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CLINICAL PHARMACOLOGY Mechanism Of Action Influenza illness and its complications follow infection with influenza viruses. Global surveillance of influenza identifies yearly antigenic variants. For example, since 1977, antigenic variants of influenza A (H1N1 and H3N2) viruses and influenza B viruses have been in global circulation. Specific levels of hemagglutination inhibition (HI) antibody titer post-vaccination with inactivated influenza virus vaccines have not been correlated with protection from influenza virus infection. In some human studies, antibody titers ≥ 1:40 have been associated with protection from influenza illness in up to 50% of participants. (See references 3 and 4.) Antibodies against one influenza virus type or subtype confer limited or no protection against another. Furthermore, antibodies to one antigenic variant of influenza virus might not protect against a new antigenic variant of the same type or subtype. Frequent development of antigenic variants through antigenic drift is the virologic basis for seasonal epidemics and the reason for the usual change of one or more new strains in each year's influenza vaccine. Therefore, influenza vaccines are standardized to contain the hemagglutinins of influenza virus strains representing the influenza viruses likely to be circulating in the US during the influenza season. Annual vaccination with the current vaccine is recommended because immunity during the year after vaccination declines and because circulating strains of influenza virus change from year to year. Clinical Studies Immunogenicity Of Fluzone High-Dose In Adults 65 Years Of Age And Older Study 1 (NCT00391053) was a multi-center, double-blind pre-licensure trial conducted in the US in which adults 65 years of age and older were randomized to receive either Fluzone High-Dose or Fluzone (2006-2007 formulation). The study compared the safety and immunogenicity of Fluzone High-Dose to those of Fluzone. For immunogenicity analyses, 2576 participants were randomized to Fluzone High-Dose and 1275 participants were randomized to Fluzone. Females accounted for 51.3% of participants in the Fluzone High-Dose group and 54.7% of participants in the Fluzone group. In both groups, the mean age was 72.9 years (ranged from 65 through 97 years in the Fluzone High-Dose group and 65 through 94 years in the Fluzone group); 35% of participants in the Fluzone High-Dose group and 36% of participants in the Fluzone group were 75 years of age or older. Most participants in the Fluzone High-Dose and Fluzone groups, respectively, were White (91.7% and 92.9%), followed by Hispanic (4.8% and 3.7%), and Black (2.7% and 2.7%). The primary endpoints of the study were HI GMTs and seroconversion rates 28 days after vaccination. Pre-specified statistical superiority criteria required that the lower limit (LL) of the 2-sided 95% CI of the GMT ratio (Fluzone High-Dose/Fluzone) be greater than 1.50 for at least two of the strains, and if one strain failed, non-inferiority of that strain must be demonstrated (LL > 0.67), and that the lower limit of the 2-sided 95% CI of the seroconversion rate difference (Fluzone High-Dose minus Fluzone) be greater than 10% for at least two of the strains, and if one strain failed, non-inferiority of that strain must be demonstrated (LL > -10%). As shown in Table 3, statistically superior HI GMTs and seroconversion rates after vaccination with Fluzone High-Dose compared to Fluzone were demonstrated for influenza A subtypes, A (H1N1) and A (H3N2), but not for influenza type B. For strain B, non-inferiority of Fluzone High-Dose compared to Fluzone was demonstrated for both the HI GMTs and seroconversion rates. Table 3: Study 1a: Post-Vaccination HI Antibody GMTs and Seroconversion Rates and Analyses of Superiority of Fluzone High-Dose Relative to Fluzone, Adults 65 Years of Age and Older Influenza Strain GMT GMT Ratio Seroconversion %b Difference Met Both Pre-defined Superiority Criteriad Fluzone High- Dose Nc=2542- 2544 Fluzone Nc=1252 Fluzone High-Dose over Fluzone (95% CI) Fluzone High-Dose Nc=2529- 2531 Fluzone Nc=1248- 1249 Fluzone High-Dose minus Fluzone (95% CI) A (H1N1) 115.8 67.3 1.7 (1.6; 1.8) 48.6 23.1 25.4 (22.4; 28.5) Yes A (H3N2) 608.9 332.5 1.8 (1.7; 2.0) 69.1 50.7 18.4 (15.1; 21.7) Yes B 69.1 52.3 1.3 (1.2; 1.4) 41.8 29.9 11.8 (8.6; 15.0) No a NCT00391053 b Seroconversion: Paired samples with pre-vaccination HI titer < 1:10 and post-vaccination (day 28) titer ≥ 1:40 or a minimum 4-fold increase for participants with pre-vaccination titer ≥ 1:10 c N is the number of vaccinated participants with available data for the immunologic endpoint listed d Predefined superiority criterion for seroconversion: the lower limit of the two-sided 95% CI of the difference of the seroconversion rates (Fluzone High-Dose minus Fluzone) is > 10%. Predefined superiority criterion for the GMT ratio: the lower limit of the 95% CI of the GMT ratio (Fluzone High-Dose divided by Fluzone) is > 1.5 Efficacy Of Fluzone High-Dose In Adults 65 Years Of Age And Older Study 2 (NCT01427309) was a multi-center, double-blind post-licensure efficacy trial conducted in the US and Canada in which adults 65 years of age and older were randomized (1:1) to receive either Fluzone High-Dose or Fluzone. The study was conducted over two influenza seasons (2011-2012 and 2012-2013); 53% of participants enrolled in the first year of the study were re-enrolled and re-randomized in the second year. The per-protocol analysis set for efficacy assessments included 15,892 Fluzone High-Dose recipients and 15,911 Fluzone recipients. The majority (67%) of participants in the perprotocol analysis set for efficacy had one or more high-risk chronic comorbid conditions. In the per-protocol analysis set, females accounted for 57.2% of participants in the Fluzone High-Dose group and 56.1% of participants in the Fluzone group. In both groups, the median age was 72.2 years (range 65 through 100 years). Overall, most participants in the study were White (95%); approximately 4% of study participants were Black, and approximately 6% reported Hispanic ethnicity. The primary endpoint of the study was the occurrence of laboratory-confirmed influenza (as determined by culture or polymerase chain reaction) caused by any influenza viral type/ subtype in association with influenza-like illness (ILI), defined as the occurrence of at least one of the following respiratory symptoms: sore throat, cough, sputum production, wheezing, or difficulty breathing; concurrent with at least one of the following systemic signs or symptoms: temperature > 99.0°F, chills, tiredness, headaches or myalgia. Participants were monitored for the occurrence of a respiratory illness by both active and passive surveillance, starting 2 weeks post-vaccination for approximately 7 months. After an episode of respiratory illness, nasopharyngeal swab samples were collected for analysis; attack rates and vaccine efficacy were calculated (see Table 4). Table 4: Study 2a: Relative Efficacy Against Laboratory-Confirmed Influenzab Regardless of Similarity to the Vaccine Components, Associated with Influenza-Like Illnessc, Adults 65 Years of Age and Older Fluzone High-Dose Nd=15,892 ne (%) Fluzone Nd=15,911 ne (%) Relative Efficacy % (95% CI) Any type/ subtypef 227 (1.43) 300 (1.89) 24.2 (9.7; 36.5)g Influenza A 190 (1.20) 249 (1.56) 23.6 (7.4; 37.1) A (H1N1) 8 (0.05) 9 (0.06) 11.0 (-159.9; 70.1) A (H3N2) 171 (1.08) 222 (1.40) 22.9 (5.4; 37.2) Influenza Bh 37 (0.23) 51 (0.32) 27.4 (-13.1; 53.8) a NCT01427309 b Laboratory-confirmed: culture- or polymerase-chain-reaction-confirmed c Occurrence of at least one of the following respiratory symptoms: sore throat, cough, sputum production, wheezing, or difficulty breathing; concurrent with at least one of the following systemic signs or symptoms: temperature > 99.0°F, chills, tiredness, headaches or myalgia d N is the number of vaccinated participants in the per-protocol analysis set for efficacy assessments e n is the number of participants with protocol-defined influenza-like illness with laboratory confirmation f Primary endpoint g The pre-specified statistical superiority criterion for the primary endpoint (lower limit of the 2-sided 95% CI of the vaccine efficacy of Fluzone High-Dose relative to Fluzone > 9.1%) was met. h In the first year of the study the influenza B component of the vaccine and the majority of influenza B cases were of the Victoria lineage; in the second year the influenza B component of the vaccine and the majority of influenza B cases were of the Yamagata lineage A secondary endpoint of the study was the occurrence of culture-confirmed influenza caused by viral types/subtypes antigenically similar to those contained in the respective annual vaccine formulations in association with a modified CDC-defined ILI, defined as the occurrence of a temperature > 99.0°F ( > 37.2°C) with cough or sore throat. The efficacy of Fluzone High-Dose relative to Fluzone for this endpoint was 51.1% (95% CI: 16.8; 72.0). REFERENCES 3 Hannoun C, Megas F, Piercy J. Immunogenicity and protective efficacy of influenza vaccination. Virus Res 2004;103:133-138. 4 Hobson D, Curry RL, Beare AS, Ward-Gardner A. The role of serum haemagglutination-inhibiting antibody in protection against challenge infection with influenza A2 and B viruses. J Hyg Camb 1972;70:767-777.

Fluzone High-Dose (Influenza Vaccine) for Intramuscular Injection DESCRIPTION Fluzone High-Dose (Influenza Vaccine) for intramuscular injection is an inactivated influenza vaccine, prepared from influenza viruses propagated in embryonated chicken eggs. The virus-containing allantoic fluid is harvested and inactivated with formaldehyde. Influenza virus is concentrated and purified in a linear sucrose density gradient solution using a continuous flow centrifuge. The virus is then chemically disrupted using a non-ionic surfactant, octylphenol ethoxylate (Triton® X-100), producing a “split virus”. The split virus is further purified and then suspended in sodium phosphate-buffered isotonic sodium chloride solution. The Fluzone High-Dose process uses an additional concentration factor after the ultrafiltration step in order to obtain a higher hemagglutinin (HA) antigen concentration. Fluzone High-Dose suspension for injection is clear and slightly opalescent in color. Neither antibiotics nor preservative are used in the manufacture of Fluzone High-Dose. The Fluzone High-Dose prefilled syringe presentation is not made with natural rubber latex. Fluzone High-Dose is standardized according to United States Public Health Service requirements and is formulated to contain HA of each of the following three influenza strains recommended for the 2016-2017 influenza season: A/California/07/2009 X-179A (H1N1), A/Hong Kong/4801/2014 X-263-B(H3N2), and B/Brisbane/60/2008(B Victoria lineage). The amounts of HA and other ingredients per dose of vaccine are listed in Table 2. Table 2: Fluzone High-Dose Ingredients Ingredient Quantity (per dose) Fluzone High-Dose 0.5 mL Dose Active Substance: Split influenza virus,inactivated strainsa: 180 mcg HA total A (H1N1) 60 mcg HA A (H3N2) 60 mcg HA B 60 mcg HA Other: Sodium phosphate-buffered isotonic sodium chloride solution QSb to appropriate volume Formaldehyde ≤ 100 mcg Octylphenol ethoxylate ≤ 250 mcg Gelatin None Preservative None a per United States Public Health Service (USPHS) requirement b Quantity Sufficient

INDICATIONS Fluzone® High-Dose is a vaccine indicated for active immunization for the prevention of influenza disease caused by influenza A subtype viruses and type B virus contained in the vaccine. Fluzone High-Dose is approved for use in persons 65 years of age and older. DOSAGE AND ADMINISTRATION For intramuscular use only Dose And Schedule Fluzone High-Dose should be administered as a single 0.5 mL injection by the intramuscular route in adults 65 years of age and older. Administration Inspect Fluzone High-Dose visually for particulate matter and/or discoloration prior to administration. If either of these conditions exist, the vaccine should not be administered. Before administering a dose of vaccine, shake the prefilled syringe. The preferred site for intramuscular injection is the deltoid muscle. The vaccine should not be injected into the gluteal area or areas where there may be a major nerve trunk. Do not administer this product intravenously or subcutaneously. Fluzone High-Dose should not be combined through reconstitution or mixed with any other vaccine. HOW SUPPLIED Single-dose, prefilled syringe, without needle, 0.5 mL (NDC 49281-399-88) (not made with natural rubber latex). Supplied as package of 10 (NDC 49281-399-65). Storage And Handling Store Fluzone High-Dose refrigerated at 2° to 8°C (35° to 46°F). DO NOT FREEZE. Discard if vaccine has been frozen. Do not use after the expiration date shown on the label. Manufactured by: Sanofi Pasteur Inc., Swiftwater PA 18370 USA

PATIENT INFORMATION No information provided. Please refer to the WARNINGS AND PRECAUTIONS sections.

OVERDOSE No information provided. CONTRAINDICATIONS A severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine [see DESCRIPTION], including egg protein, or to a previous dose of any influenza vaccine is a contraindication to administration of Fluzone High-Dose.

SIDE EFFECTS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse event rates observed in the clinical trial(s) of a vaccine cannot be directly compared to rates in the clinical trial(s) of another vaccine and may not reflect the rates observed in practice. Two clinical studies have evaluated the safety of Fluzone High-Dose. Study 1 (NCT00391053, see http://clinicaltrials.gov) was a multi-center, double-blind pre-licensure trial conducted in the US. In this study, adults 65 years of age and older were randomized to receive either Fluzone High-Dose or Fluzone (2006-2007 formulation). The study compared the safety and immunogenicity of Fluzone High-Dose to those of Fluzone. The safety analysis set included 2573 Fluzone High-Dose recipients and 1260 Fluzone recipients. Table 1 summarizes solicited injection-site reactions and systemic adverse events reported within 7 days post-vaccination via diary cards. Onset was usually within the first 3 days after vaccination and a majority of the reactions resolved within 3 days. Solicited injection-site reactions and systemic adverse events were more frequent after vaccination with Fluzone High-Dose compared to Fluzone. Table 1: Study 1a: Frequency of Solicited Injection-Site Reactions and Systemic Adverse Events Within 7 Days After Vaccination with Fluzone High-Dose or Fluzone, Adults 65 Years of Age and Older Fluzone High-Dose (Nb=2569-2572) Percentage Fluzone (Nb=1258-1260) Percentage Any Moderatec Severed Any Moderatec Severed Injection-Site Pain 35.6 3.7 0.3 24.3 1.7 0.2 Injection-Site Erythema 14.9 1.9 1.8 10.8 0.8 0.6 Injection-Site Swelling 8.9 1.6 1.5 5.8 1.3 0.6 Myalgia 21.4 4.2 1.6 18.3 3.2 0.2 Malaise 18.0 4.7 1.6 14.0 3.7 0.6 Headache 16.8 3.1 1.1 14.4 2.5 0.3 Fevere( ≥ 99.5°F) 3.6 1.1 0.0 2.3 0.2 0.1 a NCT00391053 b N is the number of vaccinated participants with available data for the events listed c Moderate - Injection-site pain: sufficiently discomforting to interfere with normal behavior or activities; Injection-site erythema and Injection-site swelling: ≥ 2.5 cm to < 5 cm; Fever: > 100.4°F to ≤ 102.2°F; Myalgia, Malaise, and Headache: interferes with daily activities d Severe - Injection-site pain: incapacitating, unable to perform usual activities; Injectionsite erythema and Injection-site swelling: ≥ 5 cm; Fever: > 102.2°F; Myalgia, Malaise, and Headache: prevents daily activities e Fever - The percentage of temperature measurements that were taken by oral route or not recorded were 97.9% and 2.1%, respectively, for Fluzone High-Dose; and 98.6% and 1.4%, respectively, for Fluzone Within 6 months post-vaccination, 156 (6.1%) Fluzone High-Dose recipients and 93 (7.4%) Fluzone recipients experienced a serious adverse event (SAE). No deaths were reported within 28 days post-vaccination. A total of 23 deaths were reported during Days 29 - 180 post-vaccination: 16 (0.6%) among Fluzone High-Dose recipients and 7 (0.6%) among Fluzone recipients. The majority of these participants had a medical history of cardiac, hepatic, neoplastic, renal, and/or respiratory diseases. These data do not provide evidence for a causal relationship between deaths and vaccination with Fluzone High-Dose. Study 2 (NCT01427309, see http://clinicaltrials.gov) was a multi-center, double-blind postlicensure efficacy trial conducted in the US and Canada over two influenza seasons. In this study, adults 65 years of age and older were randomized to receive either Fluzone High- Dose or Fluzone (2011-2012 and 2012-2013 formulations). The study compared the efficacy and safety of Fluzone High-Dose to those of Fluzone. The safety analysis set included 15,992 Fluzone High-Dose recipients and 15,991 Fluzone recipients. Within the study surveillance period (approximately 6 to 8 months post-vaccination), 1323 (8.3%) Fluzone High-Dose recipients and 1442 (9.0%) Fluzone recipients experienced an SAE. Within 30 days post-vaccination, 204 (1.3%) Fluzone High-Dose recipients and 200 (1.3%) Fluzone recipients experienced an SAE. The majority of these participants had one or more chronic comorbid illnesses. A total of 167 deaths were reported within 6 to 8 months post-vaccination: 83 (0.5%) among Fluzone High-Dose recipients and 84 (0.5%) among Fluzone recipients. A total of 6 deaths were reported within 30 days post-vaccination: 6 (0.04%) among Fluzone High-Dose recipients and 0 (0 %) among Fluzone recipients. These data do not provide evidence for a causal relationship between deaths and vaccination with Fluzone High-Dose. Post-Marketing Experience The following events have been spontaneously reported during the post-approval use of Fluzone or Fluzone High-Dose. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to vaccine exposure. Adverse events were included based on one or more of the following factors: severity, frequency of reporting, or strength of evidence for a causal relationship to Fluzone or Fluzone High-Dose. Events Reported During Post-Approval Use of Fluzone Blood and Lymphatic System Disorders: Thrombocytopenia, lymphadenopathy Immune System Disorders: Anaphylaxis, other allergic/hypersensitivity reactions (including urticaria, angioedema) Eye Disorders: Ocular hyperemia Nervous System Disorders: Guillain-Barré syndrome (GBS), convulsions, febrile convulsions, myelitis (including encephalomyelitis and transverse myelitis), facial palsy (Bell's palsy), optic neuritis/neuropathy, brachial neuritis, syncope (shortly after vaccination), dizziness, paresthesia Vascular Disorders: Vasculitis, vasodilatation/flushing Respiratory, Thoracic and Mediastinal Disorders: Dyspnea, pharyngitis, rhinitis, cough, wheezing, throat tightness Skin and Subcutaneous Tissue Disorders: Stevens-Johnson syndrome General Disorders and Administration Site Conditions: Pruritus, asthenia/fatigue, pain in extremities, chest pain Gastrointestinal Disorders: Vomiting Other Events Reported During Post-Approval Use of Fluzone High-Dose. Gastrointestinal Disorders: Nausea, diarrhea General Disorders and Administration Site Conditions: Chills DRUG INTERACTIONS Data evaluating the concomitant administration of Fluzone High-Dose with other vaccines are not available.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Guillain-Barré Syndrome If Guillain-Barré syndrome (GBS) has occurred within 6 weeks following previous influenza vaccination, the decision to give Fluzone High-Dose should be based on careful consideration of the potential benefits and risks. The 1976 swine influenza vaccine was associated with an elevated risk of GBS. Evidence for a causal relation of GBS with other influenza vaccines is inconclusive; if an excess risk exists, it is probably slightly more than 1 additional case per 1 million persons vaccinated. (See references 1 and 2.) Preventing And Managing Allergic Reactions Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of the vaccine. Altered Immunocompetence If Fluzone High-Dose is administered to immunocompromised persons, including those receiving immunosuppressive therapy, the expected immune response may not be obtained. Limitations Of Vaccine Effectiveness Vaccination with Fluzone High-Dose may not protect all recipients. Patient Counseling Information See FDA-approved patient labeling (PATIENT INFORMATION). Inform the patient or caregiver that Fluzone High-Dose contains killed viruses and cannot cause influenza. Among persons aged 65 years and older, Fluzone High-Dose stimulates the immune system to produce antibodies that help protect against influenza. Among persons aged 65 years and older, Fluzone High-Dose offers better protection against influenza as compared to Fluzone. Annual influenza vaccination is recommended. Instruct vaccine recipients and caregivers to report adverse reactions to their healthcare provider and/or to Vaccine Adverse Event Reporting System (VAERS). Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Fluzone High-Dose has not been evaluated for carcinogenic or mutagenic potential or for impairment of fertility. Use In Specific Populations Pregnancy Pregnancy Category C: Animal reproduction studies have not been conducted with Fluzone High-Dose. It is also not known whether Fluzone High-Dose can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Fluzone High-Dose should be given to a pregnant woman only if clearly needed. Pediatric Use Safety and effectiveness of Fluzone High-Dose in persons < 65 years of age have not been established. Geriatric Use Safety, immunogenicity, and efficacy of Fluzone High-Dose have been evaluated in adults 65 years of age and older. [See ADVERSE REACTIONS and Clinical Studies] REFERENCES 1 Lasky T, Terracciano GJ, Magder L, et al. The Guillain-Barré syndrome and the 1992- 1993 and 1993-1994 influenza vaccines. N Engl J Med 1998;339:1797-802. 2 Baxter, R, et al. Lack of Association of Guillain-Barré Syndrome with Vaccinations. Clin Infect Dis 2013;57(2):197-204.