomethasone (Oral Inhalation); Betamethasone (Systemic); Budesonide (Systemic); Corticotropin; Cortisone; Cytarabine (Liposomal); Deflazacort; Dexamethasone (Systemic); Fludrocortisone; Fluticasone (Oral Inhalation); Hydrocortisone (Systemic); Leflunomide; Mercaptopurine; Methotrexate; MethylPREDNISolone; PrednisoLONE (Systemic); PredniSONE; Triamcinolone (Systemic). Avoid combination
Leflunomide: May enhance the adverse/toxic effect of Vaccines (Live). Leflunomide may diminish the therapeutic effect of Vaccines (Live). Management: The ACIP guidelines state that live-attenuated vaccines should generally be avoided for at least 3 months after cessation of immunosuppressant therapy. However, the ACR does not recommend avoiding live vaccines in patients being treated with leflunomide. Consider therapy modification
Mercaptopurine: May enhance the adverse/toxic effect of Vaccines (Live). Mercaptopurine may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose 6-mercaptopurine (1.5 mg/kg/day or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns and is not a contraindication for administration of zoster vaccine. Higher doses of mercaptopurine should be avoided. Consider therapy modification
Methotrexate: May enhance the adverse/toxic effect of Vaccines (Live). Methotrexate may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose methotrexate (0.4 mg/kg/week or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns and is not a contraindication for administration of zoster vaccine. Higher doses of methotrexate should be avoided. Consider therapy modification
Salicylates: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. Reye's Syndrome may develop. Consider therapy modification
Tuberculin Tests: Vaccines (Live) may diminish the diagnostic effect of Tuberculin Tests. Management: If a parenteral live vaccine has been recently administered, a scheduled PPD skin test should not be administered for at least 4-6 weeks following the administration of the vaccine. Consider therapy modification
Venetoclax: May enhance the adverse/toxic effect of Vaccines (Live). Venetoclax may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live, attenuated vaccines before, during, or after (prior to B-cell recovery) venetoclax treatment. Avoid combination
Rash, fever; monitor for syncope for 15 minutes following administration (NCIRD/ACIP 2011). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
May interfere with sensitivity to tuberculin skin test; administer at separate sites before, simultaneously with, or at least 4 to 6 weeks after vaccine.
All serious adverse reactions must be reported to the US Department of Health and Human Services (DHHS) Vaccine Adverse Event Reporting System (VAERS) 1-800-822-7967 or online at https://vaers.hhs.gov/esub/index. In Canada, adverse reactions may be reported to local provincial/territorial health agencies or to the Vaccine Safety Section at Public Health Agency of Canada (1-866-844-0018).
Also refer to Measles, Mumps, and Rubella Vaccine (M-M-R II) and Varicella Virus Vaccine (Varivax) monographs for additional adverse reactions reported with those agents.
>10%:
Local: Pain at injection site (16% to 41%; pain, tenderness, soreness), erythema at injection site (11% to 24%), swelling at injection site (8% to 16%)
Miscellaneous: Fever (8% to 22%; ≥38.9 ‚ °C [ ≥102 ‚ °F])
1% to 10%:
Central nervous system: Irritability (2% to 7%), drowsiness (1%)
Dermatologic: Morbilliform rash ( ≤6%), rubella-like rash ( ≤4%), varicella-like rash ( ≤3%), rash at injection site (2%), skin rash ( ≤2%), vesicular eruption ( ≤2%), eczema (1%), pruritus (1%), viral exanthem (1%)
Gastrointestinal: Vomiting (1%), diarrhea ( ≤1%)
Local: Bleeding at injection site (1% to 2%), bruising at injection site ( ≤2%)
Respiratory: Upper respiratory tract infection (1% to 2%), rhinorrhea (1%), nasopharyngitis ( ≤1%)
<1% (Limited to important or life-threatening): Abdominal pain, abnormal dreams, acute disseminated encephalomyelitis, agitation, anaphylactoid reaction, anaphylaxis, angioneurotic edema, apathy, aplastic anemia, arthralgia, arthritis, aseptic meningitis, ataxia, atypical measles, Bells palsy, brain disease, bronchitis, bronchospasm, candidiasis, cellulitis, cerebrovascular accident, convulsions (including afebrile events), dizziness, encephalitis, epididymitis, epistaxis, erythema multiforme, extravasation, eyelid edema (in immunocompromised individuals), facial edema, febrile seizures, flatulence, Guillain-Barre syndrome, headache, hematochezia, herpes simplex infection, herpes zoster, hypersomnia, IgA vasculitis, impetigo, infection, inflammation, influenza, injection site reaction (burning and/or stinging of short duration, discoloration, eczema, edema/swelling, hematoma, hive-like rash, induration, lump, vesicles, wheal and flare), lip disease, lymphadenitis, lymphadenopathy (regional), measles, musculoskeletal pain, myalgia, necrotizing retinitis, nerve deafness, nervousness, oculomotor nerve paralysis, optic neuritis, optic papillitis, oral mucosa ulcer, orchitis, otalgia, pain (hip, leg, neck), panniculitis, paresthesia, parotitis, parotitis (disseminated), peripheral edema, pneumonia, polyneuropathy, pulmonary congestion, pulmonary infection, purpura, retinitis, retrobulbar neuritis, rhinitis, rough skin, sinusitis, skin infection, skin sclerosis, sneezing, sore throat, Stevens-Johnson syndrome, subacute sclerosing panencephalitis, sunburn, swelling, syncope, thrombocytopenia, transverse myelitis, trauma, tremor, varicella (vaccine strain), venipuncture site hemorrhage, viral infection (rubella vaccine), warm sensation at injection site, wheezing, xeroderma
Concerns related to adverse effects:
- Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (NCIRD/ACIP 2011).
- Febrile seizures: Children 12 to 23 months of age have been reported to have a higher risk of developing febrile seizures with the use of the combination product (MMRV) compared to administration of MMR and varicella separately. Because it is uncommon for a child to have their first febrile seizure after 4 years of age, the ACIP recommends the use of the combination MMRV vaccine for children receiving their first dose at ≥48 months or their second dose at any age. The ACIP recommends that children with a personal or family history of seizures be vaccinated with separate MMR and varicella vaccines, as opposed to the MMRV combination vaccine. For children receiving their first dose at 12 to 47 months of age, either the MMRV combination vaccine or separate MMR and varicella vaccines can be used. The ACIP prefers administration of separate MMR and varicella vaccines as the first dose in this age group unless the parent or caregiver expresses preference for the MMRV combination. Parents and caregivers should be provided with the benefits and risks of both options (CDC/ACIP [Marin 2010]).
- Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescents and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (NCIRD/ACIP 2011).
Disease-related concerns:
- Acute illness: The decision to administer or delay vaccination because of current or recent febrile illness depends on the severity of symptoms and the etiology of the disease. Consider deferring administration in patients with moderate or severe acute illness (with or without fever); vaccination should not be delayed for patients with mild acute illness (with or without fever) (NCIRD/ACIP 2011). Use is contraindicated with fever >38.5 ‚ °C (>101.3 ‚ °F).
- CNS disorders: Use with caution in patients with history of cerebral injury, seizures, or other conditions where stress due to fever should be avoided. Children with a personal or family history of seizures should be vaccinated with separate MMR and varicella vaccines, as opposed to the MMRV combination vaccine (CDC/ACIP [Marin 2010]).
- HIV: Safety and efficacy of this combination vaccine have not been established in patients with HIV infection. Use is contraindicated in patients with AIDS or symptomatic HIV.
- Thrombocytopenia: Use with caution in patients with thrombocytopenia and those who develop thrombocytopenia after first dose; thrombocytopenia may worsen.
- Tuberculosis: Defer vaccination in patients with active untreated tuberculosis. Use is contraindicated in patients with active untreated tuberculosis.
Concurrent drug therapy issues:
- Immune globulins: Recent administration of immune globulins may interfere with immune response. Guidelines with suggested administration intervals are available (NCIRD/ACIP 2011).
- Salicylates: Avoid use of salicylates for 6 weeks following vaccination; varicella may increase the risk of Reyes syndrome.
- Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or inactivated) for which a person is eligible at a single clinic visit, unless contraindications exist. The use of combination vaccines is generally preferred over separate injections, taking into consideration provider assessment, patient preference, and potential adverse events. When using combination vaccines, the minimum age for administration is the oldest minimum age for any individual component; the minimum interval between dosing is the greatest minimum interval between any individual components. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible (NCIRD/ACIP 2011).
Special populations:
- Altered immunocompetence: Use is contraindicated in patients with immunosuppression, including those receiving immunosuppressive therapy (including high-dose systemic corticosteroids). In general, live vaccines should be administered ≥4 weeks prior to planned immunosuppression and avoided within 2 weeks of immunosuppression when feasible (IDSA [Rubin 2014]).
Dosage form specific issues:
- Albumin: Some products may contain albumin; products containing human albumin may carry a remote risk of viral transmission, including a theoretical risk of Creutzfeldt-Jakob disease transmission.
- Egg allergy: Vaccine contains trace amounts of chick embryo antigen. Use caution in patients with history of immediate hypersensitivity/anaphylactic reactions following egg ingestion. Generally, the vaccine can be safely administered to persons with an egg allergy (NCIRD/ACIP 2011).
- Gelatin: Some products may contain gelatin. Use is contraindicated in patients with a history of anaphylactic/anaphylactoid reaction to gelatin.
- Neomycin: Manufactured with neomycin. Use is contraindicated in patients with history of anaphylactic/anaphylactoid reactions to neomycin. Contact dermatitis due to neomycin is not a contraindication to the vaccine.
Other warnings/precautions:
- Antipyretics: Antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (NCIRD/ACIP 2011). One study reported that routine prophylactic administration of acetaminophen to prevent fever prior to vaccination decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).
- Appropriate use: The safety and efficacy of this combination vaccine has not been established for postexposure prophylaxis.
- Blood products: Recent administration of blood or blood products may interfere with immune response. Guidelines with suggested administration intervals are available (NCIRD/ACIP 2011).
- Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (NCIRD/ACIP 2011).
- Transmission of virus: Vaccinated individuals should not have close association with susceptible high-risk individuals for 6 weeks following vaccination. High-risk individuals susceptible to the varicella virus include immunocompromised persons, pregnant women without evidence of immunity to varicella, newborns of mothers without evidence of varicella immunity, and infants born <28 weeks' gestation (regardless of maternal immunity); transmission of varicella virus may occur.
Animal reproduction studies have not been conducted. Use is contraindicated in pregnant females and pregnancy should be avoided for 3 months (per manufacturer labeling) following vaccination. The ACIP and manufacturer of Priorix-Tetra (Canadian product) recommends that pregnancy should be avoided for 1 month following vaccination with any of the individual components of this vaccine.
Any exposures to the vaccine during pregnancy or within 3 months prior to pregnancy should be reported to the manufacturer (Merck & Co, 877-888-4231) or to VAERS (800-822-7967) as suspected adverse reactions.
Refer to the Varicella Virus Vaccine monograph and the Measles, Mumps, and Rubella Virus Vaccine monograph for additional information.
A live, attenuated virus vaccine that induces active immunity to disease caused by the measles, mumps, rubella, and varicella-zoster viruses.
At 6 weeks postvaccination of a single dose, the antibody response rate in healthy children 12 to 23 months of age was ~91% to 99%. Following a second dose to children <3 years of age, the observed antibody response rate was ~98% to 99%.
Antibody levels persist 10 years or longer in most healthy recipients. Refer to the Varicella Virus Vaccine monograph and the Measles, Mumps, and Rubella Virus Vaccine monograph for details.
- Discuss specific use of vaccine and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience injection site pain or irritation (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.