Ribavirin BioPartners
1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX I 
 

SUMMARY OF PRODUCT CHARACTERISTICS 

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1. NAME OF THE MEDICINAL PRODUCT 
 
Ribavirin BioPartners 200 mg film-coated tablets 
 
 
2. QUALITATIVE AND QUANTITATIVE COMPOSITION 
 
Each Ribavirin BioPartners film-coated tablet contains 200 mg of ribavirin. 
 
For a full list of excipients, see section 6.1. 
 
 
3. PHARMACEUTICAL FORM 
 
Film-coated tablet. 
 
Round, white, biconvex film-coated tablet. 
 
 
4. CLINICAL PARTICULARS 
 
4.1 Therapeutic indications 
 
Ribavirin BioPartners is indicated for the treatment of chronic hepatitis C virus (HCV) infection in 
adults, children 3 years of age and older and adolescents and must only be used as part of a 
combination regimen with interferon alfa-2b. Ribavirin monotherapy must not be used.  
 
There is no safety or efficacy information on the use of Ribavirin with other forms of interferon (i.e., 
not alfa-2b). 
 
Naïve patients  
Adult patients: Ribavirin BioPartners is indicated, in combination with interferon alfa-2b, for the 
treatment of adult patients with all types of chronic hepatitis C except genotype 1, not previously 
treated, without liver decompensation, with elevated alanine aminotransferase (ALT), who are positive 
for hepatitis C viral ribonucleic acid HCV-RNA (see section 4.4).  
 
Children 3 years of age and older and adolescents: Ribavirin BioPartners is intended for use, in a 
combination regimen with interferon alfa-2b, for the treatment of children 3 years of age and older and 
adolescents, who have all types of chronic hepatitis C except genotype 1, not previously treated, 
without liver decompensation, and who are positive for HCV-RNA.  
When deciding to not to defer treatment until adulthood, it is important to consider that the 
combination therapy induced a growth inhibition. The reversibility of growth inhibition is uncertain. 
The decision to treat should be made on a case by case basis (see section 4.4). 
 
Previous treatment failure patients  
Adult patients: Ribavirin BioPartners is indicated, in combination with interferon alfa-2b, for the 
treatment of adult patients with chronic hepatitis C who have previously responded (with 
normalisation of ALT at the end of treatment) to interferon alfa monotherapy but who have 
subsequently relapsed (see section 5.1). 
 
4.2 Posology and method of administration 
 
Treatment should be initiated, and monitored, by a physician experienced in the management of 
chronic hepatitis C. 
 
Ribavirin BioPartners must be used in combination with interferon alfa-2b. 
 

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Please refer also to the interferon alfa-2b Summary of Product Characteristics (SPC) for prescribing 
information particular to that product. 
 
Dose to be administered 
The dose of Ribavirin BioPartners is based on patient body weight. Ribavirin BioPartners tablets are 
to be administered orally each day in two divided doses (morning and evening) with food. 
 
Adult patients: 
The dose of Ribavirin BioPartners is based on patient body weight (Table 1). 
Ribavirin BioPartners must be used in combination with interferon alfa-2b (3 million international 
units [MIU] three times a week). The choice of combination regimen is based on the characteristics of 
the patient. The regimen administered should be selected based on the anticipated efficacy and safety 
of the combination treatment for an individual patient (see section 5.1). 
 
Table 1 Ribavirin BioPartners dose based on body weight  

Patient weight (kg)  Daily Ribavirin BioPartners dose  
Number of 200 mg film-coated 

tablets  
< 65  800 mg  4 a  

65 - 80  1,000 mg  5 b  
81 - 105  1,200 mg  6  c  

> 105  1,400 mg  7 d  
a: 2 morning, 2 evening 
b: 2 morning, 3 evening  
c: 3 morning, 3 evening  
d: 3 morning, 4 evening  
 
Ribavirin BioPartners film-coated tablets in combination with interferon alfa-2b: 
 
Based on the results of clinical trials, it is recommended that patients be treated for at least six months. 
During those clinical trials in which patients were treated for one year, patients who failed to show a 
virological response after six months of treatment (HCV-RNA below lower limit of detection) were 
unlikely to become sustained virological responders (HCV-RNA below lower limit of detection six 
months after withdrawal of treatment). 
 
Duration of treatment – Naïve patients  
 
• Genotype Non-1: The decision to extend therapy to one year in patients with negative 

HCVRNA after six months of treatment should be based on other prognostic factors (e.g., age 
> 40 years, male gender, bridging fibrosis). 
 

Duration of treatment – Retreatment  
 
• Genotype 1: Treatment should be continued for another six month period (i.e., a total of one 

year) in patients who exhibit negative HCV-RNA after six months of treatment. 
• Genotype Non-1: The decision to extend therapy to one year in patients with negative 

HCVRNA after six months of treatment should be based on other prognostic factors (e.g., age 
> 40 years, male gender, bridging fibrosis). 

 
Children 3 years of age and older and adolescents: 
Note: For patients who weigh < 47 kg, or are unable to swallow tablets, ribavirin oral solution is 
available and should be used if appropriate.  
 
Dosing for children and adolescent patients is determined by body weight for Ribavirin BioPartners 
and by body surface area for interferon alfa-2b. 
 
 
Dose to be administered for the combination therapy with interferon alfa-2b: 

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In clinical studies performed in this population ribavirin and interferon alfa-2b were used in doses of 
15 mg/kg/day and 3 million international units (MIU)/m2 three times a week respectively (Table 2). 
 

a1 morning, 2 evening 
b2 morning, 2 evening 
 
Duration of treatment in children and adolescents 

 Genotype 2 or 3: The recommended duration of treatment is 24 weeks. 
 
Dose modification for all patients 
If severe adverse reactions or laboratory abnormalities develop during therapy with ribavirin and 
interferon alfa-2b, modify the dosages of each product if appropriate, until the adverse reactions abate. 
Guidelines were developed in clinical trials for dose modification (see Dosage modification 
guidelines, Table 3). As adherence might be of importance for outcome of therapy, the dose should be 
kept as close as possible to the recommended standard dose. The potential negative impact of ribavirin 
dose reduction on efficacy results could not be ruled out. 
 
Table 3 Dosage modification guidelines based on laboratory parameters 

Laboratory values 

Reduce only Ribavirin 
BioPartners 
daily dose 

(see note 1) if: 

Reduce only 
interferon alfa-2b dose 

(see note 2) if: 

Discontinue 
combination therapy 
when the below test 
value is reported:** 

Haemoglobin < 10 g/dl - < 8.5 g/dl 
Adults: 
Haemoglobin in: 
patients with 
history of stable 
cardiac disease 
Children and 
adolescents: not 
applicable (see 
section 4.4) 

 
≥ 2 g/dl decrease in haemoglobin during any 

4 week period during treatment 
(permanent dose reduction) 

 
< 12 g/dl after 4 weeks 

of dose 
reduction 

Leukocytes - < 1.5 x 109/l < 1.0 x 109/l 
Neutrophils - < 0.75 x 109/l < 0.5 x 109/l 
Platelets - < 50 x 109/l (adults) 

< 70 x 109/l (children 
and adolescents) 

< 25 x 109/l (adults) 
< 50 x 109/l 

(children and 
adolescents) 

Bilirubin – Direct - - 2.5 x ULN* 
Bilirubin – 
Indirect 

> 5 mg/dl - > 4 mg/dl (adults) 
> 5 mg/dl 

(for > 4 weeks) 
(children and 

adolescents treated 
with interferon alfa-2b), 

 
Serum Creatinine - -- > 2.0 mg/dl 
Creatinine - - Discontinue Ribavirin 

Table 2 Ribavirin BioPartners dose based on body weight when used in combination   with 
interferon alfa-2b in children and adolescents 

Patient weight (kg)  Daily Ribavirin BioPartners dose  Number of 200 mg tablets  

47 - 49  600 mg  3 tablets a  
50 - 65  800 mg  4 tablets b  

> 65  Refer to adult dosing table (Table 1)  

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Clearance BioPartners 
if 

CrCl < 50 ml/minute 
Alanine 
aminotransferase 
(ALT) 

or 
Aspartate 
aminotransferase 
(AST) 

- - 2 x baseline and 
> 10 x ULN* 

 
or 

2 x baseline and 
> 10 x ULN* 

* Upper limit of normal 
** Refer to the SPC for interferon alfa-2b for dose modification and discontinuation. 
 

Note 1: In adult patients, 1st dose reduction of Ribavirin BioPartners is by 200 mg/day (except in 
patients receiving the 1,400 mg, dose reduction should be by 400 mg/day). If needed, 
2nd dose reduction of Ribavirin BioPartners is by an additional 200 mg/day. Patients whose 
dose of Ribavirin BioPartners is reduced to 600 mg daily receive one 200 mg tablet in the 
morning and two 200 mg tablets in the evening. 
In children and adolescent patients treated with Ribavirin BioPartners plus interferon 
alfa-2b, reduce ribavirin dose to 7.5 mg/kg/day. 

Note 2: In adult patients and children and adolescent patients treated with Ribavirin BioPartners plus 
interferon alfa-2b, reduce the interferon alfa-2b dose by one-half dose. 

 
Special populations 
 
Use in renal impairment: The pharmacokinetics of ribavirin are altered in patients with renal 
dysfunction due to reduction of apparent creatinine clearance in these patients (see section 5.2). 
Therefore, it is recommended that renal function be evaluated in all patients prior to initiation of 
ribavirin. Patients with creatinine clearance < 50 ml/minute must not be treated with ribavirin (see 
section 4.3). Subjects with impaired renal function should be more carefully monitored with respect to 
the development of anaemia. If serum creatinine rises to > 2.0 mg/dl (Table 3), Ribavirin BioPartners 
and interferon alfa-2b must be discontinued. 
 
Use in hepatic impairment: No pharmacokinetic interaction appears between ribavirin and hepatic 
function (see section 5.2). Therefore, no dose adjustment of ribavirin is required in patients with 
hepatic impairment. The use of ribavirin is contraindicated in patients with severe hepatic impairment 
or decompensated cirrhosis (see section 4.3). 
 
Use in the elderly (≥ 65 years of age): There does not appear to be a significant age-related effect on 
the pharmacokinetics of ribavirin. However, as in younger patients, renal function must be determined 
prior to administration of Ribavirin (see section 5.2). 
 
Use in patients under the age of 18 years: Ribavirin may be used in combination with interferon 
alfa-2b in children 3 years of age and older and adolescents. The selection of the formulation is based 
on individual characteristics of the patient (see section 4.1). Safety and effectiveness of ribavirin with 
other forms of interferon (i.e. not alfa-2b) in these patients have not been evaluated. 
 
Patients co-infected with HCV/HIV: Patients taking nucleoside reverse transcriptase inhibitor (NRTI) 
treatment in association with ribavirin and interferon alfa-2b may be at increased risk of mitochondrial 
toxicity, lactic acidosis and hepatic decompensation (see section 4.4). Please refer also to the relevant 
product information for antiretroviral medicinal products. 
 
4.3 Contraindications 
 
- Hypersensitivity to the active substance or to any of the excipients. 

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- Pregnant women (see sections 4.4, 4.6 and 5.3). Ribavirin BioPartners must not be initiated until 
a report of a negative pregnancy test has been obtained immediately prior to initiation of 
therapy. 

- Lactation. 
- A history of severe pre-existing cardiac disease, including unstable or uncontrolled cardiac 

disease, in the previous six months (see section 4.4). 
- Patients with severe, debilitating medical conditions. 
- Patients with chronic renal failure, patients with creatinine clearance < 50 ml/minute and/or on  

haemodialysis. 
- Severe hepatic impairment (Child-Pugh Classification B or C) or decompensated cirrhosis of  

the liver. 
- Haemoglobinopathies (e.g., thalassemia, sickle-cell anaemia). 
- Initiation of peginterferon alfa-2b is contraindicated in HCV/HIV patients with cirrhosis and a 

Child-Pugh score ≥6.  
 
Children and adolescents: 
- Existence of, or history of severe psychiatric condition, particularly severe depression, suicidal 

ideation, or suicide attempt.  
 
Because of co-administration with peginterferon alfa-2b or interferon alfa-2b: 
- Autoimmune hepatitis; or history of autoimmune disease.  
 
4.4 Special warnings and precautions for use 
 
Psychiatric and Central Nervous System (CNS): 
Severe CNS effects, particularly depression, suicidal ideation and attempted suicide have been 
observed in some patients during ribavirin combination therapy with peginterferon alfa-2b or 
interferon alfa-2b, and even after treatment discontinuation mainly during the 6-month follow-up 
period. Among children and adolescents, treated with ribavirin in combination with interferon alfa-2b, 
suicidal ideation or attempts were reported more frequently compared to adult patients (2.4 % versus 
1 %) during treatment and during the 6-month follow-up after treatment. As in adult patients, children 
and adolescents experienced other psychiatric adverse reactions (e.g. depression, emotional lability, 
and somnolence). Other CNS effects including aggressive behaviour (sometimes directed against 
others such as homicidal ideation), bipolar disorder, mania, confusion and alterations of mental status 
have been observed with alpha interferons. Patients should be closely monitored for any signs or 
symptoms of psychiatric disorders. If such symptoms appear, the potential seriousness of these 
undesirable effects must be borne in mind by the prescribing physician and the need for adequate 
therapeutic management should be considered. If psychiatric symptoms persist or worsen, or suicidal 
ideation is identified, it is recommended that treatment with Ribavirin and peginterferon alfa-2b or 
interferon alfa-2b be discontinued, and the patient followed, with psychiatric intervention as 
appropriate. 
 
Patients with existence of or history of severe psychiatric conditions: If treatment with Ribavirin in 
combination with peginterferon alfa-2b or interferon alfa-2b is judged necessary in adult patients with 
existence or history of severe psychiatric conditions, this should only be initiated after having ensured 
appropriate individualised diagnostic and therapeutic management of the psychiatric condition.  
The use of Ribavirin and interferon alfa-2b or peginterferon alfa-2b in children and 
adolescents with existence of or history of severe psychiatric conditions is contraindicated 
(see section 4.3). 
 
Patients with substance use/abuse: 
HCV infected patients having a co-occurring substance use disorder (alcohol, cannabis, etc) are at 
an increased risk of developing psychiatric disorders or exacerbation of already existing 
psychiatric disorders when treated with alpha interferon. If treatment with alpha interferon is 
judged necessary in these patients, the presence of psychiatric co-morbidities and the potential for 
other substance use should be carefully assessed and adequately managed before initiating 

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therapy. If necessary, an inter-disciplinary approach including a mental health care provider or 
addiction specialist should be considered to evaluate, treat and follow the patient. Patients should 
be closely monitored during therapy and even after treatment discontinuation. Early intervention 
for re-emergence or development of psychiatric disorders and substance use is recommended. 
 
 
Growth and development (children and adolescents): 
During the course of interferon (standard and pegylated)/ribavirin therapy lasting up to 48 weeks in 
patients ages 3 through 17 years, weight loss and growth inhibition were common (see sections 4.8 
and 5.1). The longer term data available in children treated with the combination therapy with standard 
interferon/ribavirin are also indicative of substantial growth retardation (> 15 percentile decrease in 
height percentile as compared to baseline) in 21 % of children despite being off treatment for more 
than 5 years. 
 
Case by case benefit/risk assessment in children: 
The expected benefit of treatment should be carefully weighed against the safety findings observed for 
children and adolescents in the clinical trials (see sections 4.8 and 5.1). 
– It is important to consider that the combination therapy induced a growth inhibition, the 

reversibility of which is uncertain. 
– This risk should be weighed against the disease characteristics of the child, such as evidence of 

disease progression (notably fibrosis), co-morbidities that may negatively influence the disease 
progression (such as HIV-co-infection), as well as prognostic factors of response (HCV 
genotype and viral load). 

 
Whenever possible the child should be treated after the pubertal growth spurt, in order to reduce the 
risk of growth inhibition. There are no data on long term effects on sexual maturation. 
 
Based on results of clinical trials, the use of ribavirin as monotherapy is not effective and Ribavirin 
must not be used alone. The safety and efficacy of this combination have been established only using 
ribavirin together with peginterferon alfa-2b or interferon alfa-2b solution for injection. 
 
All patients in selected chronic hepatitis C studies had a liver biopsy before inclusion, but in certain 
cases (i.e. patients with genotype 2 and 3), treatment may be possible without histological 
confirmation. Current treatment guidelines should be consulted as to whether a liver biopsy is needed 
prior to commencing treatment. 
 
Haemolysis: A decrease in haemoglobin levels to < 10 g/dl was observed in up to 14 % of adult 
patients and 7 % of children and adolescents treated with ribavirin in combination with peginterferon 
alfa-2b or interferon alfa-2b in clinical trials. Although ribavirin has no direct cardiovascular effects, 
anaemia associated with ribavirin may result in deterioration of cardiac function, or exacerbation of 
the symptoms of coronary disease, or both. Thus, ribavirin must be administered with caution to 
patients with pre-existing cardiac disease (see section 4.3). Cardiac status must be assessed before start 
of therapy and monitored clinically during therapy; if any deterioration occurs, therapy must be 
stopped (see section 4.2). 
 
Cardiovascular: Adult patients with a history of congestive heart failure, myocardial infarction and/or 
previous or current arrhythmic disorders must be closely monitored. It is recommended that those 
patients who have pre-existing cardiac abnormalities have electrocardiograms taken prior to and 
during the course of treatment. Cardiac arrhythmias (primarily supraventricular) usually respond to 
conventional therapy but may require discontinuation of therapy. There are no data in children or 
adolescents with a history of cardiac disease. 
 
Acute hypersensitivity: If an acute hypersensitivity reaction (e.g., urticaria, angioedema, 
bronchoconstriction, anaphylaxis) develops, Ribavirin must be discontinued immediately and 
appropriate medical therapy instituted. Transient rashes do not necessitate interruption of treatment. 

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Ocular changes: Ribavirin is used in combination therapy with alpha interferons. Retinopathy 
including retinal haemorrhages, retinal exudates, papilloedema, optic neuropathy and retinal artery or 
vein occlusion which may result in loss of vision have been reported in rare instances with 
combination therapy with alpha interferons. All patients should have a baseline eye examination. Any 
patient complaining of decrease or loss of vision must have a prompt and complete eye examination. 
Patients with preexisting ophthalmologic disorders (e.g., diabetic or hypertensive retinopathy) should 
receive periodic ophthalmologic exams during combination therapy with alpha interferons. 
Combination therapy with alpha interferons should be discontinued in patients who develop new or 
worsening ophthalmologic disorders. 
 
Liver function: Any patient developing significant liver function abnormalities during treatment must 
be monitored closely. Discontinue treatment in patients who develop prolongation of coagulation 
markers which might indicate liver decompensation. 
 
Potential to exacerbate immunosuppression: Pancytopenia and bone marrow suppression have been 
reported in the literature to occur within 3 to 7 weeks after the administration of a peginterferon and 
ribavirin concomitantly with azathioprine. This myelotoxicity was reversible within 4 to 6 weeks upon 
withdrawal of HCV antiviral therapy and concomitant azathioprine and did not recur upon 
reintroduction of either treatment alone (see section 4.5). 
  
Thyroid supplemental monitoring specific for children and adolescents: 
Approximately 12 to 21 % of children treated with ribavirin and interferon alfa-2b (pegylated and 
nonpegylated) developed increase in thyroid stimulating hormone (TSH). Another approximately 4 % 
had a transient decrease below the lower limit of normal. Prior to initiation of interferon alfa-2b 
therapy, TSH levels must be evaluated and any thyroid abnormality detected at that time must be 
treated with conventional therapy. Interferon alfa-2b (pegylated and non-pegylated) therapy may be 
initiated if TSH levels can be maintained in the normal range by medication. Thyroid dysfunction 
during treatment with ribavirin and interferon alfa-2b and during treatment with ribavirin and 
peginterferon alfa-2b has been observed. If thyroid abnormalities are detected, the patient’s thyroid 
status should be evaluated and treated as clinically appropriate. Children and adolescents should be 
monitored every 3 months for evidence of thyroid dysfunction (e.g. TSH). 
 
HCV/HIV Co-infection: 
Mitochondrial toxicity and lactic acidosis: 
Caution should be taken in HIV-positive subjects co-infected with HCV who receive nucleoside 
reverse transcriptase inhibitor (NRTI) treatment (especially ddI and d4T) and associated interferon 
alfa-2b/ribavirin treatment. In the HIV-positive population receiving an NRTI regimen, physicians 
should carefully monitor markers of mitochondrial toxicity and lactic acidosis when ribavirin is 
administered. In particular: 
- co-administration of Ribavirin BioPartners and didanosine is not recommended due to the risk 

of mitochondrial toxicity (see section 4.5). 
- co-administration of Ribavirin BioPartners and stavudine should be avoided to limit the risk of 

overlapping mitochondrial toxicity. 
 

Hepatic decompensation in HCV/HIV co-infected patients with advanced cirrhosis: 
Co-infected patients with advanced cirrhosis receiving highly active anti-retroviral therapy (HAART) 
may be at increased risk of hepatic decompensation and death. Adding treatment with alfa interferons 
alone or in combination with ribavirin may increase the risk in this patient subset. Other baseline 
factors in co-infected patients that may be associated with a higher risk of hepatic decompensation 
include treatment with didanosine and elevated bilirubin serum concentrations. 
Co-infected patients receiving both antiretroviral (ARV) and anti-hepatitis treatment should be closely 
monitored, assessing their Child-Pugh score during treatment. Patients progressing to hepatic 
decompensation should have their anti-hepatitis treatment immediately discontinued and the ARV 
treatment reassessed. 
 

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Haematological abnormalities in HCV/HIV co-infected patients: 
HCV/HIV co-infected patients receiving peginterferon alfa-2b/ribavirin treatment and HAART may 
be at increased risk to develop haematological abnormalities (as neutropenia, thrombocytopenia and 
anaemia) compared to HCV mono-infected patients. Although, the majority of them could be managed 
by dose reduction, close monitoring of haematological parameters should be undertaken in this 
population of patients (see section 4.2 and below “Laboratory tests” and section 4.8). 
Patients treated with ribavirin and zidovudine are at increased risk of developing anaemia; therefore, 
the concomitant use of ribavirin with zidovudine is not recommended (see section 4.5). 
 
Patients with low CD4 counts: 
In patients co-infected with HCV/HIV, limited efficacy and safety data (N = 25) are available in 
subjects with CD4 counts less than 200 cells/µl. Caution is therefore warranted in the treatment of 
patients with low CD4 counts. 
 
Please refer to the respective Summary of Product Characteristics of the antiretroviral medicinal 
products that are to be taken concurrently with HCV therapy for awareness and management of 
toxicities specific for each product and the potential for overlapping toxicities with Ribavirin 
BioPartners and peginterferon alfa-2b. 
 
Dental and periodontal disorders: Dental and periodontal disorders, which may lead to loss of teeth, 
have been reported in patients receiving ribavirin and peginterferon alfa-2b or interferon alfa-2b 
combination therapy. In addition, dry mouth could have a damaging effect on teeth and mucous 
membranes of the mouth during long-term treatment with the combination of ribavirin and 
peginterferon alfa-2b or interferon alfa-2b. Patients should brush their teeth thoroughly twice daily and 
have regular dental examinations. In addition some patients may experience vomiting. If this reaction 
occurs, they should be advised to rinse out their mouth thoroughly afterwards. 
 
Laboratory tests: Standard haematologic tests and blood chemistries (complete blood count [CBC] and 
differential, platelet count, electrolytes, serum creatinine, liver function tests, uric acid) must be 
conducted in all patients prior to initiating therapy. Acceptable baseline values that may be considered 
as a guideline prior to initiation of Ribavirin therapy: 
 
 Haemoglobin  Adults: ≥ 12 g/dl (females); ≥ 13 g/dl (males) 

 Children and adolescents: ≥ 11 g/dl (females); ≥ 12 g/dl (males) 
 Platelets ≥ 100,000/mm3 
 Neutrophil Count ≥ 1,500/mm3 
 
Laboratory evaluations are to be conducted at weeks 2 and 4 of therapy, and periodically thereafter as 
clinically appropriate. HCV-RNA should be measured periodically during treatment (see section 4.2). 
 
For females of childbearing potential: Female patients must have a routine pregnancy test performed 
monthly during treatment and for four months thereafter. Female partners of male patients must have a 
routine pregnancy test performed monthly during treatment and for seven months thereafter (see 
section 4.6). 
 
Uric acid may increase with ribavirin due to haemolysis; therefore, the potential for development of 
gout must be carefully monitored in pre-disposed patients. 
 
4.5 Interaction with other medicinal products and other forms of interaction 
 
Results of in vitro studies using both human and rat liver microsome preparations indicated no 
cytochrome P450 enzyme mediated metabolism of ribavirin. Ribavirin does not inhibit cytochrome 
P450 enzymes. 
There is no evidence from toxicity studies that ribavirin induces liver enzymes. Therefore, there is a 
minimal potential for P450 enzyme-based interactions. 
 

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Ribavirin, by having an inhibitory effect on inosine monophosphate dehydrogenase, may interfere 
with azathioprine metabolism possibly leading to an accumulation of 6-methylthioinosine 
monophosphate (6-MTIMP), which has been associated with myelotoxicity in patients treated with 
azathioprine. The use of pegylated alpha interferons and ribavirin concomitantly with azathioprine 
should be avoided. In individual cases where the benefit of administering ribavirin concomitantly with 
azathioprine warrants the potential risk, it is recommended that close hematologic monitoring be done 
during concomitant azathioprine use to identify signs of myelotoxicity, at which time treatment with 
these medicines should be stopped (see section 4.4). 
 
No interaction studies have been conducted with ribavirin and other medicinal products, except for 
peginterferon alfa-2b, interferon alfa-2b and antacids. 
 
Interferon alfa-2b: No pharmacokinetic interactions were noted between ribavirin and peginterferon 
alfa-2b or interferon alfa-2b in a multiple-dose pharmacokinetic study. 
 
Antacid: The bioavailability of ribavirin 600 mg was decreased by co-administration with an antacid 
containing magnesium aluminium and simethicone; AUCtf decreased 14 %. It is possible that the 
decreased bioavailability in this study was due to delayed transit of ribavirin or modified pH. This 
interaction is not considered to be clinically relevant. 
 
Nucleoside analogs: Use of nucleoside analogs, alone or in combination with other nucleosides, has 
resulted in lactic acidosis. Pharmacologically, ribavirin increases phosphorylated metabolites of purine 
nucleosides in vitro. This activity could potentiate the risk of lactic acidosis induced by purine 
nucleoside analogs (e.g. didanosine or abacavir). Co-administration of Ribavirin BioPartners and 
didanosine is not recommended. Reports of mitochondrial toxicity, in particular lactic acidosis and 
pancreatitis, of which some fatal, have been reported (see section 4.4). 
The exacerbation of anaemia due to ribavirin has been reported when zidovudine is part of the regimen 
used to treat HIV although the exact mechanism remains to be elucidated. The concomitant use of 
ribavirin with zidovudine is not recommended due to an increased risk of anaemia (see section 4.4). 
Consideration should be given to replacing zidovudine in a combination anti-retroviral treatment 
(ART) regimen if this is already established. This would be particularly important in patients with a 
known history of zidovudine induced anaemia. 
 
Any potential for interactions may persist for up to two months (five half-lives for ribavirin) after 
cessation of ribavirin therapy due to the long half-life (see section 5.2). 
 
There is no evidence that ribavirin interacts with non-nucleoside reverse transcriptase inhibitors or 
protease inhibitors. 
 
Conflicting findings are reported in literature on co-administration between abacavir and ribavirin. 
Some data suggest that HIV/HCV co-infected patients receiving abacavir-containing ART may be at 
risk of a lower response rate to pegylated interferon/ribavirin therapy. Caution should be exercised 
when both medicines are co-administered. 
 
4.6 Fertility, pregnancy and lactation 
 
The use of Ribavirin BioPartners is contraindicated during pregnancy. 
 
Preclinical data: 
- Fertility: In animal studies, ribavirin produced reversible effects on spermatogenesis (see 

section 5.3). 
- Teratogenicity: Significant teratogenic and/or embryocidal potential have been demonstrated for 

ribavirin in all animal species in which adequate studies have been conducted, occurring at 
doses as low as one twentieth of the recommended human dose (see section 5.3). 

- Genotoxicity: Ribavirin induces genotoxicity (see section 5.3). 
 

Female patients: Ribavirin must not be used by females who are pregnant (see sections 4.3 and 5.3). 

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Extreme care must be taken to avoid pregnancy in female patients (see section 5.3). Ribavirin therapy 
must not be initiated until a report of a negative pregnancy test has been obtained immediately prior to 
initiation of therapy. Females of childbearing potential must use an effective contraceptive during 
treatment and for four months after treatment has been concluded; routine monthly pregnancy tests 
must be performed during this time. If pregnancy does occur during treatment or within four months 
from stopping treatment, the patient must be advised of the significant teratogenic risk of ribavirin to 
the foetus. 
 
Male patients and their female partners: Extreme care must be taken to avoid pregnancy in partners of 
male patients taking Ribavirin (see sections 4.3 and 5.3). Ribavirin accumulates intracellularly and is 
cleared from the body very slowly. It is unknown whether the ribavirin that is contained in sperm will 
exert its potential teratogenic or genotoxic effects on the human embryo/foetus. Although data on 
approximately 300 prospectively followed pregnancies with paternal exposure to ribavirin have not 
shown an increased risk of malformation compared to the general population, nor any specific pattern 
of malformation, either male patients or their female partners of childbearing age must be advised to 
use an effective contraceptive during treatment with Ribavirin and for seven months after treatment. 
Men whose partners are pregnant must be instructed to use a condom to minimise delivery of ribavirin 
to the partner. 
 
Breast-feeding: It is not known whether ribavirin is excreted in human milk. Because of the potential 
for adverse reactions in breast-fed infants, breast-feeding must be discontinued prior to initiation of 
treatment. 
 
4.7 Effects on ability to drive and use machines 
 
Ribavirin has no or negligible influence on the ability to drive and use machines; however, 
peginterferon alfa-2b or interferon alfa-2b used in combination may have an effect. Thus, patients who 
develop fatigue, somnolence, or confusion during treatment must be cautioned to avoid driving or 
operating machinery. 
 
4.8 Undesirable effects 
 
Adult patients:  
The safety of ribavirin is evaluated from data from four clinical trials in patients with no previous 
exposure to interferon (interferon-naïve patients): two trials studied ribavirin in combination with 
interferon alfa-2b, two trials studied ribavirin in combination with peginterferon alfa-2b. 
 
Patients who are treated with interferon alfa-2b and ribavirin after previous relapse from interferon 
therapy or who are treated for a shorter period are likely to have an improved safety profile than that 
described below. 
 
The adverse reactions listed in Table 4 are based on experience from clinical trials in adult naïve 
patients treated for 1 year and post-marketing use. A certain number of adverse reactions, generally 
attributed to interferon therapy but that have been reported in the context of hepatitis C therapy (in 
combination with ribavirin) are also listed for reference in Table 4. Also, refer to peginterferon alfa-2b 
and interferon alfa-2b SPCs for adverse reactions that may be attributable to interferons monotherapy. 
Within the organ system classes, adverse reactions are listed under headings of frequency using the 
following categories: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥ 1/1,000 to 
<1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known. Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness. 
 
Table 4 Adverse reactions reported during clinical trials or following the marketing use of 

Ribavirin with pegylated interferon alfa-2b or interferon alfa-2b 
System Organ Class Adverse Reactions 

Infections and infestations 
Very common: Viral infection, pharyngitis 

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Common: Bacterial infection (including sepsis), fungal infection, 
influenza, respiratory tract infection, bronchitis, herpes 
simplex, sinusitis, otitis media, rhinitis, urinary tract infection 

Uncommon: Injection site infection, lower respiratory tract infection 
Rare: Pneumonia* 
Neoplasms benign, malignant and unspecified (including cysts and polyps) 
Common: Neoplasm unspecified 
Blood and lymphatic system disorders 
Very common: Anaemia, neutropenia 
Common: Haemolitic anaemia, leukopenia, thrombocytopenia, 

lymphadenopathy, lymphopenia 
Very rare: Aplastic anaemia* 
Not known: Pure red cell aplasia, idiopathic thrombocytopenic purpura, 

thrombotic thrombocytopenic purpura 
Immune system disorders 
Uncommon: Drug hypersensitivity 
Rare: Sarcoidosis*, rheumatoid arthritis (new or aggravated) 
Not known: Vogt-Koyanagi-Harada syndrome, systemic lupus 

erythematosus, vasculitis, acute hypersensitivity reactions 
including urticaria, angioedema, bronchoconstriction, 
anaphylaxis 

Endocrine disorders 
Common: Hypothyroidism, hyperthyroidism 
Metabolism and nutrition disorders 
Very common: Anorexia 
Common: Hyperglycaemia, hyperuricaemia, hypocalcaemia, 

dehydration, increased appetite 
Uncommon: Diabetes mellitus, hypertriglyceridemia* 
Psychiatric disorders 
Very common: Depression, anxiety, emotional lability, insomnia 
Common: Suicidal ideation, psychosis, aggressive behaviour, confusion, 

agitation, anger, mood altered, abnormal behaviour, 
nervousness, sleep disorder, decreased libido apathy, 
abnormal dreams, crying 

Uncommon: Suicide attempts, panic attack, hallucination 
Rare: Bipolar disorder* 
Very rare: Suicide* 
Not known: Homicidal ideation*, mania*, mental status change 
Nervous system disorders 
Very common: Headache, dizziness, dry mouth, concentration impaired 
Common: Amnesia, memory impairment, syncope, migraine, ataxia, 

paraesthaesia, dysphonia, taste loss, hypoaesthesia, 
hyperaesthesia, hypertonia, somnolence, disturbance in 
attention, tremor, dysgeusia 

Uncommon: Neuropathy, peripheral neuropathy 
Rare: Seizure (convulsion)* 
Very rare: Cerebrovascular haemorrhage*, cerebrovascular ischaemia*, 

encephalopathy*, polyneuropathy* 
Not known: Facial palsy, mononeuropathies 
Eye disorders 
Common: Visual disturbance, blurred vision, conjunctivitis, eye 

irritation, eye pain, abnormal vision, lacrimal gland disorder, 
dry eye 

Rare: Retinal haemorrhages*, retinopathies (including macular 

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oedema)*, retinal artery occlusion*, retinal vein occlusion*, 
optic neuritis*, papilloedema*, loss of visual acuity or visual 
field*, retinal exudates 

Ear and labyrinth disorders 
Common: Vertigo, hearing impaired/loss, tinnitus, ear pain 
Cardiac disorders 
Common: Palpitation, tachycardia 
Uncommon: Myocardial infarction 
Rare: Cardiomyopathy, arrhythmia* 
Very rare: Cardiac ischaemia* 
Not known: Pericardial effusion*, pericarditis* 
Vascular disorders 
Common: Hypotension, hypertension, flushing 
Rare: Vasculitis 
Very rare: Peripheral ischaemia* 
Respiratory, thoracic and mediastinal disorders 
Very common: Dyspnoea, coughing 
Common: Epistaxis, respiratory disorder, respiratory tract congestion, 

sinus congestion, nasal congestion, rhinorrhea, increased 
upper airway secretion, pharyngolaryngeal pain, 
nonproductive cough 

Very rare: Pulmonary infiltrates*, pneumonitis*, interstitial 
pneumonitis* 

Gastro-intestinal disorders 
Very common: Diarrhoea, vomiting, nausea, abdominal pain 
Common: Ulcerative stomatitis, stomatitis, mouth ulceration, colitis, 

upper right quadrant pain, dyspepsia, gastroesophoageal 
reflux*, glossitis, cheilitis, abdominal distension, gingival 
bleeding, gingivitis, loose stools, tooth disorder, constipation, 
flatulence 

Uncommon: Pancreatitis, oral pain 
Rare: Ischaemic colitis 
Very rare: Ulcerative colitis* 
Not Known: Periodontal disorder, dental disorder 
Hepatobiliary disorders 
Common: Hepatomegaly, jaundice, hyperbilirubinemia* 
Very rare: Hepatotoxicity (including fatalities)* 
Skin and subcutaneous tissue disorders 
Very common: Alopecia, pruritus, skin dry, rash 
Common: Psoriasis, aggravated psoriasis, eczema, photosensitivity 

reaction, maculopapular rash, erythematous rash, night 
sweats, hyperhidrosis, dermatitis, acne, furuncule, erythema, 
urticaria, skin disorder, bruise, sweating increased, abnormal 
hair texture, nail disorder* 

Rare: Cutaneous sarcoidosis 
Very rare: Stevens Johnson syndrome*, toxic epidermal necrolysis*, 

erythema multiforme* 
Musculoskeletal and connective tissue disorders 
Very common: Arthralgia, myalgia, musculoskeletal pain 
Common: Arthritis, back pain, muscle spasms, pain in extremity 
Uncommon: Bone pain, muscle weakness 
Rare: Rhabdomyolysis*, myositis* 
Renal and urinary disorders 
Common: Micturition frequency, polyuria, urine abnormality 

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Rare: Renal failure, renal insufficiency* 
Very rare: Nephrotic syndrome* 
Reproductive system and breast disorders 
Common: Female: amenorrhea, menorrhagia, menstrual disorder, 

dysmenorrhea, breast pain, ovarian disorder, vaginal disorder. 
Male: impotence, prostatitis, erectile dysfunction, Sexual 
dysfunction (not specified)* 

General disorders and administration site conditions 
Very common: Injection site inflammation, injection site reaction, fatigue, 

rigors, pyrexia, influenza like illness, asthenia, irritability 
Common: Chest pain, chest discomfort, peripheral oedema, malaise, 

injection site pain, feeling abnormal, thirst 
Uncommon: Face oedema 
Rare: Injection site necrosis 
Investigations 
Very common: Weight decrease 
Common: Cardiac murmur 
* Since ribavirin is always prescribed with an alpha interferon product, and the listed adverse drug reactions included 
reflecting post-marketing experience do not allow precise quantification of frequency, the frequency reported above is from 
clinical trials using ribavirin in combination with interferon alfa-2b (pegylated or non-pegylated). 
 
A reduction in haemoglobin concentrations by > 4 g/dl was observed in 30 % of patients treated with 
ribavirin and peginterferon alfa-2b and 37 % of patients treated with ribavirin and interferon alfa-2b. 
Haemoglobin levels dropped below 10 g/dl in up to 14 % of adult patients and 7 % of children and 
adolescents treated with ribavirin in combination with either peginterferon alfa-2b or interferon 
alfa-2b. 
 
Most cases of anaemia, neutropenia, and thrombocytopenia were mild (WHO grades 1 or 2). There 
were some cases of more severe neutropenia in patients treated with ribavirin in combination with 
peginterferon alfa-2b (WHO grade 3: 39 of 186 [21 %]; and WHO grade 4: 13 of 186 [7 %]); WHO 
grade 3 leukopenia was also reported in 7 % of this treatment group. 
 
An increase in uric acid and indirect bilirubin values associated with haemolysis was observed in some 
patients treated with ribavirin used in combination with peginterferon alfa-2b or interferon alfa-2b in 
clinical trials, but values returned to baseline levels by four weeks after the end of therapy. Among 
those patients with elevated uric acid levels, very few patients treated with the combination developed 
clinical gout, none of which required treatment modification or discontinuation from the clinical trials. 
 
HCV/HIV co-infected patients: 
For HCV/HIV co-infected patients receiving ribavirin in combination with peginterferon alfa-2b, other 
adverse reactions (that were not reported in mono-infected patients) which have been reported in the 
studies with a frequency > 5 % were: oral candidiasis (14 %), lipodystrophy acquired (13 %), CD4 
lymphocytes decreased (8 %), appetite decreased (8 %), gamma-glutamyltransferase increased (9 %), 
back pain (5 %), blood amylase increased (6 %), blood lactic acid increased (5 %), cytolytic hepatitis 
(6 %), lipase increased (6 %) and pain in limb (6 %). 
 
Mitochondrial toxicity: 
Mitochondrial toxicity and lactic acidosis have been reported in HIV-positive patients receiving NRTI 
regimen and associated-ribavirin for co-HCV infection (see section 4.4). 
 
Laboratory values for HCV/HIV co-infected patients: 
Although haematological toxicities of neutropenia, thrombocytopenia and anaemia occurred more 
frequently in HCV/HIV co-infected patients, the majority could be managed by dose modification and 
rarely required premature discontinuation of treatment (see section 4.4). Haematological abnormalities 
were more frequently reported in patients receiving ribavirin in combination with peginterferon 
alfa-2b when compared to patients receiving ribavirin in combination with interferon alfa-2b. In 

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Study 1 (see section 5.1), decrease in absolute neutrophil count levels below 500 cells/mm3 was 
observed in 4 % (8/194) of patients and decrease in platelets below 50,000/mm3 was observed in 4 % 
(8/194) of patients receiving ribavirin in combination with peginterferon alfa-2b. Anaemia 
(haemoglobin < 9.4 g/dl) was reported in 12 % (23/194) of patients treated with ribavirin in 
combination with peginterferon alfa-2b. 
 
CD4 lymphocytes decrease: 
Treatment with ribavirin in combination with peginterferon alfa-2b was associated with decreases in 
absolute CD4+ cell counts within the first 4 weeks without a reduction in CD4+ cell percentage. The 
decrease in CD4+ cell counts was reversible upon dose reduction or cessation of therapy. The use of 
ribavirin in combination with peginterferon alfa-2b had no observable negative impact on the control 
of HIV viraemia during therapy or follow-up. Limited safety data (N = 25) are available in co-infected 
patients with CD4+ cell counts < 200/µl (see section 4.4). 
 
Please refer to the respective Summary of Product Characteristics of the antiretroviral medicinal 
products that are to be taken concurrently with HCV therapy for awareness and management of 
toxicities specific for each product and the potential for overlapping toxicities with ribavirin in 
combination with peginterferon alfa-2b. 
 
Children and adolescents: 
In combination with peginterferon alfa-2b 
In a clinical trial with 107 children and adolescent patients (3 to 17 years of age) treated with 
combination therapy of peginterferon alfa-2b and ribavirin, dose modifications were required in 25 % 
of patients, most commonly for anaemia, neutropenia and weight loss. In general, the adverse 
reactions profile in children and adolescents was similar to that observed in adults, although there is a 
paediatric-specific concern regarding growth inhibition. During combination therapy for up to 
48 weeks with pegylated interferon alfa-2b and ribavirin, growth inhibition is observed, the 
reversibility of which is uncertain (see section 4.4). Weight loss and growth inhibition were very 
common during the treatment (at the end of treatment, mean decrease from baseline in weight and in 
height percentiles were of 15 percentiles and 8 percentiles, respectively) and growth velocity was 
inhibited (< 3rd percentile in 70 % of the patients). 
 
At the end of 24 weeks post-treatment follow-up, mean decrease from baseline in weight and height 
percentiles were still 3 percentiles and 7 percentiles, respectively, and 20 % of the children continued 
to have inhibited growth (growth velocity < 3rd percentile). Based on interim data from the long-term 
follow-up portion of this study, 22 % (16/74) of children had a > 15 percentile decrease in height 
percentile, of whom 3 (4 %) children had a > 30 percentile decrease despite being off treatment for 
more than 1 year. In particular, decrease in mean height percentile at year 1 of long term follow-up 
was most prominent in prepubertal age children (see section 4.4). 
 
In this study, the most prevalent adverse reactions in all subjects were pyrexia (80 %), headache 
(62 %), neutropenia (33 %), fatigue (30 %), anorexia (29 %) and injection-site erythema (29 %). Only 
1 subject discontinued therapy as the result of an adverse reaction (thrombocytopenia). The majority 
of adverse reactions reported in the study were mild or moderate in severity. Severe adverse reactions 
were reported in 7 % (8/107) of all subjects and included injection site pain (1 %), pain in extremity 
(1 %), headache (1 %), neutropenia (1 %), and pyrexia (4 %). Important treatment-emergent adverse 
reactions that occurred in this patient population were nervousness (8 %), aggression (3 %), anger 
(2 %), depression/depressed mood (4 %) and hypothyroidism (3 %) and 5 subjects received 
levothyroxine treatment for hypothyroidism/elevated TSH. 
 
In combination with interferon alfa-2b 
In clinical trials of 118 children and adolescents 3 to 16 years of age treated with combination therapy 
of interferon alfa-2b and ribavirin, 6 % discontinued therapy due to adverse reactions. In general, the 
adverse reaction profile in the limited children and adolescent population studied was similar to that 
observed in adults, although there is a paediatric-specific concern regarding growth inhibition, as 
decrease in height percentile (mean percentile decrease of 9 percentile) and weight percentile (mean 

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percentile decrease of 13 percentile) were observed during treatment. Within the 5 years follow-up 
post-treatment period, the children had a mean height of 44th percentile, which was below the median 
of the normative population and less than their mean baseline height (48th percentile). Twenty (21 %) 
of 97 children had a > 15 percentile decrease in height percentile, of whom 10 of the 20 children had a 
> 30 percentile decrease in their height percentile from the start of treatment to the end of long-term 
follow-up (up to 5 years). During combination therapy for up to 48 weeks with interferon alfa-2b and 
ribavirin, growth inhibition is observed, the reversibility of which is uncertain. In particular, decrease 
in mean height percentile from baseline to the end of the long-term follow-up was most prominent in 
prepubertal age children (see section 4.4). 
 
Furthermore, suicidal ideation or attempts were reported more frequently compared to adult patients 
(2.4 % vs. 1 %) during treatment and during the 6 month follow-up after treatment. As in adult 
patients, children and adolescents also experienced other psychiatric adverse reactions (e.g., 
depression, emotional lability, and somnolence) (see section 4.4). In addition, injection site disorders, 
pyrexia, anorexia, vomiting and emotional lability occurred more frequently in children and 
adolescents compared to adult patients. Dose modifications were required in 30 % of patients, most 
commonly for anaemia and neutropenia. 
 
Reported adverse reactions listed in Table 5 are based on experience from the two multicentre 
children and adolescents clinical trials using ribavirin with interferon alfa-2b or peginterferon alfa-2b. 
Within the organ system classes, adverse reactions are listed under headings of frequency using the 
following categories: very common (≥ 1/10); common (≥ 1/100 to < 1/10), and uncommon (≥ 1/1,000 
to < 1/100). Within each frequency grouping, undesirable effects are presented in order of decreasing 
seriousness. 
 
Table 5 Adverse reactions very commonly, commonly and uncommonly reported during clinical 

trials in children and adolescents with ribavirin in combination with interferon alfa-2b or 
peginterferon alfa-2b 

System Organ Class Adverse Reactions 
Infections and infestations 
Very common: Viral infection, pharyngitis 
Common: Fungal infection, bacterial infection, pulmonary infection, 

nasopharyngitis, pharyngitis streptococcal, otitis media, 
sinusitis, tooth abscess, influenza, oral herpes, herpes 
simplex, urinary tract infection, vaginitis, gastroenteritis 

Uncommon: Pneumonia, ascariasis, enterobiasis, herpes zoster, cellulitis 
Neoplasms benign, malignant and unspecified (including cysts and polyps) 
Common: Neoplasm unspecified 
Blood and lymphatic system disorders 
Very common: Anaemia, neutropenia 
Common: Thrombocytopenia, lymphadenopathy 
Endocrine disorders 
Very common: Hypothyroidism 
Common: Hyperthyroidism, virilism 
Metabolism and nutrition disorders 
Very common: Anorexia, increased appetite, decreased appetite 
Common: Hypertriglyceridemia, hyperuricemia 
Psychiatric disorders 
Very common: Depression, insomnia, emotional lability 
Common: Suicidal ideation, aggression, confusion, affect liability, 

behaviour disorder, agitation, somnambulism, anxiety, mood 
altered, restlessness, nervousness, sleep disorder, abnormal 
dreaming, apathy 

Uncommon: Abnormal behaviour, depressed mood, emotional disorder, 
fear, nightmare 

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Nervous system disorders 
Very common: Headache, dizziness 
Common: Hyperkinesia, tremor, dysphonia, paresthaesia, 

hypoaesthesia, hyperaesthesia, concentration impaired, 
somnolence, disturbance in attention, poor quality of sleep 

Uncommon: Neuralgia, lethargy, psychomotor hyperactivity 
Eye disorders 
Common: Conjunctivitis, eye pain, abnormal vision, lacrimal gland 

disorder 
Uncommon: Conjunctival haemorrhage, eye pruritus, keratitis, vision 

blurred, photophobia 
Ear and labyrinth disorders 
Common: Vertigo 
Cardiac disorders 
Common: Tachycardia, palpitations 
Vascular disorders 
Common: Pallor, flushing 
Uncommon: Hypotension 
Respiratory, thoracic and mediastinal disorders 
Common: Dyspnoea, tachypnea, epistaxis, coughing, nasal congestion, 

nasal irritation, rhinorrhoea, sneezing, pharyngolaryngeal 
pain 

Uncommon: Wheezing, nasal discomfort 
Gastro-intestinal disorders 
Very common: Abdominal pain, abdominal pain upper, vomiting , diarrhoea, 

nausea 
Common: Mouth ulceration, stomatitis ulcerative, stomatitis, aphthous 

stomatitis, dyspepsia, cheilosis, glossitis, gastroesophoageal 
reflux, rectal disorder, gastrointestinal disorder, constipation, 
loose stools, toothache, tooth disorder, stomach discomfort, 
oral pain 

Uncommon: Gingivitis 
Hepatobiliary disorders 
Common: Hepatic function abnormal 
Uncommon: Hepatomegaly 

Skin and subcutaneous tissue disorders 
Very common: Alopecia, rash 
Common: Pruritus, photosensitivity reaction, maculopapular rash, 

eczema, hyperhidrosis, acne, skin disorder, nail disorder, skin 
discolouration, dry skin, erythema, bruise 

Uncommon: Pigmentation disorder, dermatitis atopic, skin exfoliation 
Musculoskeletal and connective tissue disorders 
Very common: Arthralgia, myalgia, musculoskeletal pain 
Common: Pain in extremity, back pain, muscle contracture 
Renal and urinary disorders 
Common: Enuresis, micturition disorder, urinary incontinence, 

proteinuria 
Reproductive system and breast disorders 
Common: Female: amenorrhea, menorrhagia, menstrual disorder, 

vaginal disorder, Male: testicular pain 
Uncommon: Female: dysmenorrhoea 
General disorders and administration site conditions 
Very common: Injection site inflammation, injection site reaction, injection 

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site erythema, injection site pain, fatigue, rigors, pyrexia, 
influenza-like illness, asthenia, malaise, irritability 

Common: Chest pain, oedema, pain, injection site pruritus, injection site 
rash, injection site dryness, feeling cold 

Uncommon: Chest discomfort, facial pain, injection site induration 
Investigations 
Very common: Growth rate decrease (height and/or weight decrease for age) 
Common: Blood thyroid stimulating hormone increased, thyroglobulin 

increased 
Uncommon: Anti-thyroid antibody positive 
Injury, poisoning and procedural complications 
Common: Skin laceration 
Uncommon: Contusion 
 
Most of the changes in laboratory values in the ribavirin/peginterferon alfa-2b clinical trial were mild 
or moderate. Decreases in haemoglobin, white blood cells, platelets, neutrophils and increase in 
bilirubin may require dose reduction or permanent discontinuation from therapy (see section 4.2). 
While changes in laboratory values were observed in some patients treated with ribavirin used in 
combination with peginterferon alfa-2b in the clinical trial, values returned to baseline levels within a 
few weeks after the end of therapy. 
 
4.9 Overdose 
 
In clinical trials with ribavirin used in combination with peginterferon alfa-2b or interferon alfa-2b, the 
maximum overdose reported was a total dose of 10 g of ribavirin (50 x 200 mg) and 39 MIU of 
interferon alfa-2b (13 subcutaneous injections of 3 MIU each) taken in one day by a patient in an 
attempt at suicide. The patient was observed for two days in the emergency room, during which time 
no adverse reaction from the overdose was noted. 
 
 
5. PHARMACOLOGICAL PROPERTIES 
 
5.1 Pharmacodynamic properties 
 
Pharmacotherapeutic group: Direct acting antivirals, nucleosides and nucleotides (excl. reverse 
transcriptase inhibitors), ATC code: J05AB04. 
 
Ribavirin is a synthetic nucleoside analogue which has shown in vitro activity against some RNA and 
DNA viruses. The mechanism by which ribavirin in combination with interferon alfa-2b exerts its 
effects against HCV is unknown. Oral formulations of ribavirin monotherapy have been investigated 
as therapy for chronic hepatitis C in several clinical trials. Results of these investigations showed that 
ribavirin monotherapy had no effect on eliminating hepatitis virus (HCV-RNA) or improving hepatic 
histology after 6 to 12 months of therapy and 6 months of follow-up. 
 
Ribavirin clinical trials in adults 
The use of ribavirin in combination treatment with interferon alfa-2b was evaluated in a number of 
clinical trials. Eligible patients for these trials had chronic hepatitis C confirmed by a positive 
HCV-RNA polymerase chain reaction assay (PCR) (> 30 IU/ml), a liver biopsy consistent with a 
histological diagnosis of chronic hepatitis with no other cause for the chronic hepatitis, and abnormal 
serum ALT. 
 
Naïve patients 
Three trials examined the use of interferon in naïve patients, two with ribavirin + interferon alfa-2b 
(C95-132 and I95-143) and one with ribavirin + peginterferon alfa-2b (C/I98-580). In all cases the 
treatment was for one year with a follow-up of six months. The sustained response at the end of 

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follow-up was significantly increased by the addition of ribavirin to interferon alfa-2b (41 % vs 16 %, 
p < 0.001). 
 
In clinical trials C95-132 and I95-143, ribavirin + interferon alfa-2b combination therapy proved to be 
significantly more effective than interferon alfa-2b monotherapy (a doubling in sustained response). 
Combination therapy also decreased the relapse rate. 
 
In clinical trial C/I98-580, 1,530 naïve patients were treated for one year with one of the following 
combination regimens: 
 Ribavirin (800 mg/day) + peginterferon alfa-2b (1.5 micrograms/kg/week) (n = 511). 
 Ribavirin (1,000/1,200 mg/day) + peginterferon alfa-2b (1.5 micrograms/kg/week for one 

month followed by 0.5 microgram/kg/week for 11 months) (n = 514). 
 Ribavirin (1,000/1,200 mg/day) + interferon alfa-2b (3 MIU three times a week) (n = 505). 
 
In this trial, the combination of ribavirin and peginterferon alfa-2b (1.5 micrograms/kg/week) was 
significantly more effective than the combination of ribavirin and interferon alfa-2b, particularly in 
patients infected with Genotype 1. Sustained response was assessed by the response rate six months 
after the cessation of treatment.  
 
HCV genotype and baseline virus load are prognostic factors which are known to affect response rates. 
However, response rates in this trial were shown to be dependent also on the dose of ribavirin 
administered in combination with peginterferon alfa-2b or interferon alfa-2b. In those patients that 
received > 10.6 mg/kg ribavirin (800 mg dose in typical 75 kg patient), regardless of genotype or viral 
load, response rates were significantly higher than in those patients that received ≤ 10.6 mg/kg 
ribavirin (Table 6), while response rates in patients that received > 13.2 mg/kg ribavirin were even 
higher. 
 
Table 6 Sustained response rates with Ribavirin + peginterferon alfa-2b  
 (by ribavirin dose [mg/kg], genotype and viral load) 
HCV Genotype  
 

Ribavirin dose 
(mg/kg) 

P 1.5/R P 0.5/R 
 

I/R 
 

All Genotypes All 54 % 47 % 47 % 
 10.6 50 % 41 % 27 % 
> 10.6 61 % 48 % 47 % 

Genotype 1 All 42 % 34 % 33 % 
 10.6 38 % 25 % 20 % 
> 10.6 48 % 34 % 34 % 

 Genotype 1  
  600,000 IU/ml 

All 73 % 51 % 45 % 
 10.6 74 % 25 % 33 % 
> 10.6 71 % 52 % 45 % 

 Genotype 1 
 > 600,000 IU/ml 

All 30 % 27 % 29 % 
 10.6 27 % 25 % 17 % 
> 10.6 37 % 27 % 29 % 

Genotype 2/3 All 82 % 80 % 79 % 
 10.6 79 % 73 % 50 % 
> 10.6 88 % 80 % 80 % 

P1.5/R Ribavirin (800 mg) + peginterferon alfa-2b (1.5 micrograms/kg)  
P0.5/R Ribavirin (1,000/1,200 mg) + peginterferon alfa-2b (1.5 to 0.5 microgram/kg) 
I/R Ribavirin (1,000/1,200 mg) + interferon alfa-2b (3 MIU) 
 
HCV/HIV Co-infected patients 
Two trials have been conducted in patients co-infected with HIV and HCV. The response to treatment 
in both of these trials is presented in Table 7. Study 1 (RIBAVIC; P01017) was a randomized, 
multicentre study which enrolled 412 previously untreated adult patients with chronic hepatitis C who 
were co-infected with HIV. Patients were randomized to receive either ribavirin (800 mg/day) plus 

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peginterferon alfa-2b (1.5 μg/kg/week) or ribavirin (800 mg/day) plus interferon alfa-2b (3 MIU TIW) 
for 48 weeks with a follow-up period of 6 months. Study 2 (P02080) was a randomized, single centre 
study that enrolled 95 previously untreated adult patients with chronic hepatitis C who were coinfected 
with HIV. Patients were randomized to receive either ribavirin (800-1,200 mg/day based on weight) 
plus peginterferon alfa-2b (100 or 150 μg/week based on weight) or ribavirin (800-1,200 mg/day 
based on weight) plus interferon alfa-2b (3 MIU TIW). The duration of therapy was 48 weeks with a 
follow-up period of 6 months except for patients infected with genotypes 2 or 3 and viral load 
< 800,000 IU/ml (Amplicor) who were treated for 24 weeks with a 6 month follow-up period. 
 
Table 7 Sustained virological response based on genotype after ribavirin in combination with 

peginterferon alfa-2b in HCV/HIV co-infected patients 
 Study 11 Study 22 
 

Ribavirin 
(800 mg/day) 

+ 
peginterferon 

alfa-2b 
(1.5 μg/kg/ 

week) 

Ribavirin 
(800 mg/day) 

+ 
interferon 

alfa-2b 
(3 MIU 
TIW) 

p 
value 

a 

Ribavirin 
(800-1,200 mg

/day)d + 
peginterferon 

alfa-2b 
(100 or 

150c μg/week) 

Ribavirin 
(800-1,200 mg

/day) 
d 

+ 
interferon 

alfa-2b 
(3 MIU TIW) 

p 
value

b 
All 27 % (56/205) 20 % (41/205) 0.047 44 % (23/52) 21 % (9/43) 0.017 

Genotype 1, 4 17 % (21/125) 6 % (8/129) 0.006 38 % (12/32) 7 % (2/27) 0.007
Genotype 2, 3 44 % (35/80) 43 % (33/76) 0.88 53 % (10/19) 47 % (7/15) 0.730

MIU = million international units; TIW = three times a week. 
a: p value based on Cochran-Mantel Haenszel Chi square test. 
b: p value based on chi-square test. 
c: subjects < 75 kg received 100 μg/week peginterferon alfa-2b and subjects ≥ 75 kg received 150 μg/week peginterferon 

alfa-2b. 
d: Ribavirin dosing was 800 mg for patients < 60 kg, 1,000 mg for patients 60-75 kg, and 1,200 mg for patients > 75 kg. 
 
1 Carrat F, Bani-Sadr F, Pol S et al. JAMA 2004; 292(23): 2839-2848. 
2 Laguno M, Murillas J, Blanco J.L et al. AIDS 2004; 18(13): F27-F36. 
 
Histological response 
Liver biopsies were obtained before and after treatment in Study 1 and were available for 210 of the 
412 subjects (51 %). Both the Metavir score and Ishak grade decreased among subjects treated with 
ribavirin in combination with peginterferon alfa-2b. This decline was significant among responders 
(-0.3 for Metavir and -1.2 for Ishak) and stable (-0.1 for Metavir and -0.2 for Ishak) among 
non-responders. In terms of activity, about one-third of sustained responders showed improvement and 
none showed worsening. There was no improvement in terms of fibrosis observed in this study. 
Steatosis was significantly improved in patients infected with HCV Genotype 3. 
 
Retreatment of relapse patients with ribavirin and interferon alfa-2b combination treatment 
Two trials examined the use of ribavirin and interferon alfa-2b combination treatment in relapse 
patients (C95-144 and I95-145); 345 chronic hepatitis patients who had relapsed after previous 
interferon treatment were treated for six months with a six month follow-up. Combination therapy 
with ribavirin and interferon alfa-2b resulted in a sustained virological response that was ten-fold 
higher than that with interferon alfa-2b alone (49 % vs 5 %, p < 0.0001). This benefit was maintained 
irrespective of standard predictors of response to interferon alfa-2b such as virus level, HCV genotype 
and histological staging. 
 
Long-term efficacy data - Adults 
Two large long-term follow-up studies enrolled 1,071 patients and 567 patients after treatment in prior 
studies with non-pegylated interferon alfa-2b (with or without ribavirin) and pegylated interferon 
alfa-2b (with or without ribavirin), respectively. The purpose of the studies was to evaluate the 
durability of sustained virologic response (SVR) and assess the impact of continued viral negativity on 
clinical outcomes. At least 5 years of long-term follow-up was completed after treatment in 

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462 patients and 327 patients, respectively. Twelve out of 492 sustained responders and only 3 out of 
366 sustained responders relapsed, respectively, in the studies. 
The Kaplan-Meier estimate for continued sustained response over 5 years is 97 % (95 % CI: 95-99 %) 
for patients receiving non-pegylated interferon alfa-2b (with or without ribavirin), and is 99 % (95 % 
CI: 98-100 %) for patients receiving pegylated interferon alfa-2b (with or without ribavirin). 
SVR after treatment of chronic HCV with interferon alfa-2b (pegylated and non-pegylated, with or 
without ribavirin) results in long-term clearance of the virus providing resolution of the hepatic 
infection and clinical 'cure' from chronic HCV. However, this does not preclude the occurrence of 
hepatic events in patients with cirrhosis (including hepatocarcinoma). 
 
Ribavirin clinical trials in children and adolescents: 
Ribavirin in combination with interferon alfa-2b 
Children and adolescents 3 to 16 years of age with compensated chronic hepatitis C and detectable 
HCV-RNA (assessed by a central laboratory using a research-based RT-PCR assay) were enrolled in 
two multicentre trials and received ribavirin 15 mg/kg per day plus interferon alfa-2b 3 MIU/m2 
3 times a week for 1 year followed by 6 months follow-up after treatment. A total of 118 patients were 
enrolled: 57 % male, 80 % Caucasian, and 78 % genotype 1, 64 %  12 years of age. The population 
enrolled mainly consisted in children with mild to moderate hepatitis C. In the two multicentre trials, 
sustained virological response rates in children and adolescents were similar to those in adults. Due to 
the lack of data in these two multicentre trials for children with severe progression of the disease, and 
the potential for undesirable effects, the benefit/risk of the combination of ribavirin and interferon 
alfa-2b needs to be carefully considered in this population (see sections 4.1, 4.4 and 4.8).The study 
results are summarized in Table 8. 
 
Table 8 Sustained virological response in previously untreated children and adolescents 
 Ribavirin 15 mg/kg/day  

+ 
interferon alfa-2b 3 MIU/m2 3 times a week 

Overall Responsea (n = 118) 54 (46 %)* 

Genotype 1 (n = 92) 33 (36 %)* 

Genotype 2/3/4 (n = 26) 21 (81 %)* 

* Number (%) of patients 
a. Defined as HCV-RNA below limit of detection using a research based RT-PCR assay at end of treatment and during 
follow-up period. 
 
Long-term efficacy data - Children and adolescents 
A five-year long-term, observational, follow-up study enrolled 97 paediatric chronic hepatitis C 
patients after treatment in two previously mentioned multicentre trials. Seventy percent (68/97) of all 
enrolled subjects completed this study of which 75 % (42/56) were sustained responders. The purpose 
of the study was to annually evaluate the durability of sustained virologic response (SVR) and assess 
the impact of continued viral negativity on clinical outcomes for patients who were sustained 
responders 24 weeks post-treatment of the 48-week interferon alfa-2b and ribavirin treatment. All but 
one of the paediatric subjects remained sustained virologic responders during long-term follow-up 
after completion of treatment with interferon alfa-2b plus ribavirin. The Kaplan-Meier estimate for 
continued sustained response over 5 years is 98 % [95 % CI: 95 %, 100 %] for paediatric patients 
treated with interferon alfa-2b and ribavirin. Additionally, 98 % (51/52) with normal ALT levels at 
follow-up week 24 maintained normal ALT levels at their last visit. 
 
SVR after treatment of chronic HCV with non-pegylated interferon alfa-2b with ribavirin results in 
long-term clearance of the virus providing resolution of the hepatic infection and clinical 'cure' from 

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chronic HCV. However, this does not preclude the occurrence of hepatic events in patients with 
cirrhosis (including hepatocarcinoma). 
 
5.2 Pharmacokinetic properties 
 
Ribavirin is absorbed rapidly following oral administration of a single dose (mean Tmax= 1.5 hours), 
followed by rapid distribution and prolonged elimination phases (single dose half-lives of absorption, 
distribution and elimination are 0.05, 3.73 and 79 hours, respectively). Absorption is extensive with 
approximately 10 % of a radiolabelled dose excreted in the faeces. However, absolute bioavailability 
is approximately 45 %-65 %, which appears to be due to first pass metabolism. There is a linear 
relationship between dose and AUCtf following single doses of 200-1,200 mg ribavirin. Volume of 
distribution is approximately 5,000 l. Ribavirin does not bind to plasma proteins. 
 
Ribavirin has been shown to produce high inter- and intra-subject pharmacokinetic variability 
following single oral doses (intrasubject variability of approximately 30 % for both AUC and Cmax), 
which may be due to extensive first pass metabolism and transfer within and beyond the blood 
compartment. 
 
Ribavirin transport in non-plasma compartments has been most extensively studied in red cells, and 
has been identified to be primarily via an es-type equilibrative nucleoside transporter. This type of 
transporter is present on virtually all cell types and may account for the high volume of distribution of 
ribavirin. The ratio of whole blood:plasma ribavirin concentrations is approximately 60:1; the excess 
of ribavirin in whole blood exists as ribavirin nucleotides sequestered in erythrocytes. 
 
Ribavirin has two pathways of metabolism: 1) a reversible phosphorylation pathway; 2) a degradative 
pathway involving deribosylation and amide hydrolysis to yield a triazole carboxyacid metabolite. 
Both ribavirin and its triazole carboxamide and triazole carboxylic acid metabolites are also excreted 
renally. 
 
Upon multiple dosing, ribavirin accumulates extensively in plasma with a six-fold ratio of 
multiple-dose to single-dose AUC12hr. Following oral dosing with 600 mg BID, steady-state was 
reached by approximately four weeks, with mean steady state plasma concentrations approximately 
2,200 ng/ml. Upon discontinuation of dosing the half-life was approximately 298 hours, which 
probably reflects slow elimination from non-plasma compartments. 
 
Transfer into seminal fluid: Seminal transfer of ribavirin has been studied. Ribavirin concentration in 
seminal fluid is approximately two-fold higher compared to serum. However, ribavirin systemic 
exposure of a female partner after sexual intercourse with a treated patient has been estimated and 
remains extremely limited compared to therapeutic plasma concentration of ribavirin. 
 
Food effect: The bioavailability of a single oral dose of ribavirin was increased by co-administration 
of a high fat meal (AUCtf and Cmax both increased by 70 %). It is possible that the increased 
bioavailability in this study was due to delayed transit of ribavirin or modified pH. The clinical 
relevance of results from this single dose study is unknown. In the pivotal clinical efficacy trial, 
patients were instructed to take ribavirin with food to achieve the maximal plasma concentration of 
ribavirin. 
 
Renal function: Single-dose ribavirin pharmacokinetics were altered (increased AUCtf and Cmax) in 
patients with renal dysfunction compared with control subjects (creatinine clearance > 90 ml/minute). 
This appears to be due to reduction of apparent clearance in these patients. Ribavirin concentrations 
are essentially unchanged by haemodialysis. 
 
Hepatic function: Single-dose pharmacokinetics of ribavirin in patients with mild, moderate or severe 
hepatic dysfunction (Child-Pugh Classification A, B or C) are similar to those of normal controls. 
 

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Elderly patients (≥ 65 years of age): Specific pharmacokinetic evaluations for elderly subjects have not 
been performed. However, in a population pharmacokinetic study, age was not a key factor in the 
kinetics of ribavirin; renal function is the determining factor. 
 
Population pharmacokinetic analysis was performed using sparsely sampled serum concentration 
values from four controlled clinical trials. The clearance model developed showed that body weight, 
gender, age, and serum creatinine were the main covariates. For males, clearance was approximately 
20 % higher than for females. Clearance increased as a function of body weight and was reduced at 
ages greater than 40 years. Effects of these covariates on ribavirin clearance appear to be of limited 
clinical significance due to the substantial residual variability not accounted for by the model. 
 
Children and adolescents: 
 
Ribavirin in combination with interferon alfa-2b 
Multiple-dose pharmacokinetic properties for ribavirin and interferon alfa-2b in children and 
adolescents with chronic hepatitis C between 5 and 16 years of age are summarized in Table 9. The 
pharmacokinetics of ribavirin and interferon alfa-2b (dose-normalized) are similar in adults and 
children or adolescents. 
 
Table 9 Mean (% CV) multiple-dose pharmacokinetic parameters for interferon alfa-2b and 

Ribavirin when administered to children or adolescents with chronic 
 hepatitis C  

Parameter Ribavirin 
15 mg/kg/day as 2 divided 

doses 
(n = 17) 

Interferon alfa-2b 
3 MIU/m2 3 times a week 

(n = 54) 

Tmax (hr) 1.9 (83) 5.9 (36) 
Cmax (ng/ml) 3,275 (25) 51 (48) 
AUC* 29,774 (26) 622 (48) 
Apparent clearance l/hr/kg 0.27 (27) Not done 
*AUC12 (ng.hr/ml) for Ribavirin; AUC0-24 (IU.hr/ml) for interferon alfa-2b 
 
5.3 Preclinical safety data 
 
Ribavirin: Ribavirin is embryotoxic or teratogenic, or both, at doses well below the recommended 
human dose in all animal species in which studies have been conducted. Malformations of the skull, 
palate, eye, jaw, limbs, skeleton and gastrointestinal tract were noted. The incidence and severity of 
teratogenic effects increased with escalation of the dose. Survival of foetuses and offspring was 
reduced. 
 
In a juvenile rat toxicity study, pups dosed from postnatal day 7 to 63 with 10, 25 and 50 mg/kg of 
ribavirin demonstrated a dose-related decrease in overall growth, which was subsequently manifested 
as slight decreases in body weight, crown-rump length and bone length. At the end of the recovery 
period, tibial and femoral changes were minimal although generally statistically significant compared 
to controls in males at all dose levels and in females dosed with the two highest doses compared to 
controls. No histopathological effects on bone were observed. No ribavirin effects were observed 
regarding neurobehavioural or reproductive development. Plasma concentrations achieved in rat pups 
were below human plasma concentrations at the therapeutic dose. 
 
Erythrocytes are a primary target of toxicity for ribavirin in animal studies. Anaemia occurs shortly 
after initiation of dosing, but is rapidly reversible upon cessation of treatment. 
 
In 3- and 6-month studies in mice to investigate Ribavirin-induced testicular and sperm effects, 
abnormalities in sperm, occurred at doses of 15 mg/kg and above. These doses in animals produce 
systemic exposures well below those achieved in humans at therapeutic doses. Upon cessation of 

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treatment, essentially total recovery from ribavirin-induced testicular toxicity occurred within one or 
two spermatogenic cycles (see section 4.6). 
 
Genotoxicity studies have demonstrated that ribavirin does exert some genotoxic activity. Ribavirin 
was active in the Balb/3T3 in vitro Transformation Assay. Genotoxic activity was observed in the 
mouse lymphoma assay, and at doses of 20-200 mg/kg in a mouse micronucleus assay. A dominant 
lethal assay in rats was negative, indicating that if mutations occurred in rats they were not transmitted 
through male gametes. 
 
Conventional carcinogenicity rodent studies with low exposures compared to human exposure under 
therapeutic conditions (factor 0.1 in rats and 1 in mice) did not reveal tumorigenicity of ribavirin. In 
addition, in a 26 week carcinogenicity study using the heterozygous p53(+/-) mouse model, ribavirin 
did not produce tumours at the maximally tolerated dose of 300 mg/kg (plasma exposure factor 
approximately 2.5 compared to human exposure). These studies suggest that a carcinogenic potential 
of ribavirin in humans is unlikely. 
 
Ribavirin plus interferon: When used in combination with peginterferon alfa-2b or interferon alfa-2b, 
ribavirin did not cause any effects not previously seen with either active substance alone. The major 
treatment-related change was a reversible mild to moderate anaemia, the severity of which was greater 
than that produced by either active substance alone. 
 
 
6. PHARMACEUTICAL PARTICULARS 
 
6.1 List of excipients 
 
Film-coated tablet contents: 

Microcrystalline cellulose 
Povidone K 25 
Crospovidone 
Silica colloidal 
Magnesium stearate 
Coating:  
Hypromellose (E464) 
Titanium dioxide (E171) 
Macrogol 

 
6.2 Incompatibilities 
 
Not applicable. 
 
6.3 Shelf life 
 
5 years 
 
6.4 Special precautions for storage 
 
Do not store above 25°C. 
 
6.5 Nature and contents of container 
 
Ribavirin BioPartners film-coated tablets are packaged in blisters consisting of polyvinyl chloride 
(PVC)/polyvinylidene chloride (PVdC) and aluminium foil. 
 
Packs of 84, 112, 140 and 168 film-coated tablets. 
 

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Not all pack sizes may be marketed. 
 
6.6 Special precautions for disposal 
 
No special requirements. 
 
 
7. MARKETING AUTHORISATION HOLDER 
 
Biopartners GmbH 
Kaiserpassage 11 
D-72764 Reutlingen 
Germany 
 
 
8. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/10/626/001 84 film-coated tablets 
EU/1/10/626/002 112 film-coated tablets 
EU/1/10/626/003 140 film-coated tablets 
EU/1/10/626/004 168 film-coated tablets 
 
 
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 
 
Date of first authorisation: 06 April 2010 
 
 
10. DATE OF REVISION OF THE TEXT 
 
 
 
Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu/ 
 

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26 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX II 
 

A. MANUFACTURING AUTHORISATION HOLDER 
RESPONSIBLE FOR BATCH RELEASE 

 
B. CONDITIONS OF THE MARKETING AUTHORISATION 

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A. MANUFACTURING AUTHORISATION HOLDER RESPONSIBLE FOR BATCH 
RELEASE 

 
Name and address of the manufacturer responsible for batch release 
 
Biopartners GmbH 
Kaiserpassage 11 
D-72764 Reutlingen 
Germany 
 
 
B. CONDITIONS OF THE MARKETING AUTHORISATION 
 
 CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE IMPOSED ON 

THE MARKETING AUTHORISATION HOLDER 
 
Medicinal product subject to restricted medical prescription (See Annex I: Summary of Product 
Characteristics, section 4.2) 
 
 CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND 

EFFECTIVE USE OF THE MEDICINAL PRODUCT 
 
Not applicable 
 
 OTHER CONDITIONS 
 
Pharmacovigilance system 
The MAH must ensure that the system of pharmacovigilance, as described in version 5 dated 27 April 
2009 presented in Module 1.8.2 of the Marketing Authorisation Application, is in place and 
functioning before and whilst the product is on the market. 
 
Risk Management plan 
Not applicable. The application is based on a reference medicinal product for which no safety 
concerns requiring additional risk minimization activities have been identified. 
 
PSURs 
The PSUR submission schedule should follow the PSUR schedule for the reference medicinal product. 
 
 

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28 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX III 
 

LABELLING AND PACKAGE LEAFLET 

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A. LABELLING 

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PARTICULARS TO APPEAR ON THE OUTER PACKAGING 
 
Outer carton 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
Ribavirin BioPartners 200 mg film-coated tablets 
 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each Ribavirin BioPartners tablet contains 200 mg of ribavirin. 
 
 
3. LIST OF EXCIPIENTS 
 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
84 film-coated tablets 
112 film-coated tablets 
140 film-coated tablets 
168 film-coated tablets 
 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Oral use 
Read the package leaflet before use. 
 
 
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE REACH AND SIGHT OF CHILDREN 
 
Keep out of the reach and sight of children. 
 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
 
8. EXPIRY DATE 
 
EXP 
 
 
9. SPECIAL STORAGE CONDITIONS 
 
Do not store above 25°C. 
 
 

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10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 
 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Biopartners GmbH 
Kaiserpassage 11 
D-72764 Reutlingen 
Germany 
 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/10/626/001 (84 film-coated tablets) 
EU/1/10/626/002 (112 film-coated tablets) 
EU/1/10/626/003 (140 film-coated tablets) 
EU/1/10/626/004 (168 film-coated tablets) 
 
 
13. BATCH NUMBER 
 
Lot 
 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
Ribavirin BioPartners 
 
 

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MINIMUM PARTICULARS TO APPEAR ON BLISTERS OR STRIPS 
 
Blister foil 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
Ribavirin BioPartners 200 mg 
 
 
2. NAME OF THE MARKETING AUTHORISATION HOLDER 
 
Biopartners GmbH 
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. OTHER 
 
 

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B. PACKAGE LEAFLET 
 

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PACKAGE LEAFLET: INFORMATION FOR THE USER 

 
Ribavirin BioPartners 200 mg film-coated tablets 

ribavirin 
 
Read all of this leaflet carefully before you start taking this medicine 
- Keep this leaflet. You may need to read it again. 
- If you have any further questions, ask your doctor or pharmacist. 
- This medicine has been prescribed for you. Do not pass it on to others. It may harm them, even 

if their symptoms are the same as yours. 
- 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. 
 
In this leaflet: 
1. What Ribavirin BioPartners is and what it is used for 
2. Before you take Ribavirin BioPartners 
3. How to take Ribavirin BioPartners 
4. Possible side effects 
5. How to store Ribavirin BioPartners 
6. Further information 
 
 
1. WHAT RIBAVIRIN BIOPARTNERS IS AND WHAT IT IS USED FOR 
 
Ribavirin BioPartners contains the active ingredient ribavirin. Ribavirin BioPartners stops the 
multiplication of many types of viruses, including hepatitis C virus. Ribavirin BioPartners must not be 
used without interferon alfa-2b, i.e. Ribavirin BioPartners must not be used alone. 
 
Previously untreated patients: 
The combination of Ribavirin BioPartners with interferon alfa-2b is used to treat patients 3 years of 
age and older who have chronic hepatitis C (HCV) infection, except genotype 1. For children and 
adolescents weighing less than 47 kg a solution formulation is available. 
 
Previously treated adult patients: 
The combination of Ribavirin BioPartners with interferon alfa-2b is used to treat adult patients with 
chronic hepatitis C, who have previously responded to a treatment with an alpha interferon alone, but 
whose condition has recurred. 
 
There is no safety or efficacy information on the use of ribavirin with other forms of interferon (i.e., 
not alfa-2b). 
 
 
2. BEFORE YOU TAKE RIBAVIRIN BIOPARTNERS 
 
Ribavirin BioPartners is not recommended for use in patients under the age of 3 years. 
 
Do not take Ribavirin BioPartners 
If any of the following apply to you or your child you are caring for, do not take Ribavirin 
BioPartners, and tell your doctor if you: 
 are allergic (hypersensitive) to ribavirin or any of the other ingredients of Ribavirin BioPartners 

(see section 6, further information). 
 are pregnant or planning to become pregnant (see section “Pregnancy and breast-feeding”). 
 have any severe medical conditions that leave you very weak, including severe kidney disease.  
 are breast-feeding. 

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35 

 have had any previous severe heart problems, or have had any problems with the heart in the 
last 6 months. 

 have had severe liver problems, which are not related to hepatitis C.  
  have suffered from any blood disorder, for example anaemia (low blood count), thalassemia or 

sickle-cell anaemia.  
  have suffered from autoimmune disease in the past, or suffer from autoimmune hepatitis, or are 

taking other medicines that suppress your immune system (that protects you against infection 
and some diseases).  
 

Children and adolescents must not take combination therapy with Ribavirin BioPartners and alpha 
interferon when there is existence or history of serious nervous or mental problems, such as severe 
depression, thoughts of suicide or attempted suicide. 
 
You should tell your doctor if you have suffered from any other serious illness in the past.  
 
Reminder: Please read the “Do not use” section of the Package Leaflet for interferon alfa-2b before 

you begin combination treatment with Ribavirin BioPartners. 
 
Take special care with Ribavirin BioPartners 
Seek medical advice immediately if you develop symptoms of a severe allergic reaction (such as 
difficulty in breathing, wheezing or hives) while taking this treatment. 
 
Children and adolescents weighing less than 47 kg: 
The use of Ribavirin BioPartners tablets is not recommended.  
 
You should tell your doctor if you or your child you are caring for: 
 are an adult who has or had a severe nervous or mental disorder, confusion, unconsciousness, 

or have had thoughts of suicide or have attempted suicide, or have a history of substance 
abuse (e.g., alcohol or drugs). 

 have ever had depression or develop symptoms associated with depression (e.g. feeling of 
sadness, dejection, etc.) while on treatment with Ribavirin. 

 are a woman of childbearing age (see section “Pregnancy and breast-feeding”). 
 are a male and your female partner is of childbearing age (see section “Pregnancy and 

breast-feeding”). 
 had a previous serious heart condition or have cardiac disease. 
 are older than 65 years or if you have problems with your kidneys. 
 have or have had any serious illness. 
 have thyroid problems. 
 
During treatment with Ribavirin in combination therapy with an alpha interferon, dental and gum 
disorders, which may lead to loss of teeth, have been reported. In addition, dry mouth that could 
have a damaging effect on teeth and membranes of the mouth has been reported during long-term 
treatment with ribavirin in combination therapy with an alpha interferon. You should brush your teeth 
thoroughly twice daily and have regular dental examinations. In addition some patients may 
experience vomiting. If you have this reaction, be sure to rinse your mouth thoroughly afterwards. 
 
During treatment with Ribavirin BioPartners in combination therapy with an alpha interferon, patients 
may experience eye problems, or loss of vision in rare instances. If you receive ribavirin in 
combination with an alpha interferon, you should have a baseline eye examination. Any patient 
complaining of decrease or loss of vision must have a prompt and complete eye examination. Patients 
with pre-existing eye disorders (e.g., diabetic or hypertensive retinopathy) should receive periodic eye 
exams during combination therapy with ribavirin and an alpha interferon. Combination therapy with 
ribavirin and an alpha interferon should be discontinued in patients who develop new or worsening 
eye disorders. 
 

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Reminder: Please read the “Take special care” section of the Package Leaflet for interferon alfa-2b 
before you begin combination treatment. 

 
Taking other medicines 
Please tell your doctor or pharmacist if you or the child you are caring for: 

- are taking or have recently taken any other medicines, including medicines obtained without 
a prescription. 

- are receiving azathioprine in combination with ribavirin and pegylated alpha interferons and, 
therefore may be at an increased risk of developing severe blood disorders. 

- are infected with both Human Immunodeficiency Virus (HIV-positive) and Hepatitis C 
Virus (HCV) and are being treated with an anti-HIV medicinal product(s) - [nucleoside 
reverse transcriptase inhibitor (NRTI), and/or highly active anti-retroviral therapy 
(HAART)]: 
– Taking Ribavirin BioPartners in combination with an alpha interferon and an anti-HIV 

medicinal product(s) may increase the risk of lactic acidosis, liver failure, and blood 
abnormalities development (reduction in number of red blood cells which carry 
oxygen, certain white blood cells that fight infection, and blood clotting cells called 
platelets). 

– With zidovudine or stavudine, it is not certain if Ribavirin BioPartners will change 
the way these medicines work. Therefore, your blood will be checked regularly to be 
sure that the HIV infection is not getting worse. If it gets worse, your doctor will 
decide whether or not your Ribavirin BioPartners treatment needs to be changed. 
Additionally, patients receiving zidovudine with ribavirin in combination with alpha 
interferons could be at increased risk of developing anaemia (low number of red 
blood cells). Therefore the use of zidovudine and ribavirin in combination with alpha 
interferons is not recommended. 

– Due to the risk of lactic acidosis (a build-up of lactic acid in the body) and 
pancreatitis, the use of ribavirin and didanosine is not recommended and the use of 
ribavirin and stavudine should be avoided. 

– Co-infected patients with advanced liver disease receiving HAART may be at 
increased risk of worsening liver function. Adding treatment with an alpha interferon 
alone or in combination with ribavirin may increase the risk in this patient subset. 

 
Reminder: Please read the “Taking other medicines” section of the Package Leaflet for interferon 

alfa-2b before you begin combination treatment. 
 
Taking Ribavirin BioPartners with food and drink 
Ribavirin BioPartners must be taken with food. 
 
Pregnancy and breast-feeding 
If you are pregnant, you must not take Ribavirin BioPartners. Ribavirin BioPartners can be very 
damaging to your unborn baby (embryo). 
 
Both female and male patients must take special precautions in their sexual activity if there is any 
possibility for pregnancy to occur: 
- Girl or woman of childbearing age: 

You must have a negative pregnancy test before treatment, each month during treatment, and for 
the 4 months after treatment is stopped. This should be discussed with your doctor. 

- Men: 
Do not have sex with a pregnant woman unless you use a condom. This will lessen the 
possibility for ribavirin to be left in the woman’s body. 
If your female partner is not pregnant now but is of childbearing age, she must be tested for 
pregnancy each month during treatment and for the 7 months after treatment has stopped. 
You or your female partner must use an effective contraceptive during the time you are taking 
Ribavirin BioPartners and for 7 months after stopping treatment. This should be discussed with 
your doctor (see section “Do not take Ribavirin BioPartners”). 

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37 

 
If you are a woman who is breast-feeding, you must not take Ribavirin BioPartners. Discontinue 
breast-feeding before starting to take Ribavirin BioPartners. 
 
Driving and using machines 
Ribavirin BioPartners does not affect your ability to drive or use machines; however, interferon 
alfa-2b may affect your ability to drive or use machines. Therefore,. do not drive or use machines if 
you become tired, sleepy, or confused from this treatment. 
 
 
3. HOW TO TAKE RIBAVIRIN BIOPARTNERS 
 
General information about taking Ribavirin BioPartners: 
If the child you are caring for is under the age of 3 years, do not administer. 
 
Always take Ribavirin BioPartners exactly as your doctor has told you. You should check with your 
doctor or pharmacist if you are not sure. 
Do not take more than the recommended dosage and take the medicine for as long as prescribed. Your 
doctor has determined the correct dose of Ribavirin BioPartners based on how much you or the child 
you are caring for weighs. 
 
Standard blood tests will be taken to check your blood, kidney and liver function. 

- Blood tests will be done regularly to help your doctor to know if this treatment is working. 
- Depending upon the results of these tests, your doctor may change/adjust the number of 

tablets you or the child you are caring for take, prescribe a different pack size of Ribavirin 
BioPartners, and/or change the length of time to take this treatment. 

- If you have or develop severe kidney or liver problems, this treatment will be stopped. 
 
The usual dose, according to how much the patient weighs, is shown in the table below: 
1. Look for the line that shows how much the adult or child/adolescent weighs. 

Reminder: If the child is under the age of 3 years, do not administer. 
2. Read across on the same line to see how many tablets to take. 

Reminder: If your doctor’s instructions are different from the amounts in the below table, 
follow your doctor’s instructions. 

3. If you have any questions about the dose, ask your doctor. 
 

Ribavirin BioPartners film-coated tablets for oral use - dose based on body weight 
If the adult 

weighs 
(kg) 

Usual 
daily Ribavirin 

BioPartners dose Number of 200 mg tablets 
< 65 800 mg 2 tablets in the morning and 2 tablets in the evening 

65 – 80 1,000 mg 2 tablets in the morning and 3 tablets in the evening 
81 - 105 1,200 mg 3 tablets in the morning and 3 tablets in the evening 

> 105 1,400 mg 3 tablets in the morning and 4 tablets in the evening 
   

If the 
child/adolescent 

weighs (kg) 

Usual 
daily Ribavirin 

BioPartners dose Number of 200 mg tablets 
47 – 49 600 mg 1 tablet in the morning and 2 tablets in the evening 
50 – 65 800 mg 2 tablets in the morning and 2 tablets in the evening 

> 65 see adult dose and corresponding number of film-coated tablets 
 
Take your prescribed dose by mouth with water and during your meal. Do not chew the film-coated 
tablets. 

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For children or adolescents who cannot swallow a film-coated tablet, an oral solution of ribavirin is 
available. 
 
Reminder: Ribavirin BioPartners is only to be used in combination with interferon alfa-2b for 

hepatitis C virus infection. For complete information be sure to read the “How to use” 
section of the Package Leaflet for interferon alfa-2b. 

 
Interferon medicine that is used in combination with Ribavirin BioPartners may cause unusual 
tiredness; if you are injecting this medicine yourself or giving it to a child, use it at bedtime. 
 
If you take more Ribavirin BioPartners than you should 
Tell your doctor or pharmacist as soon as possible. 
 
If you forget to take Ribavirin BioPartners 
If you are self-administering treatment, or if you are the caregiver of a child taking Ribavirin 
BioPartners in combination with interferon alfa-2b, take/administer the missed dose as soon as 
possible during the same day. If an entire day has gone by, check with your doctor. Do not take a 
double dose to make up for a forgotten dose. 
 
 
4. POSSIBLE SIDE EFFECTS 
 
Please read the “Possible side effects” section of the Package Leaflet for interferon alfa-2b. 
 
Like all medicines, Ribavirin BioPartners used in combination with an alpha interferon product can 
cause side effects, although not everybody gets them.  
 
You should consult your doctor immediately if any of the following side effects occur during 
treatment with Ribavirin BioPartners and interferon alfa-2b: 
 
Psychiatric and Central Nervous System: 
Some people get depressed when taking ribavirin in combination treatment with an interferon, and in 
some cases people had thoughts about threatening the life of others, suicidal thoughts or aggressive 
behaviour (sometimes directed against others). Some patients have actually committed suicide. Be sure 
to seek emergency care if you notice that you are becoming depressed or have suicidal thoughts or 
change in your behaviour. You may want to consider asking a family member or close friend to help 
you stay alert to signs of depression or changes in your behaviour. 
 
Children and adolescents are particularly prone to develop depression when being treated with 
ribavirin and interferon alpha. Immediately contact the doctor or seek emergency treatment if they 
display any unusual behavioural symptoms, feel depressed, or feel they want to harm themselves or 
others. 
 
Growth and development (children and adolescents): 
During the one year of treatment with ribavirin in combination with interferon alfa-2b, some children 
and adolescents did not grow or gain weight as much as expected. 
Some children did not reach their projected height within 1-5 years after completing treatment. 
 
Contact your doctor immediately if any of the following side effects occur during treatment with 
Ribavirin BioPartners in combination with an alpha interferon product: 
– chest pain or persistent cough; changes in the way your heart beats, fainting, 
– confusion, feeling depressed; suicidal thoughts or aggressive behaviour, attempt suicide, 

thoughts about threatening the life of others, 
– feelings of numbness or tingling, 
– trouble sleeping, thinking or concentrating, 

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– severe stomach pain, black or tar-like stools, blood in stool or urine, lower back or side pain, 
– painful or difficult urination, 
– severe bleeding from your nose, 
– fever or chills beginning after a few weeks of treatment, 
– problems with your eyesight or hearing, 
– severe skin rash or redness. 
 
The frequency of possible side effects listed below is defined using the following convention:  

Very common (affects more than 1 user in 10) 
Common  (affects 1 to 10 users in 100) 
Uncommon  (affects 1 to 10 users in 1,000) 
Rare   (affects 1 to 10 users in 10,000) 
Very rare  (affects less than 1 user in 10,000) 
Not known  (frequency cannot be estimated from the available data) 

 
The following side effects have been reported with the combination of ribavirin and an alpha 
interferon product in adults: 
 
Very commonly reported side effects: 
– decreases in the number of red blood cells (that may cause fatigue, shortness of breath, 

dizziness), decrease in neutrophils(that make you more susceptible to different infections), 
– difficulty concentrating, feeling anxious or nervous, mood swings, feeling depressed or irritable, 

tired feeling, trouble falling asleep or staying asleep, 
– cough, dry mouth, pharyngitis (sore throat), 
– diarrhoea, dizziness, fever, flu-like symptoms, headache, nausea, shaking chills, virus infection, 

vomiting, weakness, 
– loss of appetite, loss of weight, stomach pain, 
– dry skin, irritation, pain or redness at the site of injection, hair loss, itching, muscle pain, muscle 

aches, pain in joints and muscles, rash. 
 
Commonly reported side effects: 
– decrease in blood clotting cells called platelets that may result in easy bruising and spontaneous 

bleeding, decrease in certain white blood cells called lymphocytes that help fight infection, 
decrease in thyroid gland activity (which may make you feel tired, depressed, increase your 
sensitivity to cold and other symptoms), excess of sugar or uric acid (as in gout) in the blood, 
low calcium level in the blood, severe anaemia, 

– fungal or bacterial infections, crying, agitation, amnesia, memory impaired, nervousness, 
abnormal behaviour, aggressive behaviour, anger, feeling confused, lack of interest, mental 
disorder, mood changes, unusual dreams, wanting to harm yourself, feeling sleepy, trouble 
sleeping, lack of interest in sex or inability to perform, vertigo (spinning feeling), 

– blurred or abnormal vision, eye irritation or pain or infection, dry or teary eyes, changes in your 
hearing or voice, ringing in ears, ear infection, earache, cold sores (herpes simplex), change in 
taste, taste loss, bleeding gums or sores in mouth, burning sensation on tongue, sore tongue, 
inflamed gums, tooth problem, migraine, respiratory infections, sinusitis, nose bleed, 
nonproductive cough, rapid or difficult breathing, stuffy or runny nose, thirst, tooth disorder, 

– cardiac murmur (abnormal heart beat sounds), chest pain or discomfort, feeling faint, feeling 
unwell, flushing, increased sweating, heat intolerance and excessive sweating, low or high 
blood pressure, palpitations (pounding heart beat), rapid heart rate, 

– bloating, constipation, indigestion, intestinal gas (flatus), increased appetite, irritated colon, 
irritation of prostate gland, jaundice (yellow skin), loose stools, pain on the right side around 
your ribs, enlarged liver, stomach upset, frequent need to urinate, passing more urine than usual, 
urinary tract infection, abnormal urine, 

– difficult, irregular, or no menstrual period, abnormally heavy and prolonged menstrual periods, 
painful menstruation, disorder of ovary or vagina, breast pain, erectile problem, 

– abnormal hair texture, acne, arthritis, bruising, eczema (inflamed, red, itchy and dryness of the 
skin with possible oozing lesions), hives, increased or decreased sensitivity to touch, nail 

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disorder, muscle spasms, numbness or tingling feeling, limb pain, pain at the site of injection, 
pain in joints, shaky hands, psoriasis, puffy or swollen hands and ankles, sensitivity to sunlight, 
rash with raised spotted lesions, redness of skin or skin disorder, swollen face, swollen glands 
(swollen lymph nodes), tense muscles, tumour (unspecified), unsteady when walking, water 
impairment. 

 
Uncommonly reported side effects: 
– hearing or seeing images that are not present, 
– heart attack, panic attack, 
– hypersensitivity reaction to the medication, 
– inflammation of pancreas, pain in bone, diabetes mellitus, 
– muscle weakness. 
 
Rarely reported side effects: 
– seizure (convulsions) 
– pneumonia, 
– rheumatoid arthritis, kidney problems, 
– dark or bloody stools, intense abdominal pain 
– sarcoidosis (a disease characterised by persistent fever, weight loss, joint pain and swelling, skin 

lesions and swollen glands), 
– vasculitis. 
 
Very rarely reported side effects: 
– suicide. 

 
Not known side effects: 
– thoughts about threatening the life of others, 
– mania (excessive or unreasonable enthusiasm), 
– pericarditis (inflammation of the lining of the heart), pericardial effusion [a fluid collection that 

develops between the pericardium (the lining of the heart) and the heart itself. 
 
The following side effects have been reported with children and adolescents taking ribavirin and 
interferon alfa-2b  
 
Very commonly reported side effects: 
– decreases in the number of red blood cells (that may cause fatigue, shortness of breath, 

dizziness), decrease in neutrophils (that make you more susceptible to different infections), 
– decrease in thyroid gland activity (which may make you feel tired, depressed, increase your 

sensitivity to cold and other symptoms), 
– feeling depressed or irritable, feeling sick to stomach, feeling unwell, mood swings, tired 

feeling, trouble falling asleep or staying asleep, virus infection, weakness, 
– diarrhoea, dizziness, fever, flu-like symptoms, headache, loss of or increase in appetite, loss of 

weight, decrease in the rate of growth (height and weight), pain on right side of ribs, pharyngitis 
(sore throat), shaking chills, stomach pain, vomiting, 

– dry skin, hair loss, irritation, pain or redness at the site of injection, itching, muscle pain, muscle 
aches, pain in joints and muscles, rash. 

 
Commonly reported side effects: 
– decrease in blood clotting cells called platelets (that may result in easy bruising and spontaneous 

bleeding), 
– excess of triglycerides in the blood, excess of uric acid (as in gout) in the blood, increase in 

thyroid gland activity (which may cause nervousness, heat intolerance and excessive sweating, 
weight loss, palpitation, tremors), 

– agitation, anger, aggressive behaviour, behaviour disorder, difficulty concentrating, emotional 
instability, fainting, feeling anxious or nervous, feeling cold, feeling confused, feeling of 

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restlessness, feeling sleepy, lack of interest or attention, mood changes, pain, poor quality sleep, 
sleepwalking, suicide attempt, trouble sleeping, unusual dreams, wanting to harm yourself, 

– bacterial infections, common cold, fungal infections, abnormal vision, dry or teary eyes, ear 
infection, eye irritation or pain or infection, change in taste, changes in your voice, cold sores, 
coughing, inflamed gums, nose bleed, nose irritation, oral pain, pharyngitis (sore throat), rapid 
breathing, respiratory infections, scaling lips and clefts in the corners of the mouth, shortness of 
breath, sinusitis, sneezing, sores in mouth, sore tongue, stuffy or runny nose, throat pain, 
toothache, tooth abscess, tooth disorder, vertigo (spinning feeling), weakness, 

– chest pain, flushing, palpitations (pounding heart beat), rapid heart rate, 
– abnormal liver function, 
– acid reflux, back pain, bedwetting, constipation, gastroesophageal or rectal disorder, 

incontinence, increased appetite, inflammation of the membrane of the stomach and intestine, 
stomach upset, loose stools, 

– urination disorders, urinary tract infection, 
– difficult, irregular, or no menstrual period, abnormally heavy and prolonged menstrual periods, 

disorder of vagina, inflammation of the vagina, testis pain, development of male body traits, 
– acne, bruising, eczema (inflamed, red, itchy and dryness of the skin with possible oozing 

lesions), increased or decreased sensitivity to touch, increased sweating, increase in muscle 
movement, tense muscle, irritation or itching at the site of injection, limb pain, nail disorder, 
numbness or tingling feeling, pale skin, rash with raised spotted lesions, shaky hands, redness of 
skin or skin disorder, skin discolouration, skin sensitive to sunlight, skin wound, swelling due to 
a build-up of excess water, swollen glands (swollen lymph nodes), tremor, tumour 
(unspecified). 

 
Uncommonly reported side effects: 
– abnormal behaviour, emotional disorder, fear, nightmare, 
– bleeding of the mucous membrane that lines the inner surface of the eyelids, blurred vision, 

drowsiness, intolerance to light, itchy eyes, facial pain, inflamed gums, 
– chest discomfort, difficult breathing, lung infection, nasal discomfort, pneumonia, wheezing, 
– low blood pressure, 
– enlarged liver, 
– painful menstruation, 
– itchy anal area (pinworms or ascarids), blistering rash (shingles), decreased sensitivity to touch, 

muscle twitching, pain in skin, paleness, peeling of skin, redness, swelling. 
 
The attempt to harm yourself has also been reported in adults, children, and adolescents. 
 
Ribavirin BioPartners in combination with an alpha interferon product may also cause: 
– aplastic anaemia, pure red cell aplasia (a condition where the body stopped or reduced the 

production of red blood cells); this causes severe anaemia, symptoms of which would include 
unusual tiredness and a lack of energy, 

– delusions, 
– upper and lower respiratory tract infection, 
– inflammation of the pancreas, 
– severe rashes which may be associated with blisters in the mouth, nose, eyes and other mucosal 

membranes (erythema multiforme, Stevens Johnson syndrome), toxic epidermal necrolysis 
(blistering and peeling of the top layer of skin). 

 
The following other side effects have also been reported with the combination of ribavirin and an 
alpha interferon product: 
– abnormal thoughts, hearing or seeing images that are not present, altered mental status, 

disorientation, 
– angioedema (swelling of the hands, feet, ankles, face, lips, mouth, or throat which may cause 

difficulty in swallowing or breathing), stroke (cerebrovascular events), 
– Vogt-Koyanagi-Harada syndrome (an autoimmune inflammatory disorder affecting the eyes, 

skin and the membranes of the ears, brain and spinal cord), 
– bronchoconstriction and anaphylaxis (a severe, whole-body allergic reaction), constant cough, 

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– eye problems including damage to the retina, obstruction of the retinal artery, inflammation of 
the optic nerve, swelling of the eye and cotton wool spots (white deposits on the retina), 

– enlarged abdominal area, heartburn, trouble having bowel movement or painful bowel 
movement, 

– acute hypersensitivity reactions including urticaria (hives), bruises, intense pain in a limb, leg or 
thigh pain, loss of range of motion, stiffness, sarcoidosis (a disease characterised by persistent 
fever, weight loss, joint pain and swelling, skin lesions and swollen glands). 

 
Ribavirin BioPartners in combination with peginterferon alfa-2b or interferon alfa-2b may also cause: 
– dark, cloudy or abnormally coloured urine, 
– difficulty breathing, changes in the way your heart beats, chest pain, pain down left arm, jaw 

pain, 
– loss of consciousness, 
– loss of use, drooping or loss of power of facial muscles, loss of feeling sensation, 
– loss of vision. 
You or your caregiver should call your doctor immediately if you have any of these symptoms. 
 
If you are a HCV/HIV co-infected adult patient receiving anti-HIV treatment, the addition of 
Ribavirin BioPartners and peginterferon alfa-2b may increase your risk of worsening liver function 
highly active anti-retroviral therapy (HAART) and increase your risk of lactic acidosis, liver failure, 
and blood abnormalities development (reduction in number of red blood cells which carry oxygen, 
certain white blood cells that fight infection, and blood clotting cells called platelets) (NRTI). 
In HCV/HIV co-infected patients receiving HAART, the following other side effects have occurred 
with the combination of ribavirin and peginterferon alfa-2b (not listed above in adults side effects): 
– appetite decreased, 
– back pain, 
– CD4 lymphocytes decreased, 
– defective metabolism of fat, 
– hepatitis, 
– limb pain, 
– oral candidiasis (oral thrush), 
– various laboratory blood values abnormalities. 
 
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. 
 
 
5. HOW TO STORE RIBAVIRIN BIOPARTNERS 
 
Keep out of the reach and sight of children. 
 
Do not use Ribavirin BioPartners after the expiry date which is stated on the carton. 
 
Do not store above 25°C. 
 
Do not use Ribavirin BioPartners without advice of your doctor or pharmacist if you notice any 
change in the appearance of the tablets. 
 
 
6. FURTHER INFORMATION 
 
What Ribavirin BioPartners contains 
The active substance is ribavirin. 
One film-coated tablet contains 200 mg ribavirin. 
 
The other ingredients are: 

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• tablet core: microcrystalline cellulose, crospovidone, povidone K25, silica colloidal, magnesium 
stearate 

• tablet coating: hypromellose, macrogol, titanium dioxide. 
 
What Ribavirin BioPartners looks like and contents of the pack 
Ribavirin BioPartners is a round, white film coated-tablet, rounded on the upper and lower side. 
Ribavirin BioPartners is available in different pack sizes containing 84, 112, 140 or 168 film-coated 
tablets. 
Not all pack sizes may be marketed. 
 
Marketing Authorisation Holder and Manufacturer 
Biopartners GmbH 
Kaiserpassage 11 
D-72764 Reutlingen, 
Germany 
Tel: +49 (0)7121 948 7756 
 
This leaflet was last approved in  
 
 
Detailed information on this medicine is available on the European Medicines Agency website: 
http://www.ema.europa.eu/ 
 

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	SUMMARY OF PRODUCT CHARACTERISTICS
	A. MANUFACTURING AUTHORISATION HOLDER RESPONSIBLE FOR BATCH RELEASE
	B. CONDITIONS OF THE MARKETING AUTHORISATION
	A. LABELLING
	B. PACKAGE LEAFLET
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{'Title': '2. before you take ribavirin biopartners', 'Section_Content': 'ribavirin biopartners is not recommended for use in patients under the age of 3 years. do not take ribavirin biopartners if any of the following apply to you or your child you are caring for, do not take ribavirin biopartners, and tell your doctor if you: are allergic (hypersensitive) to ribavirin or any of the other ingredients of ribavirin biopartners (see section 6, further information). are pregnant or planning to become pregnant (see section "pregnancy and breast-feeding"). have any severe medical conditions that leave you very weak, including severe kidney disease. are breast-feeding. have had any previous severe heart problems, or have had any problems with the heart in the last 6 months. have had severe liver problems, which are not related to hepatitis c. have suffered from any blood disorder, for example anaemia (low blood count), thalassemia or sickle-cell anaemia. have suffered from autoimmune disease in the past, or suffer from autoimmune hepatitis, or are taking other medicines that suppress your immune system (that protects you against infection and some diseases). children and adolescents must not take combination therapy with ribavirin biopartners and alpha interferon when there is existence or history of serious nervous or mental problems, such as severe depression, thoughts of suicide or attempted suicide. you should tell your doctor if you have suffered from any other serious illness in the past. reminder: please read the "do not use" section of the package leaflet for interferon alfa-2b before you begin combination treatment with ribavirin biopartners. take special care with ribavirin biopartners seek medical advice immediately if you develop symptoms of a severe allergic reaction (such as difficulty in breathing, wheezing or hives) while taking this treatment. children and adolescents weighing less than 47 kg: the use of ribavirin biopartners tablets is not recommended. you should tell your doctor if you or your child you are caring for: are an adult who has or had a severe nervous or mental disorder, confusion, unconsciousness, or have had thoughts of suicide or have attempted suicide, or have a history of substance abuse (e.g., alcohol or drugs). have ever had depression or develop symptoms associated with depression (e.g. feeling of sadness, dejection, etc.) while on treatment with ribavirin. are a woman of childbearing age (see section "pregnancy and breast-feeding"). are a male and your female partner is of childbearing age (see section "pregnancy and breast-feeding"). had a previous serious heart condition or have cardiac disease. are older than 65 years or if you have problems with your kidneys. have or have had any serious illness. have thyroid problems. during treatment with ribavirin in combination therapy with an alpha interferon, dental and gum disorders, which may lead to loss of teeth, have been reported. in addition, dry mouth that could have a damaging effect on teeth and membranes of the mouth has been reported during long-term treatment with ribavirin in combination therapy with an alpha interferon. you should brush your teeth thoroughly twice daily and have regular dental examinations. in addition some patients may experience vomiting. if you have this reaction, be sure to rinse your mouth thoroughly afterwards. during treatment with ribavirin biopartners in combination therapy with an alpha interferon, patients may experience eye problems, or loss of vision in rare instances. if you receive ribavirin in combination with an alpha interferon, you should have a baseline eye examination. any patient complaining of decrease or loss of vision must have a prompt and complete eye examination. patients with pre-existing eye disorders (e.g., diabetic or hypertensive retinopathy) should receive periodic eye exams during combination therapy with ribavirin and an alpha interferon. combination therapy with ribavirin and an alpha interferon should be discontinued in patients who develop new or worsening eye disorders. reminder: please read the "take special care" section of the package leaflet for interferon alfa-2b before you begin combination treatment. taking other medicines please tell your doctor or pharmacist if you or the child you are caring for: - are taking or have recently taken any other medicines, including medicines obtained without a prescription. - are receiving azathioprine in combination with ribavirin and pegylated alpha interferons and, therefore may be at an increased risk of developing severe blood disorders. - are infected with both human immunodeficiency virus (hiv-positive) and hepatitis c virus (hcv) and are being treated with an anti-hiv medicinal product(s) - [nucleoside reverse transcriptase inhibitor (nrti), and/or highly active anti-retroviral therapy (haart)]: taking ribavirin biopartners in combination with an alpha interferon and an anti-hiv medicinal product(s) may increase the risk of lactic acidosis, liver failure, and blood abnormalities development (reduction in number of red blood cells which carry oxygen, certain white blood cells that fight infection, and blood clotting cells called platelets). with zidovudine or stavudine, it is not certain if ribavirin biopartners will change the way these medicines work. therefore, your blood will be checked regularly to be sure that the hiv infection is not getting worse. if it gets worse, your doctor will decide whether or not your ribavirin biopartners treatment needs to be changed. additionally, patients receiving zidovudine with ribavirin in combination with alpha interferons could be at increased risk of developing anaemia (low number of red blood cells). therefore the use of zidovudine and ribavirin in combination with alpha interferons is not recommended. due to the risk of lactic acidosis (a build-up of lactic acid in the body) and pancreatitis, the use of ribavirin and didanosine is not recommended and the use of ribavirin and stavudine should be avoided. co-infected patients with advanced liver disease receiving haart may be at increased risk of worsening liver function. adding treatment with an alpha interferon alone or in combination with ribavirin may increase the risk in this patient subset. reminder: please read the "taking other medicines" section of the package leaflet for interferon alfa-2b before you begin combination treatment. taking ribavirin biopartners with food and drink ribavirin biopartners must be taken with food. pregnancy and breast-feeding if you are pregnant, you must not take ribavirin biopartners. ribavirin biopartners can be very damaging to your unborn baby (embryo). both female and male patients must take special precautions in their sexual activity if there is any possibility for pregnancy to occur: - girl or woman of childbearing age: you must have a negative pregnancy test before treatment, each month during treatment, and for the 4 months after treatment is stopped. this should be discussed with your doctor. - men: do not have sex with a pregnant woman unless you use a condom. this will lessen the possibility for ribavirin to be left in the woman\'s body. if your female partner is not pregnant now but is of childbearing age, she must be tested for pregnancy each month during treatment and for the 7 months after treatment has stopped. you or your female partner must use an effective contraceptive during the time you are taking ribavirin biopartners and for 7 months after stopping treatment. this should be discussed with your doctor (see section "do not take ribavirin biopartners"). if you are a woman who is breast-feeding, you must not take ribavirin biopartners. discontinue breast-feeding before starting to take ribavirin biopartners. driving and using machines ribavirin biopartners does not affect your ability to drive or use machines; however, interferon alfa-2b may affect your ability to drive or use machines. 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{'Title': '3. how to take ribavirin biopartners', 'Section_Content': 'general information about taking ribavirin biopartners: if the child you are caring for is under the age of 3 years, do not administer. always take ribavirin biopartners exactly as your doctor has told you. you should check with your doctor or pharmacist if you are not sure. do not take more than the recommended dosage and take the medicine for as long as prescribed. your doctor has determined the correct dose of ribavirin biopartners based on how much you or the child you are caring for weighs. standard blood tests will be taken to check your blood, kidney and liver function. - blood tests will be done regularly to help your doctor to know if this treatment is working. - depending upon the results of these tests, your doctor may change/adjust the number of tablets you or the child you are caring for take, prescribe a different pack size of ribavirin biopartners, and/or change the length of time to take this treatment. - if you have or develop severe kidney or liver problems, this treatment will be stopped. the usual dose, according to how much the patient weighs, is shown in the table below: 1. look for the line that shows how much the adult or child/adolescent weighs. reminder: if the child is under the age of 3 years, do not administer. 2. read across on the same line to see how many tablets to take. reminder: if your doctor\'s instructions are different from the amounts in the below table, follow your doctor\'s instructions. 3. if you have any questions about the dose, ask your doctor. ribavirin biopartners film-coated tablets for oral use - dose based on body weight if the adult weighs (kg) usual daily ribavirin biopartners dose number of 200 mg tablets < 65 800 mg 2 tablets in the morning and 2 tablets in the evening 65 80 1,000 mg 2 tablets in the morning and 3 tablets in the evening 81 - 105 1,200 mg 3 tablets in the morning and 3 tablets in the evening > 105 1,400 mg 3 tablets in the morning and 4 tablets in the evening if the child/adolescent weighs (kg) usual daily ribavirin biopartners dose number of 200 mg tablets 47 49 600 mg 1 tablet in the morning and 2 tablets in the evening 50 65 800 mg 2 tablets in the morning and 2 tablets in the evening > 65 see adult dose and corresponding number of film-coated tablets take your prescribed dose by mouth with water and during your meal. do not chew the film-coated tablets. for children or adolescents who cannot swallow a film-coated tablet, an oral solution of ribavirin is available. reminder: ribavirin biopartners is only to be used in combination with interferon alfa-2b for hepatitis c virus infection. for complete information be sure to read the "how to use" section of the package leaflet for interferon alfa-2b. interferon medicine that is used in combination with ribavirin biopartners may cause unusual tiredness; if you are injecting this medicine yourself or giving it to a child, use it at bedtime. if you take more ribavirin biopartners than you should tell your doctor or pharmacist as soon as possible. if you forget to take ribavirin biopartners if you are self-administering treatment, or if you are the caregiver of a child taking ribavirin biopartners in combination with interferon alfa-2b, take/administer the missed dose as soon as possible during the same day. if an entire day has gone by, check with your doctor. do not take a double dose to make up for a forgotten dose.', 'Entity_Recognition': [{'Text': 'ribavirin biopartners', 'Type': 'PRODUCT_NAME', 'BeginOffset': 0, 'EndOffset': 0}, {'Text': 'ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 33, 'EndOffset': 54}, {'Id': 31, 'BeginOffset': 108, 'EndOffset': 109, 'Score': 0.5062719583511353, 'Text': '3', 'Category': 'PROTECTED_HEALTH_INFORMATION', 'Type': 'AGE', 'Traits': []}, {'Text': 'ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 148, 'EndOffset': 169}, {'Text': 'the medicine', 'Type': 'TREATMENT', 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{'Title': '5. how to store ribavirin biopartners', 'Section_Content': 'keep out of the reach and sight of children. do not use ribavirin biopartners after the expiry date which is stated on the carton. do not store above 25. do not use ribavirin biopartners without advice of your doctor or pharmacist if you notice any change in the appearance of the tablets.', 'Entity_Recognition': [{'Text': 'ribavirin biopartners', 'Type': 'PRODUCT_NAME', 'BeginOffset': 0, 'EndOffset': 0}, {'Text': 'ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 56, 'EndOffset': 77}, {'Text': '25.', 'Type': 'NUMBER', 'BeginOffset': 150, 'EndOffset': 153}, {'Text': 'ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 165, 'EndOffset': 186}, {'Id': 2, 'BeginOffset': 249, 'EndOffset': 273, 'Score': 0.5434321165084839, 'Text': 'change in the appearance', 'Category': 'MEDICAL_CONDITION', 'Type': 'DX_NAME', 'Traits': []}]}
{'Title': '6. further information', 'Section_Content': 'what ribavirin biopartners contains the active substance is ribavirin. one film-coated tablet contains 200 mg ribavirin. the other ingredients are: 43 tablet core: microcrystalline cellulose, crospovidone, povidone k25, silica colloidal, magnesium stearate tablet coating: hypromellose, macrogol, titanium dioxide. what ribavirin biopartners looks like and contents of the pack ribavirin biopartners is a round, white film coated-tablet, rounded on the upper and lower side. ribavirin biopartners is available in different pack sizes containing 84, 112, 140 or 168 film-coated tablets. not all pack sizes may be marketed.', 'Entity_Recognition': [{'Text': 'ribavirin biopartners', 'Type': 'PRODUCT_NAME', 'BeginOffset': 0, 'EndOffset': 0}, {'Id': 2, 'BeginOffset': 5, 'EndOffset': 26, 'Score': 0.5431118011474609, 'Text': 'ribavirin biopartners', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 3, 'BeginOffset': 60, 'EndOffset': 69, 'Score': 0.9968324303627014, 'Text': 'ribavirin', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': [], 'Attributes': [{'Type': 'DOSAGE', 'Score': 0.8737079501152039, 'RelationshipScore': 0.7986028790473938, 'RelationshipType': 'DOSAGE', 'Id': 4, 'BeginOffset': 71, 'EndOffset': 79, 'Text': 'one film', 'Category': 'MEDICATION', 'Traits': []}, {'Type': 'FORM', 'Score': 0.5135079026222229, 'RelationshipScore': 0.6755265593528748, 'RelationshipType': 'FORM', 'Id': 5, 'BeginOffset': 80, 'EndOffset': 93, 'Text': 'coated tablet', 'Category': 'MEDICATION', 'Traits': []}]}, {'Text': 'one film-coated tablet', 'Type': 'TREATMENT', 'BeginOffset': 71, 'EndOffset': 93}, {'Text': '200 mg ribavirin', 'Type': 'TREATMENT', 'BeginOffset': 103, 'EndOffset': 119}, {'Text': '43', 'Type': 'NUMBER', 'BeginOffset': 148, 'EndOffset': 150}, {'Id': 8, 'BeginOffset': 164, 'EndOffset': 190, 'Score': 0.9945279955863953, 'Text': 'microcrystalline cellulose', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 9, 'BeginOffset': 192, 'EndOffset': 204, 'Score': 0.994929850101471, 'Text': 'crospovidone', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 10, 'BeginOffset': 206, 'EndOffset': 218, 'Score': 0.8300111293792725, 'Text': 'povidone k25', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 11, 'BeginOffset': 220, 'EndOffset': 236, 'Score': 0.9656346440315247, 'Text': 'silica colloidal', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Text': 'magnesium stearate tablet coating', 'Type': 'TREATMENT', 'BeginOffset': 238, 'EndOffset': 271}, {'Id': 14, 'BeginOffset': 273, 'EndOffset': 285, 'Score': 0.9913073182106018, 'Text': 'hypromellose', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 15, 'BeginOffset': 287, 'EndOffset': 295, 'Score': 0.8365654945373535, 'Text': 'macrogol', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Id': 16, 'BeginOffset': 297, 'EndOffset': 313, 'Score': 0.9982660412788391, 'Text': 'titanium dioxide', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Text': 'ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 320, 'EndOffset': 341}, {'Text': 'the pack ribavirin biopartners', 'Type': 'TREATMENT', 'BeginOffset': 369, 'EndOffset': 399}, {'Text': 'white film coated', 'Type': 'TEST', 'BeginOffset': 412, 'EndOffset': 429}, {'Id': 19, 'BeginOffset': 475, 'EndOffset': 496, 'Score': 0.5104398131370544, 'Text': 'ribavirin biopartners', 'Category': 'MEDICATION', 'Type': 'GENERIC_NAME', 'Traits': []}, {'Text': '84', 'Type': 'NUMBER', 'BeginOffset': 545, 'EndOffset': 547}, {'Text': '112', 'Type': 'NUMBER', 'BeginOffset': 549, 'EndOffset': 552}, {'Text': '140', 'Type': 'NUMBER', 'BeginOffset': 554, 'EndOffset': 557}, {'Text': '168', 'Type': 'NUMBER', 'BeginOffset': 561, 'EndOffset': 564}, {'Text': 'film', 'Type': 'TEST', 'BeginOffset': 565, 'EndOffset': 569}]}