Viramune - patient leaflet, side effects, dosage

1. 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 substance of your medicine is called nevirapine. Nevirapine 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. Nevirapine stops reverse transcriptase from working. By stopping reverse transcriptase from working, Viramune helps control HIV-1 infection.

Viramune is indicated for the treatment of HIV-1 infected adults, adolescents, and children of any age. You must take Viramune together with other antiretroviral medicines. Your doctor will recommend the best medicines for you.

If Viramune has been prescribed for your child, please note that all information in this leaflet is addressed to your child (in this case please read “your child” instead of “you”).

2. What you need to know before you take Viramune

Do not take Viramune

• – if you are allergic to nevirapine or any of the other ingredients of this medicine (listed in section 6 ).

• – 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.

Warnings and precautions

Talk to your doctor or pharmacist before taking 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 dose of Viramune as prescribed by your doctor. This is especially important within the first 14 days of treatment (see more information in “

How to take Viramune”

).

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.

In addition to the opportunistic infections, autoimmune disorders (a condition that occurs when the immune system attacks healthy body tissue) may also occur after you start taking medicines for the treatment of your HIV infection. Autoimmune disorders may occur many months after the start of treatment. If you notice any symptoms of infection or other symptoms such as muscle weakness, weakness beginning in the hands and feet and moving up towards the trunk of the body, palpitations, tremor or hyperactivity, please inform your doctor immediately to seek necessary treatment.

Changes of body fat may occur in patients receiving combination antiretroviral therapy. Contact your doctor if you notice changes in body fat (see section 4 “Possible side effects” ).

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.

If you are taking nevirapine and zidovudine concomitantly please inform your doctor since he might need to check your white blood cells.

Do not take Viramune after an exposure to HIV unless you have been diagnosed with HIV and instructed to do so by 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. You can still pass on HIV when taking this medicine, although the risk is lowered by effective antiretroviral therapy. Discuss with your doctor the precautions needed to avoid infecting other people.

Prednisone should not be used to treat a rash related to Viramune.

If you are taking oral contraceptives (e.g. „pill“) or other hormonal methods of birth control during treatment with Viramune, you should use a barrier contraception (e.g. condoms) in addition to prevent pregnancy and further HIV transmission.

If you are receiving post-menopausal hormone therapy, ask your doctor for advice before taking this medicine.

If you are taking or are prescribed rifampicin to treat tuberculosis please inform your doctor before taking this medicine with Viramune.

Children and adolescents

Viramune tablets can be taken by:

• – children 16 years 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.

Other medicines and Viramune

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. Inform your 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)

• – etravirine (another medicine to treat HIV-infection)

• – rilpivirine (another medicine to treat HIV-infection)

• – delavirdine (another medicine to treat HIV-infection)

• – zidovudine (another medicine to treat HIV-infection)

• – boceprevir (medicine to treat hepatitis C)

• – telaprevir (medicine to treat hepatitis C)

• – elvitegravir/co­bicistat (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.

Pregnancy and breast-feeding

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this 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

You may experience fatigue when taking Viramune. Use caution when engaging in activities such as driving, using any tools or machines. If you experience fatigue you should avoid potentially hazardous tasks such as driving or using any tools or machines.

Viramune contains lactose and sodium

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 this medicinal product.

Viramune tablets contain less than 1 mmol sodium (23 mg) per tablet, that is to say essentially

‘sodium-free’.

3.   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 this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.

Dose:

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.

As explained in ‘Warnings and precautions’ , above, 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.

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

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 of when it was due, take the missed dose as soon as possible. If it has been more than 8 hours since the dose was due only 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 medicine, ask your doctor or pharmacist.

4. Possible side effects

During HIV therapy there may be an increase in weight and in levels of blood lipids and glucose. This is partly linked to restored health and life style, and in the case of blood lipids sometimes to the HIV medicines themselves. Your doctor will test for these changes.

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

As mentioned in ‘Warnings and precautions' , above, 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

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

Very common (may affect more than 1 in 10 people):

• – rash

Common (may affect up to 1 in 10 people):

• – 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)

• – feeling tired (fatigue)

• – fever

• – abnormal liver function tests

Uncommon (may affect up to 1 in 100 people):

• – 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)

• – muscle pain (myalgia)

• – decreased blood phosphorus

• – increased blood pressure

Rare (may affect up to 1 in 1000 people):

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

• – drug reaction with systemic symptoms (drug reaction with eosinophilia and systemic symptoms)

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.

Additional side effects in children and adolescents

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.

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the national reporting system listed in. By reporting side effects you can help provide more information on the safety of this medicine.

5. How to store Viramune

Keep this medicine out of the sight and reach of children.

Do not use this medicine 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.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What Viramune contains

• – The active substance is nevirapine. Each tablet contains 200 mg nevirapine.

• – The other ingredients are: microcrystalline cellulose, lactose (as monohydrate), povidone K25, sodium starch glycolate, colloidal silicon dioxide and magnesium stearate.

What Viramune looks like and contents of the pack

White, oval, biconvex tablets. One side is marked with the code “54 193”, with a single bisect separating the “54” and “193”. The opposite side is marked with the company symbol. The score line is not intended for breaking the tablet.

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.

Marketing Authorisation Holder

Boehringer Ingelheim International GmbH

Binger Strasse 173

55216 Ingelheim am Rhein

Germany

Manufacturer

Boehringer Ingelheim Pharma GmbH & Co. KG

Binger Strasse 173

55216 Ingelheim am Rhein

Germany

or

Boehringer Ingelheim Ellas A.E.

5th km Paiania-Markopoulo

194 00 Koropi

Greece

or

Boehringer Ingelheim France

100–104 avenue de France

75013 Paris

France

For any information about this medicine, please contact the local representative of the Marketing Authorisation Holder.

België/Belgiqu­e/Belgien SCS Boehringer Ingelheim Comm.V Tél/Tel: +32 2 773 33 11	Lietuva Boehringer Ingelheim RCV GmbH & Co KG Lietuvos filialas Tel.: +370 5 2595942
Efc^rapufl EbopuHrep HHrenxaÜM PUB R-ioX u Ko Kr -K.TOH Ebnrapua	Luxembourg/Lu­xemburg SCS Boehringer Ingelheim Comm.V Tel/Tel: +32 2 773 33 11

Ten: +359 2 958 79 98

Česká republika Boehringer Ingelheim spol. s r.o. Tel: +420 234 655 111	Magyarorszag Boehringer Ingelheim RCV GmbH & Co KG Magyarorszagi Fioktelepe Tel.: +36 1 299 8900
Danmark Boehringer Ingelheim Danmark A/S Tlf: +45 39 15 88 88	Malta Boehringer Ingelheim Ireland Ltd. Tel: +35 31 295 9620
Deutschland Boehringer Ingelheim Pharma GmbH & Co. KG Tel: +49 (0) 800 77 90 900	Nederland Boehringer Ingelheim b.v. Tel: +31 (0) 800 22 55 889
Eesti Boehringer Ingelheim RCV GmbH & Co KG Eesti filiaal	Norge Boehringer Ingelheim Norway KS Tlf: +47 66 76 13 00

Tel: +372 612 8000

EXXáSa Boehringer Ingelheim Ellas A.E. Tql: +30 2 10 89 06 300	Österreich Boehringer Ingelheim RCV GmbH & Co KG Tel: +43 1 80 105–7870
España Boehringer Ingelheim España, S.A. Tel: +34 93 404 51 00	Polska Boehringer Ingelheim Sp. z o.o. Tel.: +48 22 699 0 699
France Boehringer Ingelheim France S.A.S. Tél: +33 3 26 50 45 33	Portugal Boehringer Ingelheim Portugal, Lda. Tel: +351 21 313 53 00
Hrvatska Boehringer Ingelheim Zagreb d.o.o. Tel: +385 1 2444 600	România Boehringer Ingelheim RCV GmbH & Co KG Viena – Sucursala Bucuresti Tel: +40 21 302 2800
Ireland Boehringer Ingelheim Ireland Ltd. Tel: +353 1 295 9620	Slovenija Boehringer Ingelheim RCV GmbH & Co KG Podruznica Ljubljana Tel: +386 1 586 40 00

This leaflet was last revised in {MM/YYYY}

Other sources of information

Detailed information on this medicine is available on the European Medicines Agency web site: