Viramune (Nevirapine)

What Viramune is and what it is used for

Viramune belongs to a group of medicines called antiretrovirals, used in the treatment of Human Immunodeficiency Virus (HIV-1) infection.

The active ingredient of your medicine is called nevi rapine. The active ingredient is the substance in this medicine that reduces the amount of viruses in the blood thus improving your medical condition. Nevi rapine belongs to a class of anti-HIV medicines called non-nucleoside reverse transcriptase inhibitors (NNRTIs). Reverse transcriptase is an enzyme that HIV needs in order to multiply. Nevi rapine stops reverse transcriptase from working. By stopping reverse transcriptase from working, Viramune helps control HIV-1 infection.

You must take Viramune together with other antiretroviral medicines. Your doctor will recommend the best medicines for you.

Before you take Viramune

Do not take Viramune

• if you are allergic (hypersensitive) to nevi rapine or any of the other ingredients of VIRAMUNE. See Section 6 of this leaflet for a list of other ingredients
• if you have taken Viramune before and had to stop the treatment because you suffered from:
• severe skin rash
• skin rash with other symptoms for example:
• fever
• blistering
• mouth sores
• inflammation of the eye
• swelling of the face
• general swelling
• shortness of breath
• muscle or joint pain
• general feelings of illness
• abdominal pain
• hypersensitivity (allergic) reactions
• inflammation of the liver (hepatitis)
• if you have severe liver disease
• if you have had to stop Viramune treatment in the past because of changes in your liver function
• if you are taking a medicine containing the herbal substance St John’s Wort (Hypericum perforatum). This herbal substance may stop Viramune from working properly.

Take special care with Viramune During the first 18 weeks of treatment with Viramune it is very important that you and your doctor watch out for signs of liver or skin reactions. These can become severe and even life threatening. You are at greatest risk of such a reaction during the first 6 weeks of treatment.

If you experience severe rash or hypersensitivity (allergic reactions that may appear in the form of rash) accompanied by other side effects such as

• fever,
• blistering,
• mouth sores,
• inflammation of the eye,
• swelling of the face,
• general swelling,
• shortness of breath,
• muscle or joint pain,
• general feelings of illness,
• or abdominal pain

You should discontinue taking Viramune and you must contact your doctor immediately as such reactions can be potentially life-threatening or lead to death. If you ever have only mild rash symptoms without any other reaction please inform your doctor immediately, who will advise you whether you should stop taking viramune.

If you experience symptoms suggesting damage of the liver, such as

• loss of appetite,
• feeling sick (nausea),
• vomiting,
• yellow skin (jaundice),
• abdominal pain

you should discontinue taking Viramune and must contact your doctor immediately.

If you develop severe liver, skin or hypersensitivity reactions whilst taking Viramune, Never take Viramune again without referring to your doctor. You must take the dosage of Viramune as prescribed by your doctor. This is especially important within the first 14 days of treatment.

The following patients are at increased risk of developing liver problems:

• women
• infected with hepatitis B or C
• abnormal liver function tests
• treatment-naive patients with higher CD4 cell counts at the start of Viramune therapy (women more than 250 cells/mm³, men more than 400 cells/mm³)
• pre-treated patients with detectable HIV-1 plasma viral load and higher CD4 cell counts at the start of Viramune therapy (women more than 250 cells/mm³, men more than 400 cells/mm³)

In some patients with advanced HIV infection (AIDS) and a history of opportunistic infection (AIDS defining illness), signs and symptoms of inflammation from previous infections may occur soon after anti-HIV treatment is started. It is believed that these symptoms are due to an improvement in the body’s immune response, enabling the body to fight infections that may have been present with no obvious symptoms. If you notice any symptoms of infection, please inform your doctor immediately.

Changes of body fat may occur in patients receiving combination antiretroviral therapy. Contact your doctor if you notice changes in body fat.

Some patients taking combination antiretroviral therapy may develop a bone disease called osteonecrosis (death of bone tissue caused by loss of blood supply to the bone). The length of combination antiretroviral therapy, corticosteroid use, alcohol consumption, severe weakness of the immune system and higher body mass index may be some of the many risk factors for developing this disease. Signs of osteonecrosis are joint stiffness, aches and pains (especially of the hip, knee and shoulder) and difficulty in movement. If you notice any of these symptoms please inform your doctor.

Viramune is not a cure for HIV infection. Therefore, you may continue to develop infections and other illnesses associated with HIV infection. You should therefore remain in regular contact with your doctor. In addition, Viramune does not prevent the risk of passing on HIV to others through blood or sexual contact. Use appropriate precautions to prevent passing on HIV to other people. Please refer to your doctor.

Use in children

Viramune tablets can be taken by:

• children 16years of age or older
• children under 16 years of age who: -weigh 50 kg or more
• or have a body surface area above 1.25 square metres.

For smaller children an oral suspension liquid form is available.

Taking other medicines

Please tell your doctor or pharmacist if you are taking or m have recently taken any other medicines, including

medicines obtained without a prescription. Inform your g doctor about all other medicines you are taking before  you start taking Viramune. Your doctor might need to monitor whether your other medicines are still working and adjust doses. Carefully read the package leaflet of all other HIV medicinal products you are taking in combination with Viramune.

It is particularly important that you tell your doctor if you are taking or have recently taken:

• St John’s Wort (Hypericum perforatum, medicine to treat depression)
• rifampicin (medicine to treat tuberculosis)
• rifabutin (medicine to treat tuberculosis)
• macrolides e.g. clarithromycin (medicine to treat bacterial infections)
• fluconazole (medicine to treat fungal infections)
• ketoconazole (medicine to treat fungal infections)
• itraconazole (medicine to treat fungal infections)
• methadone (medicine used for treatment of opiate addicts)
• warfarin (medicine to reduce blood clotting)
• hormonal contraceptives (e.g. the “pill”)
• atazanavir (another medicine to treat HIV-infection)
• lopinavir/ritonavir (another medicine to treat HIV-infection)
• fosamprenavir (another medicine to treat HIV-infection)
• efavirenz (another medicine to treat HIV-infection)

Your doctor will carefully monitor the effect of Viramune and any of these medicines if you are taking them together.

If you are undergoing kidney dialysis, your doctor may consider a dose adjustment of VIRAMUNE. This is because Viramune can be partly washed out of your blood by dialysis.

Taking Viramune with food and drink

There are no restrictions on taking Viramune with food and drink.

Pregnancyand breast-feeding

Ask your doctor or pharmacist for advice before taking any medicine.

You should stop breast-feeding if you are taking VIRAMUNE. It is in general recommended that you do not breast-feed if you have HIV infection because it is possible that your baby can become infected with HIV through your breast milk.

Driving and using machines

There are no specific studies on the ability to drive vehicles and use machinery. If you feel that your ability  to drive or use machines may be affected you should not drive or use machines.

Important information about some of the ingredients of VIRAMUNE

Viramune tablets contain lactose (milk sugar). If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking Viramune.

How to take Viramune

You should not use Viramune on its own. You must take it with at least two other antiretroviral medicines. Your doctor will recommend the best medicines for you.

Always take Viramune exactly as your doctor has told you. You should check with your doctor or pharmacist if you are not sure.

Only take Viramune tablets by mouth. Do not chew your tablets. You may take Viramune with or without food.

Dosage

The dose is one 200 mg tablet per day for the first 14 days of treatment (“lead-in” period). After 14 days, the usual dose is one 200 mg tablet twice a day.

It is very important that you take only one Viramune tablet a day for the first 14 days (“lead-in” period). If you have any rash during this period, do not increase the dose but consult your doctor

The 14-day “lead-in” period has been shown to lower the risk of skin rash.

As Viramune must always be taken together with other HIV antiretroviral medicines, you should follow the instructions for your other medicines carefully. These are supplied in the package leaflets for those medicines.

Viramune is also available in liquid form as an oral suspension. This is particularly suitable if:

• you have problems swallowing tablets
• or you are a child weighing less than 50 kg
• or you are a child having a body surface area less than 1.25 square metres (your doctor will work out your surface area).

You should continue to take Viramune for as long as instructed by your doctor.

Your doctor will monitor you with liver tests or for undesirable effects such as rash. Depending on the outcome your doctor may decide to interrupt or stop your Viramune treatment. Your doctor might then decide to restart you on a lower dose.

If you take more Viramune than you should

Do not take more Viramune than prescribed by your doctor and described in this leaflet. There is at present little information on the effects of Viramune overdose. Consult your doctor if you have taken more Viramune than you should.

If you forget to take Viramune

Try not to miss a dose. If you notice that you have missed a dose within 8 hours, take the next dose as soon as possible. If you notice it more than 8 hours later, take the next dose at the usual time.

If you stop taking Viramune

Taking all doses at the appropriate times:

• greatly increases the effectiveness of your combination antiretroviral medicines
• reduces the chances of your HIV infection becoming resistant to your antiretroviral medicines.

It is important that you continue taking Viramune correctly, as described above, unless your doctor instructs you to stop.

If you stop taking Viramune for more than 7 days your doctor will instruct you to start the 14 day’lead-in’ period (described above) once again, before returning to the twice daily dose.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

Possible side effects

Like all medicines, Viramune can cause side effects, although not everybody gets them.

The most important side effects of Viramune are severe and life threatening skin reactions and serious liver damage. These reactions occur mainly in the first 18 weeks of treatment with Viramune.This is therefore an important period which requires close monitoring by your doctor.

If you ever observe any rash symptoms, inform your doctor immediately.

When rash occurs it is normally mild to moderate. However, in some patients a rash, which appears as a blistering skin reaction, can be severe or life-threatening (Stevens-Johnson syndrome and toxic epidermal necrolysis) and deaths have been recorded. Most of the cases of both severe rash and mild/moderate rash occur in the first six weeks of treatment.

If rash occurs and you also feel sick, you must stop treatment and visit your doctor immediately.

Hypersensitivity (allergic) reactions can occur. Such reactions may appear in the form of anaphylaxis (a severe form of allergic reaction) with symptoms such as:

• rash
• swelling of the face
• difficulty breathing (bronchial spasm)
• anaphylactic shock

Hypersensitivity reactions can also occur as rash with other side effects such as:

• fever
• blistering of your skin
• mouth sores
• inflammation of the eye
• swelling of the face
• general swelling
• shortness of breath
• muscle or joint pain
• a reduction in the numbers of your white blood cells (granulocytopenia)
• general feelings of illness
• severe problems with liver or kidneys (liver or kidney failure).

Tell your doctor immediately if you experience rash and any of the other side effects of a hypersensitivity (allergic) reaction. Such reactions can be life-threatening.

Abnormal liver functioning has been reported with the use of VIRAMUNE. This includes some cases of inflammation of the liver (hepatitis), which can be sudden and intense (fulminant hepatitis), and liver failure, which can be both fatal.

Tell your doctor if you experience any of the following clinical symptoms of liver damage:

• loss of appetite
• feeling sick (nausea)
• vomiting
• yellow skin (jaundice)
• abdominal pain

Evaluation of the side effects is based on the following frequencies:

Very common:         in at least 1 out of 10 patients treated

Common:                in at least 1 out of 100 and                        less than 1 out of 10 patients treated

Uncommon:            in at least 1 out of 1000 and less than 1 out of 100 patients treated

Rare:                        in at least 1 out of 10,000 and less than 1 out of 1000 patients treated

The side effects described below have been experienced by patients given VIRAMUNE:

Very common:

• rash

Common:

• decreased numbers of white blood cells (granulocytopenia)
• allergic reactions (hypersensitivity)
• headache
• feeling sick (nausea)
• vomiting
• abdominal pain
• loose stools (diarrhoea)
• inflammation of the liver (hepatitis)
• muscle pain (myalgia)
• feeling tired (fatigue)
• fever
• abnormal liver function tests

Uncommon:

• drug rash with systemic symptoms (drug rash with eosinophilia and systemic symptoms)
• allergic reaction characterized by rash, swelling of the face, difficulty breathing (bronchial spasm) or anaphylactic shock
• decreased numbers of red blood cells (anaemia)
• yellow skin (jaundice)
• severe and life-threatening skin rashes (Stevens-Johnson syndrome/toxic epidermal necrolysis)
• hives (urticaria)
• fluid under the skin (angioedema)
• joint pain (arthralgia)

Rare:

• sudden and intense inflammation of the liver (fulminant hepatitis)

Combination antiretroviral therapy may cause changes in body shape due to changes in fat distribution. These may include loss of fat from legs, arms and face, increased fat in the abdomen (belly) and other internal organs, breast enlargement and fatty lumps on the back of the neck (‘buffalo hump’). The cause and long-term health effects of these conditions are not known at this time. Combination antiretroviral therapy may also cause raised lactic acid and sugar in the blood, hyperlipaemia (increased fats in the blood) and resistance to insulin.

The following events have also been reported when Viramune has been used in combination with other antiretroviral agents:

• decreased numbers of red blood cells or platelets
• inflammation of the pancreas
• decrease in or abnormal skin sensations These events are commonly associated with other antiretroviral agents and may be expected to occur when Viramune is used in combination with other agents; however, it is unlikely that these events are due to treatment with VIRAMUNE.

Use in children

A reduction in white blood cells (granulocytopenia) can occur, which is more common in children. A reduction in red blood cells (anaemia), which may be related to nevirapine therapy, is also more commonly observed in children. As with rash symptoms, please inform your doctor of any side effects.

If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

How to store Viramune

Keep out of the reach and sight of children.

Do not use Viramune after the expiry date which is stated on the carton and on the blister after “EXP”. The expiry date refers to the last day of that month.

This medicinal product does not require any special storage conditions.

Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures will help to protect the environment.

Further information

What Viramune contains

The active substance is nevirapine. Each tablet contains 200 mg nevirapine. The other ingredients are:

• microcrystalline cellulose
• lactose monohydrate
• povidone K25
• sodium starch glycolate
• colloidal silicon dioxide
• magnesium stearate

What Viramune looks like and contents of pack

White, oval, biconvex tablets. One side is marked with the code “54 193”. The opposite side is marked with the company symbol.

Viramune tablets are supplied in blisters, with 14, 60 or 120 tablets per carton. Not all pack sizes may be marketed.

Viramune is also available as an oral suspension.