Standard DoseRibavirin dosage depends on several factors, including the brand used, indication for treatment, patient lab values, and patient tolerability. It is given in either fixed doses or in doses related to weight (weight-based). The dose range is 600 mg to 1,200 mg per day taken in two divided doses. Depending upon the manufacturer, tablets are available in 200 mg, 400 mg, 500 mg, and 600 mg. Ribavirin solution (liquid) and generic tablets are also available. The authorized generic was created to help lower cost and has identical ingredients as the brand name. It must be taken with food. Ribavirin may be added to direct-acting antiviral (DAA) therapy in people that have severe hepatic impairment (decompensated cirrhosis) or in people who have certain resistance mutations that make the DAA less effective. It should never be taken by itself.
Dose adjustment in patients with kidney dysfunction varies based on brand used. In general, use of ribavirin is contraindicated in people with creatinine clearance (CrCl) less than 50 mL/min.
Take missed dose as soon as possible, unless it is closer to the time of your next dose. Do not double up on your next dose.
ManufacturerRebetol (solution): Merck
AWPAWP (based on 1,200 mg/day dosing)
Rebetol (solution): $1,960 / month;
Generic 200 mg tablet: $222–$1,670 / month
Generic 200 mg capsule: $230–$1,668 / month
Generic capsules/tablets: Manufacturers vary
Potential Side Effects and Toxicity
There are two very serious potential side effects associated with ribavirin: anemia and birth defects/miscarriage/stillbirth. The anemia caused by ribavirin can be very severe and can happen very quickly, usually within the first 1–2 weeks of starting treatment. Anemia can cause severe fatigue, dizziness, headaches, and shortness of breath; routine blood testing for anemia, neutropenia, and other blood conditions is recommended. The anemia may also cause or worsen cardiac conditions.
The other major side effect is birth defects or fetal death in pregnant women. Pregnant women or women who are trying to become pregnant cannot take ribavirin; women of childbearing age and their male sexual partners must use two forms of birth control throughout treatment and for six months post-treatment. It is unknown if ribavirin passes through breast milk or the impact it could have on breastfeeding babies.
Other side effects that have been reported with ribavirin include rash and itching, and there is a small risk of pancreatitis. If you experience any symptoms related to pancreatitis (severe stomach pain that radiates to your back, nausea, vomiting, and/or diarrhea) you should call your advice nurse (when applicable) or go to an emergency department for evaluation. If you have renal (kidney) disease, talk with your medical provider about potential dosage adjustments as the levels of ribavirin can be increased dramatically. Some people who are taking ribavirin experience what is commonly called “riba-rage,” that is they get easily irritated and get angry easier.
Potential Drug Interactions
Ribavirin cannot be used with the HIV medication didanosine (Videx-EC, Videx, ddI) as this combination can lead to potentially fatal levels of ddI. Similarly, azathioprine (an immunosuppressive) cannot be used due to increased concentrations of azathioprine. Use caution if ribavirin given with zidovudine, lamivudine, or stavudine (medications to treat HIV) due to potential for worsening side effects (anemia) and possible loss of HIV viral suppression (controversial if this actually occurs).
It’s not entirely understood how ribavirin works against HCV. It previously played a major part in HCV treatment for years when used in combination with interferon but is now generally reserved for certain patient populations with severe hepatic impairment. We are essentially in the ribavirin-free era with many of the current HCV DAAs.
If you need to take ribavirin, the side effects can be difficult. If you become anemic while on ribavirin, your medical provider may need to adjust the dose accordingly. The anemia often happens quickly, so get blood tests to monitor it early in your treatment. “Riba-rage” is not a common occurrence, but it’s good to be aware and (if disclosing HCV status is not an issue) telling the people around you about it so you can get the support you need to minimize its impact.