Stanford Antimicrobial Safety and Sustainability Program
Revision date 05/2017
Stanford Medication Usage Guide
Ribavirin (oral)
Usage
• Ribavirin is FDA approved for the treatment of hepatitis C in combination with IFN-α.
• Off-label: treatment of severe respiratory infections with community-acquired respiratory
viruses in immunocompromised patients. E.g.
o Respiratory syncytial virus (RSV)
o Metapneumovirus (MPV)
o Parainfluenza virus (PIV)
Dosing
CrCl Oral Ribavirin Dosing Regimen for RSV, MPV, PIV
(typical duration 5-10 days)
>50 15 – 20 mg/kg/day in 2 to 3 divided doses; round to nearest 200
mg dose (max dose: 1800 mg/day)
30-50 200 mg TID – 400 mg BIDa
<29, ESRD, IHD No recommendations exist. Some experts recommend 200 mg dailya
CRRT, PD No recommendations exist. Consult ASP/ID pharmacist
a. The prescribing information for Rebetol® (capsule) states that use is contraindicated if CrCl <50 mL/min.
The prescribing information for Copegus® (tablet) states that the dose should be reduced in patients with CrCl ≤ 50
mL/min.
Pharmacokinetics/Pharmacodynamics
Ribavirin pharmacokinetics
Bioavailability 64%, increased by high fat meal
Distribution Vd 2,825 L (single dose): distribution significantly prolonged in the
erythrocyte (16 to 40 days), which can be used as a marker for
intracellular metabolism
Metabolism Hepatically and intracellularly (forms active metabolites)
Half-life elimination Capsule: 24h (single dose), 298h (steady state)
Tablet: 120-170h (single dose), 288h (multiple doses)
Time to peak, serum 3h (capsule)
2h (tablet)
Excretion 61% urine, 12% feces
Note: Plasma ribavirin is removed by hemodialysis with an extraction
ratio of approximately 50%; however, due to its large Vd, plasma
exposure is not expected to change with hemodialysis
Monitoring Parameters
• Re-evaluate therapy if adverse reactions occur e.g. clinically significant anemia necessitating
transfusion may warrant discontinuation or dose decrease.
• Risk of may be increased in those with renal insufficiency, dialysis, low baseline Hgb levels,
or concomitant therapy associated with causing bone marrow suppression.
Special Circumstances
• Hazardous drug: do not crush/open capsules/tablets. Product is available as oral solution
• Pregnancy FDA risk category X
Stanford Antimicrobial Safety and Sustainability Program
Revision date 05/2017
References:
1. https://www.merck.com/product/usa/pi_circulars/r/rebetol/rebetol_pi.pdf
2. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021511s023lbl.pdf
3. Smolders, Elise J., Clara T. M. M. de Kanter, Bart van Hoek, Joop E. Arends, Joost P. H. Drenth, and
David M. Burger. “Pharmacokinetics, Efficacy, and Safety of Hepatitis C Virus Drugs in Patients with
Liver And/Or Renal Impairment.” Drug Safety 39, no. 7 (July 2016): 589–611. doi:10.1007/s40264-
016-0420-2.
4. Hirsch, Hans H., Rodrigo Martino, Katherine N. Ward, Michael Boeckh, Hermann Einsele, and Per
Ljungman. “Fourth European Conference on Infections in Leukaemia (ECIL-4): Guidelines for
Diagnosis and Treatment of Human Respiratory Syncytial Virus, Parainfluenza Virus,
Metapneumovirus, Rhinovirus, and Coronavirus.” Clinical Infectious Diseases: An Official Publication
of the Infectious Diseases Society of America 56, no. 2 (January 15, 2013): 258–66.
doi:10.1093/cid/cis844.
5. Gross, Alan E., and Michelle L. Bryson. “Oral Ribavirin for the Treatment of Noninfluenza Respiratory
Viral Infections: A Systematic Review.” The Annals of Pharmacotherapy 49, no. 10 (October 2015):
1125–35. doi:10.1177/1060028015597449.
6. Lexi-comp
Document Information:
A. Original Author/Date: Lina Meng, PharmD, BCPS, BCCCP, Roy Lee, PharmD,
BCPS, Emily Mui, PharmD, BCPS, Stan Deresinski, MD, 05/2017
B. Gatekeeper: Antimicrobial Stewardship Program
C. Review and Renewal Requirement
This document will be reviewed every three years and as required by change of
law or practice
D. Revision/Review History:
E. Approvals
1. Antimicrobial Subcommittee: 8/17/2017
2. P&T: 9/15/2017 (pending)
This document is intended only for the internal use of Stanford Health Care (SHC). It may not be copied or otherwise used, in
whole, or in part, without the express written consent of SHC. Any external use of this document is on an AS IS basis, and
SHC shall not be responsible for any external use. Direct inquiries to ASP 650-721-1908
Stanford Health Care
Stanford, CA 94305
