Drug Interactions between budesonide / formoterol and influenza virus vaccine, live

GENERALLY AVOID: The administration of live, attenuated virus or bacterial vaccines during corticosteroid therapy may be associated with a risk of disseminated infection due to enhanced replication of vaccine virus or bacteria in the presence of diminished immune competence. Patients may be immunosuppressed if they have recently received or are receiving high dosages of corticosteroids or adrenocorticotropic agents (e.g., greater than or equal to 2 mg/kg/day or 20 mg/day of prednisone or equivalent for 14 consecutive days or more), or long-term topical or inhaled corticosteroids. Such patients may also have increased adverse reactions and decreased or suboptimal immunologic response to vaccines. With respect to chronic corticosteroid inhalation therapy, a study was conducted to examine immune responsiveness to varicella vaccine in pediatric asthma patients ages 12 months to 8 years treated with budesonide inhalation suspension 0.25 mg to 1 mg daily. Compared to patients on noncorticosteroid asthma therapy, there was no significant difference in the percentage of budesonide patients who developed a seroprotective antibody titer following vaccination (85% vs. 90% for noncorticosteroid). In addition, no patient treated with budesonide inhalation suspension developed chicken pox as a result of vaccination.

MANAGEMENT: In general, live attenuated vaccines should not be used in patients receiving immunosuppressive corticosteroid therapy. Vaccination should be deferred until after such therapy is discontinued and immune function has been restored. The interval depends on the dosage and duration of corticosteroid therapy administered, but may be at least 3 months in most cases. Current local immunization guidelines should be consulted for recommendations. In patients who have recently been vaccinated, high-dose corticosteroid therapy should not be initiated for at least 2 weeks. Vaccines may generally be administered to patients receiving corticosteroids as replacement therapy (e.g., for Addison's disease).

Although they are often combined in clinical practice, the concomitant use of beta-2 adrenergic agonists and corticosteroids may result in additive hypokalemic effects. Since beta-2 agonists can sometimes cause QT interval prolongation, the development of hypokalemia may potentiate the risk of ventricular arrhythmias including torsade de pointes. However, clinical data are limited, and the potential significance is unknown. Patients who are receiving systemic or nebulized formulations of beta-2 agonists, high dosages of inhaled beta-2 agonists, or systemic corticosteroid therapy may be at a greater risk of developing hypokalemia.