VIRAMUNE 50 mg/5 ml oral suspension

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

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

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

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

Do not take VIRAMUNE

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

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

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

• fever,
• blistering,
• mouth sores,
• inflammation of the eye,
• swelling of the face,
• general swelling,
• shortness of breath,
• muscle or joint pain,
• general feelings of illness,
• or abdominal pain YOU SHOULD DISCONTINUE TAKING VIRAMUNE AND YOU MUST CONTACT your doctor IMMEDIATELY as such reactions can be potentially life-threatening or lead to death. If you ever have only mild rash symptoms without any other reaction please inform your doctor immediately, who will advise you whether you should stop taking VIRAMUNE.

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

• loss of appetite,
• feeling sick (nausea),
• vomiting,
• yellow skin (jaundice),
• abdominal pain you should discontinue taking VIRAMUNE and must contact your doctor immediately.

If you develop severe liver, skin or hypersensitivity reactions whilst taking VIRAMUNE, NEVER TAKE VIRAMUNE again without referring to your doctor.
You must take the dosage of Viramune as prescribed by your doctor. This is especially important within the first 14 days of treatment (see more information in ?How to take VIRAMUNE?).

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

• women
• infected with hepatitis B or C
• abnormal liver function tests
• treatment-naïve patients with higher CD4 cell counts at the start of Viramune therapy (women

more than 250 cells/mm³, men more than 400 cells/mm³)

• pre-treated patients with detectable HIV-1 plasma viral load and higher CD4 cell counts at the start of Viramune therapy (women more than 250 cells/mm³, men more than 400 cells/mm³)

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

Changes of body fat may occur in patients receiving combination antiretroviral therapy. Contact your doctor if you notice changes in body fat (see section 4 ? POSSIBLE SIDE EFFECTS?).

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

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

Use in children:
VIRAMUNE oral suspension can be taken by children of all age groups. Always follow the exact instructions given by your child?s doctor.
VIRAMUNE is also available as tablets. VIRAMUNE tablets can be taken by:

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

Taking other medicines

Please tell your doctor or pharmacist if you are taking or have recently taken any other medicines, including medicines obtained without a prescription. Inform your doctor about all other medicines you are taking before you start taking VIRAMUNE. Your doctor might need to monitor whether your other medicines are still working and adjust doses. Carefully read the package leaflet of all other HIV medicinal products you are taking in combination with VIRAMUNE.

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

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

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

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

Taking VIRAMUNE with food and drink

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

Pregnancy and breast-feeding

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

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

Driving and using machines

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

Important information about some of the ingredients of VIRAMUNE

VIRAMUNE oral suspension contains 150 mg sucrose and 162 mg sorbitol per ml of VIRAMUNE oral suspension. This should be taken into account in patients with diabetes mellitus. If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicinal product.

VIRAMUNE oral suspension contains methyl parahydroxybenzoate and propyl parahydroxybenzoate. These ingredients can cause allergic reactions over time.

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

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

VIRAMUNE oral suspension is in a liquid suspension form and should only be taken by mouth. Shake the bottle well before you take your medicine.
The usual dose is the same for all adults (20 ml).
Your child?s doctor will calculate the dose for your child. The calculation will include your child's age and body weight, or body surface area. Make sure that your child's doctor clearly tells you what dose you must give to your child.

Measure the exact dose using the measuring syringe and adapter supplied as follows:

1. Shake the bottle gently.

2. Open the bottle.

3. Fit the plastic adapter onto the open bottle neck by first pressing and then screwing the adapter. Make sure that the adapter is fitted tightly.

4. Insert the syringe into the adapter. Make sure that the syringe is tightly inserted.

5. Turn the bottle upside down and gently draw out the required amount of VIRAMUNE oral suspension.

6. The most that you can withdraw is 5 ml at a time. If you need a higher dose, repeat steps 4-5 above.

The bottle can be kept sealed with the lid of the plastic adapter.

If you are an adult and choose to use another measuring device (e.g. cup or teaspoon) please make sure that you take the whole dose. This is because some VIRAMUNE can remain in the cup or spoon.

For adults

The dose for adults is 20 ml (200 mg) once a day for the first 14 days of treatment (?lead in? period). After 14 days, the usual dose is 20 ml (200 mg) twice a day.

It is very important that you take only 20 ml of VIRAMUNE a day for the first 14 days (?lead-in? period). If you have any rash during this period, do not increase the dose but consult your doctor.

VIRAMUNE is also available as 200 mg tablets for adults (16 years of age and older).

For children

The dose for children is 4 mg/kg body weight or 150 mg/m 2 body surface area once a day for the first 14 days of treatment (?lead-in period?). Thereafter your child will be switched to a twice daily dosing schedule and your child?s doctor will decide the right dose based either on your child?s weight or body surface area.

It is very important that your child takes VIRAMUNE only once a day for the first 14 days (?lead-in? period). If your child develops any rash during this period, do not increase the dose but consult your child?s doctor.

VIRAMUNE is also available as 200 mg tablets for older children, particularly adolescents, weighing

more than 50 kg or having a body surface of more than 1.25 m 2. Your child's doctor will inform you exactly of the correct dose for your child. Your child?s doctor will continually check your child?s weight or body surface area to ensure the correct dose.
If you are uncertain please be sure to ask your child?s doctor or pharmacist.

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

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

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

As explained in 'Take special care with VIRAMUNE', above, your doctor will monitor you with liver tests or for undesirable effects such as rash. Depending on the outcome your doctor may decide to interrupt or stop VIRAMUNE treatment. Your doctor might then decide to restart you on a lower dose.

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

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

If you stop taking VIRAMUNE
Taking all doses at the appropriate times:

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

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

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

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

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

As mentioned in'Take special care with VIRAMUNE', above, the most important side effects of VIRAMUNE are severe and life threatening skin reactions and serious liver damage. These reactions occur mainly in the first 18 weeks of treatment with VIRAMUNE. This is therefore an important period which requires close monitoring by your doctor.

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

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

If rash occurs and you also feel sick, you must stop treatment and visit your doctor immediately. Pay special attention to any rashes that your child develops. Although these may appear normal (for example nappy rash), they might be rashes due to VIRAMUNE. If in doubt ask your child's doctor.

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

• rash
• swelling of the face
• difficulty breathing (bronchial spasm),
• anaphylactic shock Hypersensitivity reactions can also occur as rash with other side effects such as:
• fever
• blistering of your skin
• mouth sores
• inflammation of the eye
• swelling of the face
• general swelling
• shortness of breath
• muscle or joint pain
• a reduction in the number of your white blood cells (granulocytopaenia)
• general feelings of illness
• severe problems with liver or kidneys (liver or kidney failure).

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

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

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

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

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

Very common: in at least 1 out of 10 patients treated
Common: in at least 1 out of 100 and less than 1 out of 10 patients treated
Uncommon: in at least 1 out of 1000 and less than 1 out of 100 patients treated
Rare: in at least 1 out of 10,000 and less than 1 out of 1000 patients treated

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

Very common:

• rash

Common:

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

Uncommon:

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

Rare:

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

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

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

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

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

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

Keep out of the reach and sight of children.

Do not use VIRAMUNE after the expiry date which is stated on the carton and on the bottle after ?EXP?. The expiry date refers to the last day of that month.
VIRAMUNE should be used within 6 months of opening the bottle.

This medicinal product does not require any special storage conditions.

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

What VIRAMUNE contains

• The active substance is nevirapine. Each ml contains 10 mg of the active substance nevirapine (as nevirapine hemihydrate).
• The other ingredients are:
• carbomer
• methyl parahydroxybenzoate
• propyl parahydroxybenzoate
• sorbitol
• sucrose
• polysorbate 80
• sodium hydroxide
• water

What VIRAMUNE looks like and contents of pack

VIRAMUNE oral suspension is a white to off-white homogenous suspension.
VIRAMUNE oral suspension is supplied in plastic bottles of suspension for oral use, with 240 ml suspension per bottle. A plastic measuring syringe is included for measuring the correct dose.

VIRAMUNE is also supplied as 200 mg tablets for older children and adults.

Marketing Authorisation Holder

Boehringer Ingelheim International GmbH
Binger Strasse 173
55216 Ingelheim am Rhein
Germany

Manufacturer

Boehringer Ingelheim Pharma GmbH & Co. KG
Binger Strasse 173
55216 Ingelheim am Rhein
Germany

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

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This leaflet was last approved in {MM/YYYY}