4.1. Therapeutic indications

Nevirapine is indicated in combination with other anti-retroviral medicinal products for the treatment of HIV-1 infected adults, adolescents, and children of any age (see section 4.2.).

Most of the experience with nevirapine is in combination with nucleoside reverse transcriptase inhibitors (NRTIs). The choice of a subsequent therapy after nevirapine should be based on clinical experience and resistance testing (see section 5.1).

4.2. Posology and method of administration

Nevirapine should be administered by physicians who are experienced in the treatment of HIV infection.

Posology

Patients 16 years and older

The recommended dose of Nevirapine is one 200 mg tablet daily for the first 14 days (this lead-in period should be used because it has been found to lessen the frequency of rash), followed by one 200 mg tablet twice daily, in combination with at least two additional antiretroviral agents.

If a dose is recognised as missed within 8 hours of when it was due, the patient should take the missed dose as soon as possible. If a dose is missed and it is more than 8 hours later, the patient should only take the next dose at the usual time.

Dose management considerations

Patients experiencing rash during the 14-day lead-in period of 200 mg/day should not have their Nevirapine dose increased until the rash has resolved. The isolated rash should be closely monitored (see section 4.4). The 200 mg once daily dosing regimen should not be continued beyond 28 days at which point in time an alternative treatment should be sought due to the possible risk of underexposure and resistance.

Patients who interrupt nevirapine dosing for more than 7 days should restart the recommended dosing regimen using the two-week lead-in period.

There are toxicities that require interruption of nevirapine therapy (see section 4.4).

Elderly

Nevirapine has not been specifically investigated in patients over the age of 65.

Renal impairment

For patients with renal dysfunction requiring dialysis an additional 200 mg dose of nevirapine following each dialysis treatment is recommended. Patients with CLcr ≥ 20 mL/min do not require a dose adjustment, see section 5.2.

Hepatic impairment

Nevirapine should not be used in patients with severe hepatic impairment (Child-Pugh C, see section 4.3). No dose adjustment is necessary in patients with mild to moderate hepatic impairment (see sections 4.4 and 5.2).

Paediatric population

Nevirapine 200 mg tablets, following the dosing schedule described above, are suitable for larger children, particularly adolescents, below the age of 16 who weigh more than 50 kg or whose body surface area is above 1.25 m2 according to the Mosteller formula. An oral suspension dosage form, which can be dosed according to body weight or body surface area, is available for children in this age group weighing less than 50 kg or whose body surface area is below 1.25 m2.

Children less than three years old.

For patients less than 3 years and for all other age groups, an immediate-release oral suspension dosage form is available.

Method of administration

The tablets shall be taken with liquid, and should not be crushed or chewed. Nevirapine may be taken with or without food.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Re-administration to patients who have required permanent discontinuation for severe rash, rash accompanied by constitutional symptoms, hypersensitivity reactions, or clinical hepatitis due to nevirapine.

Patients with severe hepatic impairment (Child-Pugh C) or pre-treatment ASAT or ALAT > 5 ULN until baseline ASAT/ALAT are stabilised < 5 ULN.

Re-administration to patients who previously had ASAT or ALAT > 5 ULN during nevirapine therapy and had recurrence of liver function abnormalities upon re-administration of nevirapine (see section 4.4).

Co-administration with herbal preparations containing St. John's wort (Hypericum perforatum) due to the risk of decreased plasma concentrations and reduced clinical effects of nevirapine (see section 4.5).

4.4. Special warnings and precautions for use

Nevirapine should only be used with at least two other antiretroviral agents (see section 5.1).

Nevirapine should not be used as the sole active antiretroviral, as monotherapy with any antiretroviral has shown to result in viral resistance.

The first 18 weeks of therapy with nevirapine are a critical period which requires close monitoring of patients to disclose the potential appearance of severe and life-threatening skin reactions (including cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)) and serious hepatitis/hepatic failure. The greatest risk of hepatic and skin reactions occurs in the first 6 weeks of therapy. However, the risk of any hepatic event continues past this period and monitoring should continue at frequent intervals. Female gender and higher CD4+ counts (>250/mm3 in adult females and >400/mm3 in adult males) at the initiation of nevirapine therapy are associated with a greater risk of hepatic adverse reactions if the patient has detectable plasma HIV-1 RNA - i.e. a concentration ≥ 50 copies/mL - at the initiation of nevirapine. As serious and life threatening hepatotoxicity has been observed in controlled and uncontrolled studies predominantly in patients with a plasma HIV-1 viral load of 50 copies/mL or higher, nevirapine should not be initiated in adult females with CD4+ cell counts greater than 250 cells/mm3 or in adult males with CD4+ cell counts greater than 400 cells/mm3, who have a detectable plasma HIV-1 RNA unless the benefit outweighs the risk.

In some cases, hepatic injury has progressed despite discontinuation of treatment. Patients developing signs or symptoms of hepatitis, severe skin reaction or hypersensitivity reactions must discontinue nevirapine and seek medical evaluation immediately. Nevirapine must not be restarted following severe hepatic, skin or hypersensitivity reactions (see section 4.3).

The dose must be strictly adhered to, especially the 14-days lead-in period (see section 4.2).

Cutaneous reactions

Severe and life-threatening skin reactions, including fatal cases, have occurred in patients treated with nevirapine mainly during the first 6 weeks of therapy. These have included cases of Stevens-Johnson syndrome, toxic epidermal necrolysis and hypersensitivity reactions characterised by rash, constitutional findings and visceral involvement. Patients should be intensively monitored during the first 18 weeks of treatment. Patients should be closely monitored if an isolated rash occurs. Nevirapine must be permanently discontinued in any patient experiencing severe rash or a rash accompanied by constitutional symptoms (such as fever, blistering, oral lesions, conjunctivitis, facial oedema, muscle or joint aches, or general malaise), including Stevens-Johnson syndrome, or toxic epidermal necrolysis.

Nevirapine must be permanently discontinued in any patient experiencing hypersensitivity reaction (characterised by rash with constitutional symptoms, plus visceral involvement, such as hepatitis, eosinophilia, granulocytopenia, and renal dysfunction), see section 4.4.

Nevirapine administration above the recommended dose might increase the frequency and seriousness of skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis.

Rhabdomyolysis has been observed in patients experiencing skin and/or liver reactions associated with nevirapine use.

Concomitant prednisone use (40 mg/day for the first 14 days of nevirapine administration) has been shown not to decrease the incidence of nevirapine-associated rash and may be associated with an increase in incidence and severity of rash during the first 6 weeks of nevirapine therapy.

Some risk factors for developing serious cutaneous reactions have been identified; they include failure to follow the initial dosing of 200 mg daily during the lead-in period and a long delay between the initial symptoms and medical consultation. Women appear to be at higher risk than men of developing rash, whether receiving nevirapine or non-nevirapine containing therapy.

Patients should be instructed that a major toxicity of nevirapine is rash. They should be advised to promptly notify their physician of any rash and avoid delay between the initial symptoms and medical consultation. The majority of rashes associated with nevirapine occur within the first 6 weeks of initiation of therapy. Therefore, patients should be monitored carefully for the appearance of rash during this period. Patients should be instructed that dose escalation is not to occur if any rash occurs during the two-week lead-in dosing period, until the rash resolves. The 200 mg once daily dosing regimen should not be continued beyond 28 days at which point in time an alternative treatment should be sought due to the possible risk of underexposure and resistance.

Any patient experiencing severe rash or a rash accompanied by constitutional symptoms such as fever, blistering, oral lesions, conjunctivitis, facial oedema, muscle or joint aches, or general malaise should discontinue the medicinal product and immediately seek medical evaluation. In these patients nevirapine must not be restarted.

If patients present with a suspected nevirapine - associated rash, liver function tests should be performed. Patients with moderate to severe elevations (ASAT or ALAT > 5 ULN) should be permanently discontinued from nevirapine.

If a hypersensitivity reaction occurs, characterised by rash with constitutional symptoms such as fever, arthralgia, myalgia and lymphadenopathy, plus visceral involvement, such as hepatitis, eosinophilia, granulocytopenia, and renal dysfunction, nevirapine must be permanently stopped and not be re- introduced (see section 4.3).

Hepatic reactions

Severe and life-threatening hepatotoxicity, including fatal fulminant hepatitis, has occurred in patients treated with nevirapine. The first 18 weeks of treatment is a critical period which requires close monitoring. The risk of hepatic reactions is greatest in the first 6 weeks of therapy. However the risk continues past this period and monitoring should continue at frequent intervals throughout treatment.

Rhabdomyolysis has been observed in patients experiencing skin and/or liver reactions associated with nevirapine use.

Increased ASAT or ALAT levels ≥ 2.5 ULN and/or co-infection with hepatitis B and/or C at the start of antiretroviral therapy is associated with greater risk of hepatic adverse reactions during antiretroviral therapy in general, including nevirapine containing regimens.

Female gender and higher CD4+ counts at the initiation of nevirapine therapy in treatment-naïve patients is associated with increased risk of hepatic adverse reactions. Women have a three-fold higher risk than men for symptomatic, often rash-associated, hepatic events (5.8% versus 2.2%), and treatment-naïve patients of either gender with detectable HIV-1 RNA in plasma with higher CD4+ counts at initiation of nevirapine therapy are at higher risk for symptomatic hepatic events with nevirapine. In a retrospective review of predominantly patients with a plasma HIV-1 viral load of 50 copies/mL or higher, women with CD4+ counts >250 cells/mm3 had a 12-fold higher risk of symptomatic hepatic adverse reactions compared to women with CD4+ counts <250 cells/mm3 (11.0% versus 0.9%). An increased risk was observed in men with detectable HIV-1 RNA in plasma and CD4+ counts > 400 cells/mm3 (6.3% versus 1.2% for men with CD4+ counts <400 cells/mm3). This increased risk for toxicity based on CD4+ count thresholds has not been detected in patients with undetectable (i.e. < 50 copies/mL) plasma viral load.

Patients should be informed that hepatic reactions are a major toxicity of nevirapine requiring close monitoring during the first 18 weeks. They should be informed that occurrence of symptoms suggestive of hepatitis should lead them to discontinue nevirapine and immediately seek medical evaluation, which should include liver function tests.

Liver monitoring

Clinical chemistry tests, which include liver function tests, should be performed prior to initiating nevirapine therapy and at appropriate intervals during therapy.

Abnormal liver function tests have been reported with nevirapine, some in the first few weeks of therapy.

Asymptomatic elevations of liver enzymes are frequently described and are not necessarily a contraindication to use nevirapine. Asymptomatic GGT elevations are not a contraindication to continue therapy.

Monitoring of hepatic tests should be done every two weeks during the first 2 months of treatment, at the 3rd month and then regularly thereafter. Liver test monitoring should be performed if the patient experiences signs or symptoms suggestive of hepatitis and/or hypersensitivity.

If ASAT or ALAT ≥ 2.5 ULN before or during treatment, then liver tests should be monitored more frequently during regular clinic visits. Nevirapine must not be administered to patients with pre- treatment ASAT or ALAT > 5 ULN until baseline ASAT/ALAT are stabilised < 5 ULN (see section 4.3).

Physicians and patients should be vigilant for prodromal signs or findings of hepatitis, such as anorexia, nausea, jaundice, bilirubinuria, acholic stools, hepatomegaly or liver tenderness. Patients should be instructed to seek medical attention promptly if these occur.

If ASAT or ALAT increase to > 5 ULN during treatment, nevirapine should be immediately stopped. If ASAT and ALAT return to baseline values and if the patient had no clinical signs or symptoms of hepatitis, rash, constitutional symptoms or other findings suggestive of organ dysfunction, it may be possible to reintroduce nevirapine, on a case by case basis, at the starting dose regimen of 200 mg/day for 14 days followed by 400 mg/day. In these cases, more frequent liver monitoring is required. If liver function abnormalities recur, nevirapine should be permanently discontinued.

If clinical hepatitis occurs, characterised by anorexia, nausea, vomiting, icterus AND laboratory findings (such as moderate or severe liver function test abnormalities (excluding GGT), Nevirapine must be permanently stopped. Nevirapine must not be readministered to patients who have required permanent discontinuation for clinical hepatitis due to nevirapine.

Liver disease

The safety and efficacy of nevirapine has not been established in patients with significant underlying liver disorders. Nevirapine is contraindicated in patients with severe hepatic impairment (Child-Pugh C, see section 4.3). Pharmacokinetic results suggest caution should be exercised when nevirapine is administered to patients with moderate hepatic dysfunction (Child-Pugh B). Patients with chronic hepatitis B or C and treated with combination antiretroviral therapy are at an increased risk for severe and potentially fatal hepatic adverse reactions. In the case of concomitant antiviral therapy for hepatitis B or C, please refer also to the relevant product information for these medicinal products.

Patients with pre-existing liver dysfunction including chronic active hepatitis have an increased frequency of liver function abnormalities during combination antiretroviral therapy and should be monitored according to standard practice. If there is evidence of worsening liver disease in such patients, interruption or discontinuation of treatment must be considered.

Other warnings

Post-Exposure-Prophylaxis: Serious hepatotoxicity, including liver failure requiring transplantation, has been reported in HIV-uninfected individuals receiving multiple doses of nevirapine in the setting of post-exposure-prophylaxis (PEP), an unapproved use. The use of nevirapine has not been evaluated within a specific study on PEP, especially in term of treatment duration and therefore, is strongly discouraged.

Combination therapy with nevirapine is not a curative treatment of patients infected with HIV-1; patients may continue to experience illnesses associated with advanced HIV-1 infection, including opportunistic infections.

Hormonal methods of birth control other than Depo-medroxyprogesterone acetate (DMPA) should not be used as the sole method of contraception in women taking nevirapine, since nevirapine might lower the plasma concentrations of these medicinal products. For this reason, and to reduce the risk of HIV transmission, barrier contraception (e.g., condoms) is recommended. Additionally, when postmenopausal hormone therapy is used during administration of nevirapine, its therapeutic effect should be monitored.

Weight and metabolic parameters:

An increase in weight and in levels of blood lipids and glucose may occur during antiretroviral therapy. Such changes may in part be linked to disease control and life style. For lipids, there is in some cases evidence for a treatment effect, while for weight gain there is no strong evidence relating this to any particular treatment. For monitoring of blood lipids and glucose reference is made to established HIV treatment guidelines. Lipid disorders should be managed as clinically appropriate.

In clinical studies, Nevirapine has been associated with an increase in HDL- cholesterol and an overall improvement in the total to HDL-cholesterol ratio. However, in the absence of specific studies, the clinical impact of these findings is not known. In addition, Nevirapine has not been shown to cause glucose disturbances.

Osteonecrosis: Although the etiology is considered to be multifactorial (including corticosteroid use, alcohol consumption, severe immunosuppression, higher body mass index), cases of osteonecrosis have been reported particularly in patients with advanced HIV-disease and/or long-term exposure to combination antiretroviral therapy (CART). Patients should be advised to seek medical advice if they experience joint aches and pain, joint stiffness or difficulty in movement.

Immune Reactivation Syndrome: In HIV-infected patients with severe immune deficiency at the time of institution of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic pathogens may arise and cause serious clinical conditions, or aggravation of symptoms. Typically, such reactions have been observed within the first few weeks or months of initiation of CART. Relevant examples are cytomegalovirus retinitis, generalised and/or focal mycobacterial infections, and Pneumocystis jirovecii pneumonia. Any inflammatory symptoms should be evaluated and treatment instituted when necessary. Autoimmune disorders (such as Graves' disease and autoimmune hepatitis) have also been reported to occur in the setting of immune reactivation; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment.

The available pharmacokinetic data suggest that the concomitant use of rifampicin and nevirapine is not recommended. Furthermore, combining the following compounds with Nevirapine is not recommended: efavirenz, ketoconazole, , etravirine, rilpivirine, elvitegravir (in combination with cobicistat), atazanavir (in combination with ritonavir), fosamprenavir (if not co-administered with low dose ritonavir) (see section 4.5).

Granulocytopenia is commonly associated with zidovudine. Therefore, patients who receive nevirapine and zidovudine concomitantly and especially paediatric patients and patients who receive higher zidovudine doses or patients with poor bone marrow reserve, in particular those with advanced HIV disease, have an increased risk of granulocytopenia. In such patients haematological parameters should be carefully monitored.

Lactose:

This medicinal product contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Sodium:

This medicinal product contains sodium starch glycolate. This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.

4.5. Interaction with other medicinal products and other forms of interaction

Nevirapine is an inducer of CYP3A and potentially CYP2B6, with maximal induction occurring within 2-4 weeks of initiating multiple-dose therapy.

Compounds using this metabolic pathway may have decreased plasma concentrations when co- administered with nevirapine. Careful monitoring of the therapeutic effectiveness of P450 metabolised medicinal products is recommended when taken in combination with nevirapine.

The absorption of nevirapine is not affected by food, antacids or medicinal products which are formulated with an alkaline buffering agent.

The interaction data is presented as geometric mean value with 90% confidence interval (90% CI) whenever these data were available. ND = Not Determined, ↑ = Increased, ↓ = Decreased, ↔ = No Effect

Medicinal products by therapeutic areas

Interaction

Recommendations concerning co- administration

ANTI-INFECTIVES

ANTIRETROVIRALS

NRTIs

Didanosine 100-150 mg BID

Didanosine AUC ↔ 1.08 (0.92-1.27)

Didanosine Cmin ND

Didanosine Cmax ↔ 0.98 (0.79-1.21)

Didanosine and Nevirapine can be co-administered without dose adjustments.

Emtricitabine

Emtricitabine is not an inhibitor of human CYP 450 enzymes.

Nevirapine and emtricitabine may be co-administered without dose adjustments.

Abacavir

In human liver microsomes, abacavir did not inhibit cytochrome P450 isoforms.

Nevirapine and abacavir may be coadministered without dose adjustments.

Lamivudine 150 mg BID

No changes to lamivudine apparent clearance and volume of distribution, suggesting no induction effect of nevirapine on lamivudine clearance.

Lamivudine and Nevirapine can be co-administered without dose adjustments.

Stavudine: 30/40 mg BID

Stavudine AUC ↔ 0.96 (0.89-1.03)

Stavudine Cmin ND

Stavudine Cmax ↔ 0.94 (0.86-1.03)

Nevirapine: compared to historical controls, levels appeared to be unchanged.

Stavudine and Nevirapine can be co-administered without dose adjustments.

Tenofovir 300 mg QD

Tenofovir plasma levels remain unchanged when co-administered with Nevirapine.

Nevirapine plasma levels were not altered by co-administration of tenofovir.

Tenofovir and Nevirapine can be co-administered without dose adjustments.

Zidovudine 100-200 mg TID

Zidovudine AUC ↓ 0.72 (0.60-0.96)

Zidovudine Cmin ND

Zidovudine Cmax ↓ 0.70 (0.49-1.04)

Nevirapine: Zidovudine had no effect on its pharmacokinetics.

Zidovudine and Nevirapine can be co-administered without dose adjustments

Granulocytopenia is commonly associated with zidovudine. Therefore, patients who receive nevirapine and zidovudine concomitantly and especially paediatric patients and patients who receive higher zidovudine doses or patients with poor bone marrow reserve, in particular those with advanced HIV disease, have an increased risk of granulocytopenia. In such patients haematological parameters should be carefully monitored.

NNRTIs

Efavirenz 600 mg QD

Efavirenz AUC ↓ 0.72 (0.66-0.86)

Efavirenz Cmin ↓ 0.68 (0.65-0.81)

Efavirenz Cmax ↓ 0.88 (0.77-1.01)

It is not recommended to co-administer efavirenz and Nevirapine (see section 4.4), because of additive toxicity and no benefit in terms of efficacy over either NNRTI alone (for results of 2NN study, see section 5.1).

Etravirine

Concomitant use of etravirine with nevirapine may cause a significant decrease in the plasma concentrations of etravirine and loss of therapeutic effect of etravirine.

The concomitant administration of Nevirapine with NNRTIs is not recommended (see section 4.4).

Rilpivirine

Interaction has not been studied.

The concomitant administration of Nevirapine with NNRTIs is not recommended (see section 4.4).

PIs

Atazanavir/ritonavir

300/100 mg QD

400/100 mg QD

Atazanavir/r 300/100mg:

Atazanavir/r AUC ↓ 0.58 (0.48-0.71)

Atazanavir/r Cmin ↓ 0.28 (0.20-0.40)

Atazanavir/r Cmax ↓ 0.72 (0.60-0.86)

Atazanavir/r 400/100mg:

Atazanavir/r AUC ↓ 0.81 (0.65-1.02)

Atazanavir/r Cmin ↓ 0.41 (0.27-0.60)

Atazanavir/r Cmax ↔ 1.02 (0.85–1.24)

(compared to 300/100mg without nevirapine)

Nevirapine AUC ↑ 1.25 (1.17-1.34)

Nevirapine Cmin ↑1.32 (1.22–1.43)

Nevirapine Cmax ↑ 1.17 (1.09-1.25)

It is not recommended to co-administer atazanavir/ritonavir and Nevirapine (see section 4.4).

Darunavir/ritonavir 400/100 mg BID

Darunavir AUC ↑ 1.24 (0.97-1.57)

Darunavir Cmin ↔ 1.02 (0.79-1.32)

Darunavir Cmax ↑ 1.40 (1.14-1.73)

Nevirapine AUC ↑ 1.27 (1.12-1.44)

Nevirapine Cmin ↑ 1.47 (1.20-1.82)

Nevirapine Cmax ↑ 1.18 (1.02-1.37)

Darunavir and Nevirapine can be co-administered without dose adjustments.

Fosamprenavir 1400 mg BID

Amprenavir AUC ↓ 0.67 (0.55-0.80)

Amprenavir Cmin ↓ 0.65 (0.49-0.85)

Amprenavir Cmax ↓ 0.75 (0.63-0.89)

Nevirapine AUC ↑ 1.29 (1.19-1.40)

Nevirapine Cmin ↑ 1.34 (1.21-1.49)

Nevirapine Cmax ↑ 1.25 (1.14-1.37)

It is not recommended to co-administer fosamprenavir and Nevirapine if fosamprenavir is not co-administered with ritonavir (see section 4.4).

Fosamprenavir/ ritonavir 700/ 100 mg BID

Amprenavir AUC ↔ 0.89 (0.77-1.03)

Amprenavir Cmin ↓ 0.81 (0.69-0.96)

Amprenavir Cmax ↔ 0.97 (0.85-1.10)

Nevirapine AUC ↑ 1.14 (1.05-1.24)

Nevirapine Cmin ↑ 1.22 (1.10-1.35)

Nevirapine Cmax ↑ 1.13 (1.03-1.24)

Fosamprenavir/ritonavir and Nevirapine can be co-administered without dose adjustments

Lopinavir/ritonavir (capsules) 400/ 100 mg BID

Adult patients:

Lopinavir AUC ↓ 0.73 (0.53-0.98)

Lopinavir Cmin ↓ 0.54 (0.28-0.74)

Lopinavir Cmax ↓ 0.81 (0.62-0.95)

An increase in the dose of lopinavir/ritonavir to 533/133 mg (4 capsules) or 500/125 mg (5 tablets with 100/25 mg each) twice daily with food is recommended in combination with Nevirapine. Dose adjustment of Nevirapine is not required when co-administered with lopinavir.

Lopinavir/ritonavir (oral solution) 300/75 mg/m2 BID

Paediatric patients:

Lopinavir AUC ↓ 0.78 (0.56-1.09)

Lopinavir Cmin ↓ 0.45 (0.25-0.82)

Lopinavir Cmax ↓ 0.86 (0.64-1.16)

For children, increase of the dose of lopinavir/ritonavir to 300/75 mg/m2 twice daily with food should be considered when used in combination with Nevirapine, particularly for patients in whom reduced susceptibility to lopinavir/ ritonavir is suspected.

Ritonavir 600 mg BID

Ritonavir AUC↔ 0.92 (0.79-1.07)

Ritonavir Cmin ↔ 0.93 (0.76-1.14)

Ritonavir Cmax ↔ 0.93 (0.78-1.07)

Nevirapine: Co-administration of ritonavir does not lead to any clinically relevant change in nevirapine plasma levels.

Ritonavir and Nevirapine can be co-administered without dose adjustments.

Saquinavir/ritonavir

The limited data available with saquinavir soft gel capsule boosted with ritonavir do not suggest any clinically relevant interaction between saquinavir boosted with ritonavir and Nevirapine

Saquinavir/ritonavir and Nevirapine can be co-administered without dose adjustments.

Tipranavir/ritonavir

500/200 mg BID

No specific drug-drug interaction study has been performed.

The limited data available from a phase IIa study in HIV-infected patients have shown a clinically non significant 20% decrease of TPV Cmin.

Tipranavir and Nevirapine can be co-administered without dose adjustments.

ENTRY INHIBITORS

Enfuvirtide

Due to the metabolic pathway no clinically significant pharmacokinetic interactions are expected between enfuvirtide and nevirapine.

Enfuvirtide and Nevirapine can be co-administered without dose adjustments.

Maraviroc 300 mg QD

Maraviroc AUC ↔1.01 (0.6 -1.55)

Maraviroc Cmin ND

Maraviroc Cmax ↔ 1.54 (0.94-2.52)

compared to historical controls

Nevirapine concentrations not measured, no effect is expected.

Maraviroc and Nevirapine can be co-administered without dose adjustments.

INTEGRASE INHIBITORS

Elvitegravir/cobicistat

Interaction has not been studied. Cobicistat, a cytochrome P450 3A inhibitor significantly inhibits hepatic enzymes, as well as other metabolic pathways. Therefore coadministration would likely result in altered plasma levels of cobicistat and Nevirapine.

Coadministration of Nevirapine with elvitegravir in combination with cobicistat is not recommended (see section 4.4).

Raltegravir 400 mg BID

No clinical data available. Due to the metabolic pathway of raltegravir no interaction is expected.

Raltegravir and Nevirapine can be co-administered without dose adjustments.

ANTIBIOTICS

Clarithromycin 500 mg BID

Clarithromycin AUC↓0.69 (0.62-0.76)

Clarithromycin Cmin ↓0.44 (0.30-0.64)

Clarithromycin Cmax↓0.77 (0.69-0.86)

Metabolite 14-OH

Clarithromycin AUC↑1.42 (1.16-1.73)

Metabolite 14-OH clarithromycin

Cmin ↔0 (0.68-1.49)

Metabolite 14-OH clarithromycin

Cmax ↑1.47 (1.21-1.80)

Nevirapine AUC 1.26

Nevirapine Cmin 1.28

Nevirapine Cmax 1.24

compared to historical controls.

Clarithromycin exposure was significantly decreased, 14-OH metabolite exposure increased.

Because the clarithromycin active metabolite has reduced activity against Mycobacterium aviumintracellulare complex overall activity against the pathogen may be altered. Alternatives to clarithromycin, such as azithromycin should be considered. Close monitoring for hepatic abnormalities is recommended

Rifabutin 150 or 300 mg QD

Rifabutin AUC ↑1.17 (0.98-1.40)

Rifabutin Cmin ↔1.07 (0.84-1.37)

Rifabutin Cmax 1.28 (1.09-1.51)

Metabolite 25-O-desacetylrifabutin

AUC ↑1.24 (0.84-1.84)

Metabolite 25-O-desacetylrifabutin

Cmin ↑1.22 (0.86-1.74)

Metabolite 25-O-desacetylrifabutin

Cmax ↑1.29 (0.98-1.68)

A clinically not relevant increase in the apparent clearance of nevirapine (by 9%) compared to historical data was reported.

No significant effect on rifabutin and Nevirapine mean PK parameters is seen. Rifabutin and Nevirapine can be co-administered without dose adjustments. However, due to the high interpatient variability some patients may experience large increases in rifabutin exposure and may be at higher risk for rifabutin toxicity. Therefore, caution should be used in concomitant administration.

Rifampicin 600 mg QD

Rifampicin AUC ↔1.11 (0.96-1.28)

Rifampicin Cmin ND

Rifampicin Cmax ↔1.06 (0.91-1.22)

Nevirapine AUC ↓0.42

Nevirapine Cmin ↓0.32

Nevirapine Cmax ↓0.50

compared to historical controls.

It is not recommended to co-administer rifampicin and Nevirapine (see section 4.4).

Physicians needing to treat patients co-infected with tuberculosis and using a Nevirapine containing regimen may consider co-administration of rifabutin instead.

ANTIFUNGALS

Fluconazole 200 mg QD

Fluconazole AUC ↔0.94 (0.88-1.01)

Fluconazole Cmin ↔0.93 (0.86-1.01)

Fluconazole Cmax ↔0.92 (0.85-0.99)

Nevirapine: exposure: ↑100% compared with historical data where nevirapine was administered alone.

Because of the risk of increased exposure to Nevirapine, caution should be exercised if the medicinal products are given concomitantly and patients should be monitored closely.

Itraconazole 200 mg QD

Itraconazole AUC ↓0.39

Itraconazole Cmin ↓0.13

Itraconazole Cmax ↓0.62

Nevirapine: there was no significant difference in Nevirapine pharmacokinetic parameters.

A dose increase for itraconazole should be considered when these two agents are administered concomitantly.

Ketoconazole 400 mg QD

Ketoconazole AUC ↓0.28 (0.20-0.40)

Ketoconazole Cmin ND

Ketoconazole Cmax ↓0.56 (0.42-0.73)

Nevirapine:

plasma levels:

↑1.15- 1.28 compared to historical controls.

It is not recommended to co-administer ketoconazole and Nevirapine (see section 4.4).

ANTIVIRALS FOR CHRONIC HEPATITIS B AND C

Adefovir

Results of in vitro studies showed a weak antagonism of nevirapine by adefovir (see section 5.1), this has not been confirmed in clinical trials and reduced efficacy is not expected. Adefovir did not influence any of the common CYP isoforms known to be involved in human drug metabolism and is excreted renally. No clinically relevant drug-drug interaction is expected.

Adefovir and Nevirapine may be coadministered without dose adjustments.

Entecavir

Entecavir is not a substrate, inducer or an inhibitor of cytochrome P450 (CYP450) enzymes. Due to the metabolic pathway of entecavir, no clinically relevant drug-drug interaction is expected.

Entecavir and Nevirapine may be coadministered without dose adjustments.

Interferons (pegylated interferons alfa 2a and alfa 2b)

Interferons have no known effect on CYP 3A4 or 2B6. No clinically relevant drug-drug interaction is expected.

Interferons and Nevirapine may be coadministered without dose adjustments.

Ribavirin

Results of in vitro studies showed a weak antagonism of nevirapine by ribavirin (see section 5.1), this has not been confirmed in clinical trials and reduced efficacy is not expected. Ribavirin does not inhibit cytochrome P450 enzymes, and there is no evidence from toxicity studies that ribavirin induces liver enzymes. No clinically relevant drug-drug interaction is expected.

Ribavirin and Nevirapine may be coadministered without dose adjustments.

Telbivudine

Telbivudine is not a substrate, inducer or inhibitor of the cytochrome P450 (CYP450) enzyme system. Due to the metabolic pathway of telbivudine, no clinically relevant drug-drug interaction is expected.

Telbivudine and Nevirapine may be coadministered without dose adjustments.

ANTACIDS

Cimetidine

Cimetidine: no significant effect on cimetidine PK parameters is seen.

Nevirapine Cmin ↑1.07

Cimetidine and Nevirapine can be co-administered without dose adjustments.

ANTITHROMBOTICS

Warfarin

The interaction between Nevirapine and the antithrombotic agent warfarin is complex, with the potential for both increases and decreases in coagulation time when used concomitantly.

Close monitoring of anticoagulation levels is warranted.

CONTRACEPTIVES

Depomedroxyprogesterone acetate (DMPA) 150mg every 3 months

DMPA AUC ↔

DMPA Cmin ↔

DMPA Cmax ↔

Nevirapine AUC ↑1.20

Nevirapine Cmax ↑1.20

Nevirapine co-administration did not alter the ovulation suppression effects of DMPA. DMPA and Nevirapine can be co-administered without dose adjustments.

Ethinyl estradiol (EE)

0.035 mg

EE AUC ↓0.80 (0.67 - 0.97)

EE Cmin ND

EE Cmax ↔0.94 (0.79 - 1.12)

Oral hormonal contraceptives should not be used as the sole method of contraception in women taking Nevirapine (see section 4.4). Appropriate doses for hormonal contraceptives (oral or other forms of application) other than DMPA in combination with Nevirapine have not been established with respect to safety and efficacy.

Norethindrone (NET)

1.0 mg QD

NET AUC ↓0.81(0.70 - 0.93)

NET Cmin ND

NET Cmax ↓0.84 (0.73 - 0.97)

ANALGESICS/OPIOIDS

Methadone Individual

Patient Dosing

Methadone AUC ↓0.40 (0.31 - 0.51)

Methadone Cmin ND

Methadone Cmax ↓0.58 (0.50 - 0.67)

Methadone-maintained patients beginning Nevirapine therapy should be monitored for evidence of withdrawal and methadone dose should be adjusted accordingly.

HERBAL PRODUCTS

St. John's Wort

Serum levels of Nevirapine can be reduced by concomitant use of the herbal preparation St. John's Wort (Hypericum perforatum). This is due to induction of medicinal product metabolism enzymes and/or transport proteins by St. John's Wort.

Herbal preparations containing St. John's Wort and Nevirapine must not be co-administered (see section 4.3). If a patient is already taking St. John's Wort check nevirapine and if possible viral levels and stop St. John's Wort. Nevirapine levels may increase on stopping St John's Wort. The dose of Nevirapine may need adjusting. The inducing effect may persist for at least 2 weeks after cessation of treatment with St. John's Wort.

Other information:

Nevirapine metabolites: Studies using human liver microsomes indicated that the formation of nevirapine hydroxylated metabolites was not affected by the presence of dapsone, rifabutin, rifampicin, and trimethoprim/sulfamethoxazole. Ketoconazole and erythromycin significantly inhibited the formation of nevirapine hydroxylated metabolites.

4.6. Fertility, pregnancy and lactation

Women of childbearing potential / Contraception in males and females

Women of childbearing potential should not use oral contraceptives as the sole method for birth control, since nevirapine might lower the plasma concentrations of these medicinal products (see sections 4.4 & 4.5).

Pregnancy

Currently available data on pregnant women indicate no malformative or foeto/ neonatal toxicity. To date no other relevant epidemiological data are available. No observable teratogenicity was detected in reproductive studies performed in pregnant rats and rabbits (see section 5.3). There are no adequate and well-controlled studies in pregnant women. Caution should be exercised when prescribing nevirapine to pregnant women (see section 4.4). As hepatotoxicity is more frequent in women with CD4+ cell counts above 250 cells/mm3 with detectable HIV-1 RNA in plasma (50 or more copies/mL), these conditions should be taken in consideration on therapeutic decision (see section 4.4). There is not enough evidence to substantiate that the absence of an increased risk for toxicity seen in pre- treated women initiating nevirapine with an undetectable viral load (less than 50 copies/mL of HIV-1 in plasma) and CD4+ cell counts above 250 cells/mm3 also applies to pregnant women. All the randomised studies addressing this issue specifically excluded pregnant women, and pregnant women were under-represented in cohort studies as well as in meta-analyses.

Breast-feeding

It is recommended that women living with HIV do not breast-feed their infants in order to avoid transmission of HIV.

Fertility

In reproductive toxicology studies, evidence of impaired fertility was seen in rats.

4.7. Effects on ability to drive and use machines

There are no specific studies about the ability to drive vehicles and use machinery. However, patients should be advised that they may experience adverse reactions such as fatigue during treatment with nevirapine. Therefore, caution should be recommended when driving a car or operating machinery. If patients experience fatigue they should avoid potentially hazardous tasks such as driving or operating machinery.

4.8. Undesirable effects

Summary of the safety profile

The most frequently reported adverse reactions related to nevirapine therapy, across all clinical studies, were rash, allergic reactions, hepatitis, abnormal liver function tests, nausea, vomiting, diarrhoea, abdominal pain, fatigue, fever, headache and myalgia.

The postmarketing experience has shown that the most serious adverse reactions are Stevens-Johnson syndrome/ toxic epidermal necrolysis, serious hepatitis/hepatic failure, and drug reaction with eosinophilia and systemic symptoms, characterised by rash with constitutional symptoms such as fever, arthralgia, myalgia and lymphadenopathy, plus visceral involvement, such as hepatitis, eosinophilia, granulocytopenia, and renal dysfunction. The first 18 weeks of treatment is a critical period which requires close monitoring (see section 4.4).

Tabulated summary of adverse reactions

The following adverse reactions which may be causally related to the administration of nevirapine have been reported. The frequencies estimated are based on pooled clinical study data for adverse reactions considered related to nevirapine treatment.

Frequency is defined using the following convention:

Very common

Common

Uncommon

Rare

Very rare

(≥1/10);

(≥1/100 to <1/10);

(≥1/1,000 to <1/100);

(≥1/10,000 to <1/1,000);

(<1/10,000).

Blood and lymphatic system disorders

Common

granulocytopenia

Uncommon

anaemia

Immune system disorders

Common

hypersensitivity (incl. anaphylactic reaction, angioedema, urticaria)

Uncommon

anaphylactic reactions

Rare:

drug reaction with eosinophilia and systemic symptoms

Nervous system disorders

Common

headache

Gastrointestinal disorders

Common

nausea, vomiting, abdominal pain, diarrhoea

Hepatobiliary disorders

Common

hepatitis (including severe and life-threatening hepatotoxicity) (1.9%)

Uncommon

jaundice

Rare

hepatitis fulminant (which may be fatal)

Skin and subcutaneous tissue disorders

Very common

rash (12.5%)

Uncommon

Stevens-Johnson syndrome/ toxic epidermal necrolysis (which may be fatal) (0.2 %), angioedema, urticaria

Musculoskeletal and connective tissue disorders

Uncommon

arthralgia, myalgia

General disorders and administration site conditions

Common

pyrexia, fatigue

Investigations

Common

liver function test abnormal (alanine aminotransferase

increased; transaminases increased; aspartate aminotransferase

increased; gamma-glutamyltransferase increased; hepatic enzyme

increased; hypertransaminasaemia)

Uncommon

blood phosphorus decreased***; blood pressure increased

Description of selected adverse reactions

In study 1100.1090, from which the majority of related adverse events (n=28) were received, patients on placebo had a higher incidence of events of granulocytopenia (3.3%) than patients on nevirapine (2.5%).

Anaphylactic reaction was identified through post-marketing surveillance but not observed in randomised, controlled clinical studies. The frequency category was estimated from a statistical calculation based on the total number of patients exposed to nevirapine in randomised controlled clinical studies (n=2,718).

Decreased blood phosphorus and increased blood pressure were observed in clinical studies with co administration of tenofovir/emtricitabine.

Metabolic parameters

Weight and levels of blood lipids and glucose may increase during antiretroviral therapy (see section 4.4).

The following adverse reactions have also been reported when nevirapine has been used in combination with other anti-retroviral agents: pancreatitis, peripheral neuropathy and thrombocytopaenia. These adverse reactions are commonly associated with other antiretroviral agents and may be expected to occur when nevirapine is used in combination with other agents; however it is unlikely that these adverse reactions are due to nevirapine treatment. Hepatic-renal failure syndromes have been reported rarely.

Immune reactivation syndrome

In HIV-infected patients with severe immune deficiency at the time of initiation of combination antiretroviral therapy (CART), an inflammatory reaction to asymptomatic or residual opportunistic infections may arise. Autoimmune disorders (such as Graves' disease and autoimmune hepatitis) have also been reported; however, the reported time to onset is more variable and these events can occur many months after initiation of treatment (see section 4.4).

Cases of osteonecrosis have been reported, particularly in patients with generally acknowledged risk factors, advanced HIV disease or long-term exposure to combination antiretroviral therapy (CART). The frequency of this is unknown (see section 4.4).

Skin and subcutaneous tissues

The most common clinical toxicity of nevirapine is rash, with nevirapine attributable rash occurring in 12.5% of patients in combination regimens in controlled studies.

Rashes are usually mild to moderate, maculopapular erythematous cutaneous eruptions, with or without pruritus, located on the trunk, face and extremities. Hypersensitivity (anaphylactic reaction, angioedema and urticaria) have been reported. Rashes occur alone or in the context of drug reaction with eosinophilia and systemic symptoms, characterised by rash with constitutional symptoms such as fever, arthralgia, myalgia and lymphadenopathy, plus visceral involvement, such as hepatitis, eosinophilia, granulocytopenia, and renal dysfunction.

Severe and life-threatening skin reactions have occurred in patients treated with nevirapine, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Fatal cases of SJS, TEN and drug reaction with eosinophilia and systemic symptoms have been reported. The majority of severe rashes occurred within the first 6 weeks of treatment and some required hospitalisation, with one patient requiring surgical intervention (see section 4.4).

Hepato-biliary

The most frequently observed laboratory test abnormalities are elevations in liver function tests (LFTs), including ALAT, ASAT, GGT, total bilirubin and alkaline phosphatase. Asymptomatic elevations of GGT levels are the most frequent. Cases of jaundice have been reported. Cases of hepatitis (severe and life-threatening hepatotoxicity, including fatal fulminant hepatitis) have been reported in patients treated with nevirapine. The best predictor of a serious hepatic event was elevated baseline liver function tests. The first 18 weeks of treatment is a critical period which requires close monitoring (see section 4.4).

Paediatric population

Based on clinical study experience of 361 paediatric patients the majority of which received combination treatment with ZDV or/and ddI, the most frequently reported adverse events related to nevirapine were similar to those observed in adults. Granulocytopenia was more frequently observed in children. In an open-label clinical study (ACTG 180) granulocytopenia assessed as medicinal product- related occurred in 5/37 (13.5%) of patients. In ACTG 245, a double-blind placebo controlled study, the frequency of serious medicinal product-related granulocytopenia was 5/305 (1.6%). Isolated cases of Stevens- Johnson syndrome or Stevens-Johnson/ toxic epidermal necrolysis transition syndrome have been reported in this population.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

There is no known antidote for nevirapine overdose. Cases of nevirapine overdose at doses ranging from 800 to 6,000 mg per day for up to 15 days have been reported. Patients have experienced oedema, erythema nodosum, fatigue, fever, headache, insomnia, nausea, pulmonary infiltrates, rash, vertigo, vomiting, increase in transaminases and weight decrease. All of these effects subsided following discontinuation of nevirapine.

Paediatric Population

One case of massive accidental overdose in a newborn was reported. The ingested dose was 40 times the recommended dose of 2 mg/kg/day. Mild isolated neutropenia and hyperlactataemia was observed, which spontaneously disappeared within one week without any clinical complications. One year later, the child's development remained normal.