We premedicate with acetaminophen and/or ibuprofen prior to TVEC if not contraindicated. I recommend the patient continue this for the first 24-48 hours if feeling flu-like. I think it helps based on patient reports of how they feel when they forget to take it. There also seems to be great variability in degree of side effects among patients. Anecdotally, I have seen fewer side effects in elderly patients (similar to ICI’s), presumably due to a less robust immune system. If a patient has nausea, I will also premedicate with antiemetics.