• Management of HIV infection in combination with a nucleoside analogue.

Contraindicated in:

• Hypersensitivity
• Concurrent ketoconazole, rifampin, or St. John's wort
• Moderate to severe hepatic impairment (Child-Pugh Class B or C)
• For use as part of occupational and non-occupational post-exposure prophylaxis regimens
• Women with CD4+ cell counts >250 cells/mm³ (↑ risk of liver toxicity).
• Lactation: Breastfeeding not recommended in mothers infected with HIV

Use Cautiously in:

• Women (↑ risk of liver toxicity)
• Hepatic or renal impairment
• Concurrent clarithromycin, fluconazole, methadone, or rifabutin (careful monitoring required; alternative therapy should be considered)
• OB: Use during pregnancy only if maternal benefit justifies potential fetal risk
• Pedi: Children <6 yr or with a body surface area <1.17 m² (extended-release nevirapine) and <15 days (immediate-release nevirapine) (safety and effectiveness not established).

Reflects combination therapy

Derm: DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), rash (may progress to toxic epidermal necrolysis), STEVENS-JOHNSON SYNDROME.

GI: HEPATOTOXICITY, ↑liver enzymes, nausea, abdominal pain, diarrhea, hepatitis, ulcerative stomatitis.

GU: ↓fertility (females).

Hemat: granulocytopenia (↑ in children).

MS: myalgia.

Neuro: paresthesia, peripheral neuropathy , headache.
Misc: fever, immune reconstitution syndrome.

Drug-Drug:

• Nevirapine induces the hepatic CYP3A4 enzyme system and can affect the behavior of drugs metabolized by this system.
• Significantly ↓ ketoconazole levels (concurrent use contraindicated).
• May induce methadone withdrawal within 2 wk of starting therapy in patients physically dependent on methadone.
• May ↓ levels and effectiveness hormonal contraceptives (concurrent use of hormonal contraceptives should be avoided).
• Rifampin significantly ↓ levels and effectiveness of nevirapine (concurrent use contraindicated). ↓ Levels and effectiveness of clarithromycin (consider other agents). Also may ↓ levels and effectiveness of the following: lopinavir, fosamprenavir, saquinavir, nelfnavir, indinavir, efavirenz, amiodarone, disopyramide, lidocaine, itraconazole, carbamazepine, clonazepam, ethosuximide, diltiazem, nifedipine, verapamil, cyclosporine, tacrolimus, sirolimus, cyclophosphamide, ergotamine fentanyl rifabutin; use together only with careful monitoring; ↑ dose of lopinavir/ritonavir to 500/125 mg twice daily.
• Fluconazole↑ nevirapine levels and risk of toxicity.
• May ↑ risk of bleeding with warfarin.
• Use of prednisone during first 2 wk of therapy may ↑ risk of rash.
• Initiating other drugs that often cause rash, including trimethoprim/sulfamethoxazole and abacavir simultaneously with nevirapine may ↑ risk of rash.
• Concurrent use with atazanavir may ↓ atazanavir levels and ↑ nevirapine levels (concurrent use not recommended).
• May ↑ levels of darunavir/ritonavir and maraviroc.

Drug-Natural Products:

• St. John’s wort may ↓ efficacy.

(Generic available)

• Extended-release tablets (Viramune XR): 100 mg; 400 mg;
• Immediate-release tablets: 200 mg;
• Oral suspension: 50 mg/5 mL;

• PO (Adults): Immediate-release (IR) — 200 mg daily for the first 2 wk, then 200 mg twice daily (in combination with a nucleoside analogue antiretroviral); Extended-release (ER) (for patients not currently taking IR nevirapine) — 200 mg of IR nevirapine for the first 2 wk (to ↓ risk of rash), then 400 mg of ER nevirapine once daily; ER (for patients currently taking IR nevirapine) — switch to 400 mg of extended-release nevirapine once daily.
• PO (Children 15 days): IR — 150 mg/m² once daily for first 2 wk, then 150 mg/m² twice daily.
• PO (Children 6–<18 yr and BSA 1.17 m²): ER — 150 mg/m² of IR nevirapine once daily (max = 200 mg/day) for the first 2 wk (to ↓ risk of rash), then 400 mg of ER nevirapine once daily.
• PO (Adults and Children): Dialysis — Give additional 200 mg of IR nevirapine after each dialysis session.

Viramune, Viramune XR

• Binds to the enzyme reverse transcriptase, which results in disruption of DNA synthesis.

• Slowed progression of HIV infection and decreased occurrence of sequelae.

Therapeutic Classification: antiretrovirals

Pharmacologic Classification: non nucleoside reverse transcriptase inhibitors

Absorption: >90% absorbed after oral administration.

Distribution: Crosses placenta and enters breast milk; CSF levels are 45% of those in plasma.

Metabolism/Excretion: Mostly metabolized by the liver (CYP3A4 enzyme system); minor amounts excreted unchanged in urine.

Half-life: 25–30 hr (during multiple dosing).

(blood levels)

• Emphasize the importance of taking nevirapine as directed, at evenly spaced times throughout day. Instruct patient to read the Medication Guide prior to initiating therapy and with each Rx refill. Do not take more than prescribed amount and do not stop taking without consulting health care professional. Take missed doses as soon as remembered; do not double doses.
• Instruct patient not to share nevirapine with others.
• Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
• Inform patient that nevirapine does not cure AIDS or prevent associated or opportunistic infections. Nevirapine may reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom and avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. Advise patient that the long-term effects of nevirapine are unknown at this time.
• Instruct patient to notify health care professional immediately if signs and symptoms of hepatitis (flu-like symptoms, tiredness, nausea, lack of appetite, yellow skin or eyes, dark urine, pale stools, pain or sensitivity to touch on right side below ribs), skin reactions with symptoms (flu-like symptoms, fever, muscle aches, conjunctivitis, blisters, mouth sores, swelling of face, tiredness), or signs of immune reconstitution syndrome (signs and symptoms of an infection) occur. Nevirapine should be discontinued immediately.
• Advise patient taking oral contraceptives to use a nonhormonal method of birth control during nelfinavir therapy. If pregnancy is suspected notify health care professional promptly. Encourage pregnant women to enroll in the Antiretroviral Pregnancy Registry by calling 1-800-258-4263. Advise female patient to avoid breastfeeding during therapy. Nevirapine may decrease fertility in females.
• Emphasize the importance of regular follow-up exams and blood counts to determine progress and monitor for side effects.

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