Drugs Details

Drugs Info of Rebetron
Drugs Details
  • Drugs Type  : Multum
  • Date : 18th Mar 2015 05:41 am
  • Brand Name : Rebetron
  • Generic Name : interferon alfa-2b and ribavirin (Pronunciation: in ter FEAR on AL fa 2b and RYE ba VYE rin)
Descriptions

REBETOL®

REBETOL is Schering Corporation's brand name for ribavirin, a nucleoside analog with antiviral activity. The chemical name of ribavirin is 1-β-D-ribofuranosyl-1H-1,2,4-triazole-3-carboxamide and has the following structural formula:

 

REBETOL (ribavirin) Structural Formula Illustration

Ribavirin is a white, crystalline powder. It is freely soluble in water and slightly soluble in anhydrous alcohol. The empirical formula is C8H12N4O5 and the molecular weight is 244.21.

REBETOL Capsules consist of a white powder in a white, opaque, gelatin capsule. Each capsule contains 200 mg ribavirin and the inactive ingredients microcrystalline cellulose, lactose monohydrate, croscarmellose sodium, and magnesium stearate. The capsule shell consists of gelatin, and titanium dioxide. The capsule is printed with edible blue pharmaceutical ink which is made of shellac, anhydrous ethyl alcohol, isopropyl alcohol, n-butyl alcohol, propylene glycol, ammonium hydroxide, and FD&C Blue #2 aluminum lake.

INTRON® A

INTRON A is Schering Corporation's brand name for interferon alfa-2b, recombinant, a purified, sterile, recombinant interferon product.

Interferon alfa-2b, recombinant has been classified as an alpha interferon and is a water-soluble protein composed of 165 amino acids with a molecular weight of 19,271 daltons produced by recombinant DNA techniques. It is obtained from the bacterial fermentation of a strain of Escherichia coli bearing a genetically engineered plasmid containing an interferon alfa-2b gene from human leukocytes. The fermentation is carried out in a defined nutrient medium containing the antibiotic tetracycline hydrochloride at a concentration of 5 to 10 mg/L; the presence of this antibiotic is not detectable in the final product.

INTRON A Injection is a clear, colorless solution. The 3 million IU vial of INTRON A Injection contains 3 million IU of interferon alfa-2b, recombinant per 0.5 mL. The 18 million IU multidose vial of INTRON A Injection contains a total of 22.8 million IU of interferon alfa-2b, recombinant per 3.8 mL (3 million IU/0.5 mL) in order to provide the delivery of six 0.5 mL doses, each containing 3 million IU of INTRON A (for a label strength of 18 million IU). The 18 million IU INTRON A Injection multidose pen contains a total of 22.5 million IU of interferon alfa-2b, recombinant per 1.5 mL (3 million IU/0.2 mL) in order to provide the delivery of six 0.2-mL doses, each containing 3 million IU of INTRON A (for a label strength of 18 million IU). Each mL also contains 7.5 mg sodium chloride, 1.8 mg sodium phosphate dibasic, 1.3 mg sodium phosphate monobasic, 0.1 mg edetate disodium, 0.1 mg polysorbate 80, and 1.5 mg m-cresol as a preservative.

Based on the specific activity of approximately 2.6 x 108 IU/mg protein as measured by HPLC assay, the corresponding quantities of interferon alfa-2b, recombinant in the vials and pen described above are approximately 0.012 mg, 0.088 mg, and 0.087 mg protein, respectively.

Mechanism of Action

Ribavirin/Interferon alfa-2b, recombinant

The mechanism of inhibition of hepatitis C virus (HCV) RNA by combination therapy with REBETOL and INTRON A has not been established.

What are the possible side effects of interferon alfa-2b and ribavirin (Rebetron)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Stop using this medication and call your doctor at once if you have any of these serious side effects:

  • pale or yellowed skin, dark colored urine;
  • fever, chills, body aches, flu symptoms, easy bruising or bleeding, unusual weakness;
  • confusion, severe depression or anxiety, aggression, thoughts of hurting yourself or others;
  • vision problems;
  • high fever with...

Read All Potential Side Effects and See Pictures of Rebetron »

This monograph has been modified to include the generic and brand name in many instances.

Indications

REBETOL (ribavirin, USP) Capsules is indicated in combination with INTRON A (interferon alfa-2b, recombinant) Injection for the treatment of chronic hepatitis C in patients with compensated liver disease previously untreated with alpha interferon or who have relapsed following alpha interferon therapy.

Dosage Administration

INTRON A Injection should be administered subcutaneously and REBETOL Capsules should be administered orally. REBETOL may be administered without regard to food, but should be administered in a consistent manner. (See CLINICAL PHARMACOLOGY.)

Adults

The recommended dose of REBETOL Capsules depends on the patient's body weight. The recommended doses of REBETOL and INTRON A for adults are given in TABLE 7.

The recommended duration of treatment for patients previously untreated with interferon is 24 to 48 weeks. The duration of treatment should be individualized to the patient depending on baseline disease characteristics, response to therapy, and tolerability of the regimen (see Description of Clinical Studies and ADVERSE REACTIONS). After 24 weeks of treatment virologic response should be assessed. Treatment discontinuation should be considered in any patient who has not achieved an HCV-RNA below the limit of detection of the assay by 24 weeks. There are no safety and efficacy data on treatment for longer than 48 weeks in the previously untreated patient population.

In patients who relapse following interferon therapy, the recommended duration of treatment is 24 weeks. There are no safety and efficacy data on treatment for longer than 24 weeks in the relapse patient population.

TABLE 7. Recommended Adult Dosing

Body weight REBETOL Capsules INTRON A Injection
≤ 75 kg 2 x 200 mg capsules AM,
3 x 200 mg capsules PM daily p.o.
3 million IU 3 times weekly s.c.
> 75 kg 3 x 200 mg capsules AM,
3 x 200 mg capsules PM daily p.o.
3 million IU 3 times weekly s.c.

Pediatrics

Efficacy of REBETOL and INTRON A for pediatric patients has not been established. Based on pharmacokinetic data, the following doses of REBETOL and INTRON A provide similar exposures in pediatric patients as observed in adult patients treated with the approved doses of REBETOL and INTRON A (see TABLE 8).

Table 8. Pediatric Dosing

Body weight REBETOL Capsules INTRON A Injection
25-36 kg 1 x 200 mg capsule AM
1 x 200 mg capsule PM daily p.o.
3 million IU/m² 3 times weekly s.c.
37-49 kg 1 x 200 mg capsule AM
2 x 200 mg capsules PM daily p.o.
3 million IU/m² 3 times weekly s.c.
50-61 kg 2 x 200 mg capsules AM
2 x 200 mg capsules PM daily p.o.
3 million IU/m² 3 times weekly s.c.
> 61 kg Refer to adult dosing table Refer to adult dosing table

Under no circumstances should REBETOL capsules be opened, crushed or broken (see CONTRAINDICATIONS and WARNINGS).

Dose Modifications (TABLE 9)

In clinical trials, approximately 26% of patients required modification of their dose of REBETOL Capsules, INTRON A Injection, or both agents. If severe adverse reactions or laboratory abnormalities develop during combination REBETOL/INTRON A therapy the dose should be modified, or discontinued if appropriate, until the adverse reactions abate. If intolerance persists after dose adjustment, REBETOL/INTRON A therapy should be discontinued.

REBETOL/INTRON A therapy should be administered with caution to patients with pre-existing cardiac disease. Patients should be assessed before commencement of therapy and should be appropriately monitored during therapy. If there is any deterioration of cardiovascular status, therapy should be stopped. (See WARNINGS.)

For patients with a history of stable cardiovascular disease, a permanent dose reduction is required if the hemoglobin decreases by ≥ 2 g/dL during any 4-week period. In addition, for these cardiac history patients, if the hemoglobin remains < 12 g/dL after 4 weeks on a reduced dose, the patient should discontinue combination REBETOL/INTRON A therapy.

It is recommended that a patient whose hemoglobin level falls below 10 g/dL have his/her REBETOL dose reduced to 600 mg daily (1 x 200 mg capsule AM, 2 x 200 mg capsules PM). A patient whose hemoglobin level falls below 8.5 g/dL should be permanently discontinued from REBETOL/INTRON A therapy. (See WARNINGS.)

It is recommended that a patient who experiences moderate depression (persistent low mood, loss of interest, poor self image, and/or hopelessness) have his/her INTRON A dose temporarily reduced and/or be considered for medical therapy. A patient experiencing severe depression or suicidal ideation/attempt should be discontinued from REBETOL/INTRON A therapy and followed closely with appropriate medical management. (See WARNINGS.)

TABLE 9. Guidelines for Dose Modifications

  Dose Reduction*
REBETOL – Adults 600 mgdaily
Pediatrics: half the dose
INTRON A – Adults 1.5 million
IU TIW
Pediatrics: 1.5 million IU/m²
TIW
Permanent Discontinuation of
Treatment
REBETOL and INTRON A
Hemoglobin < 10 g/dL (REBETOL) Cardiac History Patients only. ≥ 2 g/dL decrease during any 4-week period during treatment (REBETOL/INTRON A) < 8.5 g/dL Cardiac History Patients only. < 12 g/dL after 4 weeks of dose reduction
White blood count < 1.5 x 109/L (INTRON A) < 1.0 x 109/L
Neutrophil count < 0.75 x 109/L (INTRON A) < 0.5 x 109/L
Platelet count Adults: < 50 x 109/L (INTRON A)
Pediatrics: < 80 x 109/L (INTRONA)
Adults: < 25 x 109/L
Pediatrics: < 50 x 109/L
*Study medication to be dose reduced is shown in parenthesis
Administration of INTRON A Injection

At the discretion of the physician, the patient may self-administer the INTRON A. (See illustrated MEDICATION GUIDE for instructions.)

The Intron A Injection is supplied as a clear and colorless solution. The appropriate INTRON A dose should be withdrawn from the vial or set on the multidose pen and injected subcutaneously. The INTRON A Injection supplied with the B-D Safety Lok™ syringes contain a plastic sleeve to be pulled over the needle after use. The syringe locks with an audible click when the green stripe on the safety sleeve covers the red stripe on the needle. After administration of INTRON A Injection, it is essential to follow the procedure for proper disposal of syringes and needles. (See MEDICATION GUIDE for detailed instructions.)

 

Vial/Pen Label Strength Fill Volume Concentration
3 million IU vial 0.5 mL 3 million IU/0.5 mL
18 million IU multidose vial† 3.8 mL 3 million IU/0.5 mL
18 million IU multidose pen† † 1.5 mL 3 million IU/0.2 mL
† This is a multidose vial which contains a total of 22.8 million IU of interferon alfa-2b, recombinant per 3.8 mL in order to provide the delivery of six 0.5-mL doses, each containing 3 million IU of interferon alfa-2b, recombinant (for a label strength of 18 million IU).
† † This is a multidose pen which contains a total of 22.5 million IU of interferon alfa-2b, recombinant per 1.5 mL in order to provide the delivery of six 0.2-mL doses, each containing 3 million IU of interferon alfa-2b, recombinant (for a label strength of 18 million IU).

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. INTRON A Injection may be administered using either sterilized glass or plastic disposable syringes.

Stability

INTRON A Injection provided in vials is stable at 35°C (95°F) for up to 7 days and at 30°C (86°F) for up to 14 days. INTRON A Injection provided in a multidose pen is stable at 30°C (86°F) for up to 2 days. The solution is clear and colorless.

How Supplied

REBETOL 200-mg Capsules are white, opaque capsules with REBETOL, 200 mg, and the Schering Corporation logo imprinted on the capsule shell; the capsules are packaged in a bottle.

INTRON A Injection is a clear, colorless solution packaged in single dose and multidose vials, and a multidose pen.

INTRON A Injection and REBETOL Capsules are available in the following combination package presentations:

 

View Enlarged Table

Storage Conditions

Store the REBETOL Capsules plus INTRON A Injection combination package refrigerated between 2° C and 8° C (36° and 46° F).

When separated, the individual bottle of REBETOL Capsules should be stored refrigerated between 2° and 8° C (36° and 46° F) or at 25° C (77° F); excursions are permitted between 15° and 30° C (59° and 86° F).

When separated, the individual vials of INTRON A Injection and the INTRON A Multidose Pen should be stored refrigerated between 2° and 8° C (36° and 46° F).

12/21/01. Schering Corporation, Kenilworth, NJ 07033 USA.

This monograph has been modified to include the generic and brand name in many instances.

Side Effects

The safety of combination REBETOL/INTRON A therapy was evaluated in controlled trials of 1010 HCV-infected adults who were previously untreated with interferon therapy and were subsequently treated for 24 or 48 weeks with combination REBETOL/INTRON A therapy and in 173 HCV-infected patients who had relapsed after interferon therapy and were subsequently treated for 24 weeks with combination REBETOL/INTRON A therapy. (See Description of Clinical Studies.) Overall, 19% and 6% of previously untreated and relapse patients, respectively, discontinued therapy due to adverse events in the combination arms compared to 13% and 3% in the interferon arms.

The primary toxicity of ribavirin is hemolytic anemia. Reductions in hemoglobin levels occurred within the first 1-2 weeks of therapy (see WARNINGS). Cardiac and pulmonary events associated with anemia occurred in approximately 10% of patients treated with REBETOL/INTRON A therapy. (See WARNINGS.)

The most common psychiatric events occurring in US studies of previously untreated and relapse patients treated with REBETOL/INTRON A therapy, respectively, were insomnia (39%, 26%), depression (34%, 23%), and irritability (27%, 25%). Suicidal behavior (ideation, attempts, and suicides) occurred in 1% of patients. (See WARNINGS.) In addition, the following spontaneous adverse events have been reported during the marketing surveillance of REBETOL/INTRON A therapy: hearing disorder and vertigo. Very rarely, combination REBETOL/INTRON A therapy may be associated with aplastic anemia.

Selected treatment-emergent adverse events that occurred in the US studies with ≥ 5% incidence are provided in TABLE 5 by treatment group. In general, the selected treatment-emergent adverse events reported with lower incidence in the international studies as compared to the US studies with the exception of asthenia, influenza-like symptoms, nervousness, and pruritus.

TABLE 5. Selected Treatment-Emergent Adverse Events: Previously Untreated and Relapse Patients

View Enlarged Table

Laboratory Values

Changes in selected hematologic values (hemoglobin, white blood cells, neutrophils, and platelets) during combination REBETOL/INTRON A treatment are described below (see TABLE 6).

Hemoglobin

Hemoglobin decreases among patients on combination therapy began at Week 1, with stabilization by Week 4. In previously untreated patients treated for 48 weeks the mean maximum decrease from baseline was 3.1 g/dL in the US study and 2.9 g/dL in the International study. In relapse patients the mean maximum decrease from baseline was 2.8 g/dL in the US study and 2.6 g/dL in the International study. Hemoglobin values returned to pretreatment levels within 4 - 8 weeks of cessation of therapy in most patients.

Neutrophils

There were decreases in neutrophil counts in both the combination REBETOL/INTRON A and INTRON A plus placebo dose groups. In previously untreated patients treated for 48 weeks the mean maximum decrease in neutrophil count in the US study was 1.3 x 109 /L and in the International study was 1.5 x 109 /L. In relapse patients the mean maximum decrease in neutrophil count in the US study was 1.3 x 109 /L and in the International study was 1.6 x 109 /L. Neutrophil counts returned to pretreatment levels within 4 weeks of cessation of therapy in most patients.

Platelets

In both previously untreated and relapse patients mean platelet counts generally remained in the normal range in all treatment groups, however, mean platelet counts were 10% to 15% lower in the INTRON A plus placebo group than the REBETOL/INTRON A group. Mean platelet counts returned to baseline levels within 4 weeks after treatment discontinuation.

Thyroid Function

Of patients who entered the previously untreated (24 and 48 week treatment) and relapse (24 week treatment) studies without thyroid abnormalities, approximately 3% to 6% and 1% to 2%, respectively, developed thyroid abnormalities requiring clinical intervention.

Bilirubin and Uric Acid

Increases in both bilirubin and uric acid, associated with hemolysis, were noted in clinical trials. Most were moderate biochemical changes and were reversed within 4 weeks after treatment discontinuation. This observation occurs most frequently in patients with a previous diagnosis of Gilbert's syndrome. This has not been associated with hepatic dysfunction or clinical morbidity.

TABLE 6. Selected Hematologic Values During Treatment with REBETOL plus INTRON A: Previously Untreated and Relapse Patients

View Enlarged Table

Read the Rebetron (rebetol and intron a combination therapy) Side Effects Center for a complete guide to possible side effects

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Interactions

Nucleoside Analogs

Administration of nucleoside analogues has resulted in fatal and nonfatal lactic acidosis. Coadministration of ribavirin and nucleoside analogues should be undertaken with caution and only if the potential benefit outweighs the potential risks.

This monograph has been modified to include the generic and brand name in many instances.

Warnings

Pregnancy

Category X, may cause birth defects. See BOXED CONTRAINDICATIONS AND WARNINGS. See CONTRAINDICATIONS.

Anemia

HEMOLYTIC ANEMIA (HEMOGLOBIN < 10 G/DL) WAS OBSERVED IN APPROXIMATELY 10% OF REBETOL/INTRON A-TREATED PATIENTS IN CLINICAL TRIALS (SEE ADVERSE REACTIONS LABORATORY VALUES - HEMOGLOBIN). ANEMIA OCCURRED WITHIN 1 - 2 WEEKS OF INITIATION OF RIBAVIRIN THERAPY. BECAUSE OF THIS INITIAL ACUTE DROP IN HEMOGLOBIN, IT IS ADVISED THAT COMPLETE BLOOD COUNTS (CBC) SHOULD BE OBTAINED PRETREATMENT AND AT WEEK 2 AND WEEK 4 OF THERAPY OR MORE FREQUENTLY IF CLINICALLY INDICATED. PATIENTS SHOULD THEN BE FOLLOWED AS CLINICALLY APPROPRIATE.

The anemia associated with REBETOL/INTRON A therapy may result in deterioration of cardiac function and/or exacerbation of the symptoms of coronary disease. Patients should be assessed before initiation of therapy and should be appropriately monitored during therapy. If there is any deterioration of cardiovascular status, therapy should be suspended or discontinued. (See DOSAGE AND ADMINISTRATION.) Because cardiac disease may be worsened by drug induced anemia, patients with a history of significant or unstable cardiac disease should not use combination REBETOL/INTRON A therapy. (See ADVERSE REACTIONS.)

Similarly, patients with hemoglobinopathies (eg, thalassemia, sickle-cell anemia) should not be treated with combination REBETOL/INTRON A therapy.

Psychiatric

Severe psychiatric adverse events, including depression, psychoses, aggressive behavior, hallucinations, violent behavior (suicidal ideation, suicidal attempts, suicides) and rare instances of homicidal ideation have occurred during combination Rebetol/Intron A therapy, both in patients with and without a previous psychiatric disorder. Rebetol/Intron A therapy should be used with extreme caution in patients with a history of pre-existing psychiatric disorders, and all patients should be carefully monitored for evidence of depression and other psychiatric symptoms. Suspension of Rebetol/Intron A therapy should be considered if psychiatric intervention and/or dose reduction is unsuccessful in controlling psychiatric symptoms. In severe cases, therapy should be stopped immediately and psychiatric intervention sought. (See ADVERSE REACTIONS.)

Bone marrow toxicity

INTRON A therapy suppresses bone marrow function and may result in severe cytopenias including very rare events of aplastic anemia. It is advised that complete blood counts (CBC) be obtained pre-treatment and monitored routinely during therapy (see PRECAUTIONS: Laboratory Tests). INTRON A therapy should be discontinued in patients who develop severe decreases in neutrophil ( < 0.5 x 109/L) or platelet counts ( < 25 x 109/L) (see DOSAGE AND ADMINISTRATION: Guidelines for Dose Modifications).

Pulmonary

Pulmonary symptoms, including dyspnea, pulmonary infiltrates, pneumonitis and pneumonia, have been reported during therapy with REBETOL/INTRON A; occasional cases of fatal pneumonia have occurred. In addition, sarcoidosis or the exacerbation of sarcoidosis has been reported. If there is evidence of pulmonary infiltrates or pulmonary function impairment, the patient should be closely monitored, and if appropriate, combination REBETOL/INTRON A treatment should be discontinued.

Other

  • REBETOL Capsule monotherapy is not effective for the treatment of chronic hepatitis C and should not be used for this indication.
  • Fatal and nonfatal pancreatitis has been observed in patients treated with REBETOL/INTRON A therapy. REBETOL/INTRON A therapy should be suspended in patients with signs and symptoms of pancreatitis and discontinued in patients with confirmed pancreatitis.
  • Combination REBETOL/INTRON A therapy should not be used in patients with creatinine clearance < 50 mL/min.
  • Diabetes mellitus and hyperglycemia have been observed in patients treated with INTRON A.
  • Ophthalmologic disorders have been reported with treatment with alpha interferons (including INTRON A therapy). Investigators using alpha interferons have reported the occurrence of retinal hemorrhages, cotton wool spots, and retinal artery or vein obstruction in rare instances. Any patient complaining of loss of visual acuity or visual field should have an eye examination. Because these ocular events may occur in conjunction with other disease states, a visual exam prior to initiation of combination REBETOL/INTRON A therapy is recommended in patients with diabetes mellitus or hypertension.
  • Acute serious hypersensitivity reactions (eg, urticaria, angioedema, bronchoconstriction, anaphylaxis) have been observed in INTRON A-treated patients; if such an acute reaction develops, combination REBETOL/INTRON A therapy should be discontinued immediately and appropriate medical therapy instituted.
  • Combination REBETOL/INTRON A therapy should be discontinued for patients developing thyroid abnormalities during treatment whose thyroid function cannot be controlled by medication.

Precautions

Exacerbation of autoimmune disease has been reported in patients receiving alpha interferon therapy (including INTRON A therapy). REBETOL/INTRON A therapy should be used with caution in patients with other autoimmune disorders.

There have been reports of interferon, including INTRON A (interferon alfa-2b, recombinant) exacerbating pre-existing psoriasis; therefore, combination REBETOL/INTRON A therapy should be used in these patients only if the potential benefit justifies the potential risk.

The safety and efficacy of REBETOL/INTRON A therapy has not been established in liver or other organ transplant patients, decompensated hepatitis C patients, patients who are nonresponders to interferon therapy, or patients coinfected with HBV or HIV.

The safety and efficacy of REBETOL Capsule monotherapy for the treatment of HIV infection, adenovirus, early RSV infection, parainfluenza, or influenza have not been established and REBETOL Capsules should not be used for these indications.

There is no information regarding the use of REBETOL Capsules with other interferons.

Triglycerides

Elevated triglyceride levels have been observed in patients treated with interferon including REBETOL/INTRON A therapy. Elevated triglyceride levels should be managed as clinically appropriate. Severe hypertriglyceridemia (triglycerides > 1000 mg/dL) may result in pancreatitis. Discontinuation of REBETOL/INTRON A therapy should be considered for patients with persistently elevated triglycerides (triglycerides > 1000 mg/dL) associated with symptoms of potential pancreatitis, such as abdominal pain, nausea, or vomiting (see WARNINGS - Other).

Information for Patients

Combination REBETOL/INTRON A therapy must not be used by females who are pregnant or by males whose female partners are pregnant. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients taking combination REBETOL/INTRON A therapy. Combination REBETOL/INTRON A therapy should not be initiated until a report of a negative pregnancy test has been obtained immediately prior to initiation of therapy. Patients must perform a pregnancy test monthly during therapy and for 6 months posttherapy. Females of childbearing potential must be counseled about use of effective contraception (two reliable forms) prior to initiating therapy. Patients (male and female) must be advised of the teratogenic/embryocidal risks and must be instructed to practice effective contraception during combination REBETOL/INTRON A therapy and for 6 months posttherapy. Patients (male and female) should be advised to notify the physician immediately in the event of a pregnancy. (See CONTRAINDICATIONS.)

If pregnancy does occur during treatment or during 6 months posttherapy, the patient must be advised of the significant teratogenic risk of REBETOL therapy to the fetus. Patients, or partners of patients, should immediately report any pregnancy that occurs during treatment or within 6 months after treatment cessation to their physician. Physicians are encouraged to report such cases by calling (800) 727-7064.

Patients receiving combination REBETOL/INTRON A treatment should be directed in its appropriate use, informed of the benefits and risks associated with treatment, and referred to the patient MEDICATION GUIDE. There are no data evaluating whether REBETOL/INTRON A therapy will prevent transmission of infection to others. Also, it is not known if treatment with REBETOL/INTRON A therapy will cure hepatitis C or prevent cirrhosis, liver failure, or liver cancer that may be the result of infection with the hepatitis C virus.

If home use is prescribed, a puncture-resistant container for the disposal of used syringes and needles should be supplied to the patient. Patients should be thoroughly instructed in the importance of proper disposal and cautioned against any reuse of needles and syringes. The full container should be disposed of according to the directions provided by the physician (see MEDICATION GUIDE). To avoid possible transmission of disease, do not share your multidose pen with anyone; it is for you and you alone.

The most common adverse experiences occurring with combination REBETOL/INTRON A therapy are “flu-like&rdqo; symptoms, such as headache, fatigue, myalgia, and fever (see ADVERSE REACTIONS) and appear to decrease in severity as treatment continues. Some of these “flu-like” symptoms may be minimized by bedtime administration of INTRON A therapy. Antipyretics should be considered to prevent or partially alleviate the fever and headache. Another common adverse experience associated with INTRON A therapy is thinning of the hair.

Patients should be advised that laboratory evaluations are required prior to starting therapy and periodically thereafter (see Laboratory Tests). It is advised that patients be well hydrated, especially during the initial stages of treatment.

Laboratory Tests

The following laboratory tests are recommended for all patients on combination REBETOL/INTRON A therapy, prior to beginning treatment and then periodically thereafter.

  • Standard hematologic tests - including hemoglobin (pretreatment, week 2 and week 4 of therapy, and as clinically appropriate [see WARNINGS]), complete and differential white blood cell counts, and platelet count.
  • Blood chemistries - liver function tests and TSH.
  • Pregnancy - including monthly monitoring for females of childbearing potential.

Carcinogenesis and Mutagenesis

Carcinogenicity studies with interferon alfa-2b, recombinant have not been performed because neutralizing activity appears in the serum after multiple dosing in all of the animal species tested.

Adequate studies to assess the carcinogenic potential of ribavirin in animals have not been conducted. However, ribavirin is a nucleoside analog that has produced positive findings in multiple in vitro and animal in vivo genotoxicity assays, and should be considered a potential carcinogen. Further studies to assess the carcinogenic potential of ribavirin in animals are ongoing.

Mutagenicity studies have demonstrated that interferon alfa-2b, recombinant is not mutagenic. Ribavirin demonstrated increased incidences of mutation and cell transformation in multiple genotoxicity assays. Ribavirin was active in the Balb/3T3 In Vitro Cell Transformation Assay. Mutagenic activity was observed in the mouse lymphoma assay, and at doses of 20-200 mg/kg (estimated human equivalent of 1.67 - 16.7 mg/kg, based on body surface area adjustment for a 60 kg adult; 0.1 - 1 X the maximum recommended human 24-hour dose of ribavirin) in a mouse micronucleus assay. A dominant lethal assay in rats was negative, indicating that if mutations occurred in rats they were not transmitted through male gametes.

Impairment of Fertility

No reproductive toxicology studies have been performed using interferon alfa-2b, recombinant in combination with ribavirin. However, evidence provided below for interferon alfa-2b, recombinant and ribavirin when administered alone indicate that both agents have adverse effects on reproduction. It should be assumed that the effects produced by either agent alone will also be caused by the combination of the two agents. Interferons may impair human fertility. In studies of interferon alfa-2b recombinant administration in nonhuman primates, menstrual cycle abnormalities have been observed. Decreases in serum estradiol and progesterone concentrations have been reported in females treated with human leukocyte interferon. In addition, ribavirin demonstrated significant embryocidal and/or teratogenic effects at doses well below the recommended human dose in all animal species in which adequate studies have been conducted.

Fertile females and partners of fertile females should not receive combination REBETOL/INTRON A therapy unless the patient and his/her partner are using effective contraception (two reliable forms). Based on a multiple dose half-life (t1/2 ) of ribavirin of 12 days, effective contraception must be utilized for 6 months posttherapy (eg, 15 half-lives of clearance for ribavirin).

Combination REBETOL/INTRON A therapy should be used with caution in fertile males. In studies in mice to evaluate the time course and reversibility of ribavirin-induced testicular degeneration at doses of 15 to 150 mg/kg/day (estimated human equivalent of 1.25 - 12.5 mg/kg/day, based on body surface area adjustment for a 60 kg adult; 0.1 - 0.8 X the maximum human 24-hour dose of ribavirin) administered for 3 or 6 months, abnormalities in sperm occurred. Upon cessation of treatment, essentially total recovery from ribavirin-induced testicular toxicity was apparent within 1 or 2 spermatogenesis cycles.

Pregnancy Category X

(see CONTRAINDICATIONS) Interferon alfa-2b, recombinant has been shown to have abortifacient effects in Macaca mulatta (rhesus monkeys) at 15 and 30 million IU/kg (estimated human equivalent of 5 and 10 million IU/kg, based on body surface area adjustment for a 60 kg adult). There are no adequate and well-controlled studies in pregnant females.

Ribavirin produced significant embryocidal and/or teratogenic effects in all animal species in which adequate studies have been conducted. Malformations of the skull, palate, eye, jaw, limbs, skeleton, and gastrointestinal tract were noted. The incidence and severity of teratogenic effects increased with escalation of the drug dose. Survival of fetuses and offspring was reduced. In conventional embryotoxicity/teratogenicity studies in rats and rabbits, observed no effect dose levels were well below those for proposed clinical use (0.3 mg/kg/day for both the rat and rabbit; approximately 0.06 X the recommended human 24-hour dose of ribavirin). No maternal toxicity or effects on offspring were observed in a peri/postnatal toxicity study in rats dosed orally at up to 1 mg/kg/day (estimated human equivalent dose of 0.17 mg/kg based on body surface area adjustment for a 60 kg adult; approximately 0.01 X the maximum recommended human 24-hour dose of ribavirin).

Treatment and Posttreatment

Potential Risk to the Fetus Ribavirin is known to accumulate in intracellular components from where it is cleared very slowly. It is not known whether ribavirin contained in sperm will exert a potential teratogenic effect upon fertilization of the ova. In a study in rats, it was concluded that dominant lethality was not induced by ribavirin at doses up to 200 mg/kg for 5 days (estimated human equivalent doses of 7.14 - 28.6 mg/kg, based on body surface area adjustment for a 60 kg adult; up to 1.7 X the maximum recommended human dose of ribavirin). However, because of the potential human teratogenic effects of ribavirin, male patients should be advised to take every precaution to avoid risk of pregnancy for their female partners.

Females of childbearing potential should not receive combination REBETOL/INTRON A therapy unless they are using effective contraception (two reliable forms) during the therapy period. In addition, effective contraception should be utilized for 6 months posttherapy based on a multiple dose half-life (t1/2 ) of ribavirin of 12 days.

Male patients and their female partners must practice effective contraception (two reliable forms) during treatment with combination REBETOL/INTRON A therapy and for the 6-month posttherapy period (eg, 15 half-lives for ribavirin clearance from the body).

If pregnancy occurs in a patient or partner of a patient during treatment or during the 6 months after treatment cessation, physicians are encouraged to report such cases by calling (800) 727-7064.

Nursing Mothers

It is not known whether REBETOL and INTRON A are excreted in human milk. However, studies in mice have shown that mouse interferons are excreted into the milk. Because of the potential for serious adverse reactions from the drugs in nursing infants, a decision should be made whether to discontinue nursing or to discontinue combination REBETOL/INTRON A therapy, taking into account the importance of the therapy to the mother.

Pediatric Use

One hundred twenty-five pediatric patients between three and sixteen years of age with chronic hepatitis C virus infection (median duration 10.7 years) received REBETOL Capsules with INTRON A for up to 48 weeks. The overall sustained response rate cannot be calculated since all patients have not yet completed 24-weeks of off-therapy follow-up.

Suicidal ideation or attempts occurred more frequently among pediatric patients compared to adult patients (2.4% versus 1%) during treatment and off therapy follow-up (see WARNINGS). As in adult patients, pediatric patients experienced other psychiatric adverse events (e.g., depression, emotional lability, somnolence), anemia, and neutropenia (see WARNINGS). During a 48 week course of therapy there was a decrease in the rate of linear growth (mean percentile assignment decrease of 7%) and a decrease in the rate of weight gain (mean percentile assignment decrease of 9%). A general reversal of these trends was noted during the 24 week post treatment period.

Injection site disorders, fever, anorexia, vomiting, and emotional lability occurred more frequently in pediatric patients compared to adult patients. Conversely, pediatric patients experienced less fatigue, dyspepsia, arthralgia, insomnia, irritability, impaired concentration, dyspnea, and pruritis compared to adult patients.

Geriatric Use

Clinical studies of REBETRON (rebetol and intron a combination therapy) Combination Therapy did not include sufficient numbers of subjects aged 65 and over to determine if they respond differently from younger subjects. In clinical trials, elderly subjects had a higher frequency of anemia (67%) than did younger patients (28%) (see WARNINGS).

In general, REBETOL (ribavirin) should be administered to elderly patients cautiously, starting at the lower end of the dosing range, reflecting the greater frequency of decreased renal, hepatic and/or cardiac function, and of concomitant disease or other drug therapy.

REBETOL (ribavirin) is known to be substantially excreted by the kidney, and the risk of adverse reactions to ribavirin may be greater in patients with impaired renal function. Because elderly patients often have decreased renal function, care should be taken in dose selection. Renal function should be monitored and dosage adjustments of ribavirin should be made accordingly (see DOSAGE AND ADMINISTRATION: Guidelines for Dose Modification).

REBETOL should not be used in elderly patients with creatinine clearance < 50mL/min (see WARNINGS).

REBETRON (rebetol and intron a combination therapy) Combination Therapy should be used very cautiously in elderly patients with a history of psychiatric disorders (see WARNINGS).

This monograph has been modified to include the generic and brand name in many instances.

OverDose

There is limited experience with overdosage. Acute ingestion of up to 20 grams of REBETOL Capsules, INTRON A ingestion of up to 120 million units, and subcutaneous doses of INTRON A up to 10 times the recommended doses have been reported. Primary effects that have been observed are increased incidence and severity of the adverse events related to the therapeutic use of INTRON A and REBETOL. However, hepatic enzyme abnormalities, renal failure, hemorrhage, and myocardial infarction have been reported with administration of single subcutaneous doses of INTRON A that exceed dosing recommendations.

There is no specific antidote for INTRON A or REBETOL, and hemodialysis and peritoneal dialysis are not effective for treatment of overdose of either agent.

ContrainDications

Combination REBETOL/INTRON A therapy must not be used by females who are pregnant or by males whose female partners are pregnant. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients taking combination REBETOL/INTRON A therapy. Combination REBETOL/INTRON A therapy should not be initiated until a report of a negative pregnancy test has been obtained immediately prior to initiation of therapy. Females of childbearing potential and males must use two forms of effective contraception during treatment and during the 6 months after treatment has been concluded. Significant teratogenic and/or embryocidal effects have been demonstrated for ribavirin in all animal species in which adequate studies have been conducted. These effects occurred at doses as low as one twentieth of the recommended human dose of REBETOL Capsules. If pregnancy occurs in a patient or partner of a patient during treatment or during the 6 months after treatment stops, physicians are encouraged to report such cases by calling (800) 727-7064. See BOXED CONTRAINDICATIONS AND WARNINGS. See WARNINGS.

REBETOL Capsules in combination with INTRON A Injection is contraindicated in patients with a history of hypersensitivity to ribavirin and/or alpha interferon or any component of the capsule and/or injection.

Patients with autoimmune hepatitis must not be treated with combination REBETOL/INTRON A therapy.

This monograph has been modified to include the generic and brand name in many instances.

Clinical Pharamacology

Pharmacokinetics

Interferon alfa-2b, recombinant

Single- and multiple-dose pharmacokinetic properties of INTRON A (interferon alfa-2b, recombinant) are summarized in TABLE 1. Following a single 3 million IU (MIU) subcutaneous dose in 12 patients with chronic hepatitis C, mean (% CV*) serum concentrations peaked at 7 (44%) hours. Following 4 weeks of subcutaneous dosing with 3 MIU three times a week (TIW), interferon serum concentrations were undetectable predose. However, a twofold increase in bioavailability was noted upon multiple dosing of interferon; the reason for this is unknown. Mean half-life values following single- and multiple-dose administrations were 6.8 (24%) hours and 6.5 (29%) hours, respectively.

Ribavirin

Single- and multiple-dose pharmacokinetic properties in adults with chronic hepatitis C are summarized in TABLE 1. Ribavirin was rapidly and extensively absorbed following oral administration. However, due to first-pass metabolism, the absolute bioavailability averaged 64% (44%). There was a linear relationship between dose and AUCtf (AUC from time zero to last measurable concentration) following single doses of 200-1200 mg ribavirin. The relationship between dose and Cmax was curvilinear, tending to asymptote above single doses of 400-600 mg.

Upon multiple oral dosing, based on AUC12hr, a sixfold accumulation of ribavirin was observed in plasma. Following oral dosing with 600 mg BID, steady-state was reached by approximately 4 weeks, with mean steady-state plasma concentrations of 2200 (37%) ng/mL. Upon discontinuation of dosing, the mean half-life was 298 (30%) hours, which probably reflects slow elimination from nonplasma compartments.

Effect of Food on Absorption of Ribavirin

Both AUCtf and Cmax increased by 70% when REBETOL Capsules were administered with a high-fat meal (841 kcal, 53.8 g fat, 31.6 g protein, and 57.4 g carbohydrate) in a single-dose pharmacokinetic study. There are insufficient data to address the clinical relevance of these results. Clinical efficacy studies were conducted without instructions with respect to food consumption. (See DOSAGE AND ADMINISTRATION.)

Effect of Antacid on Absorption of Ribavirin

Coadministration with an antacid containing magnesium, aluminum, and simethicone (Mylanta®) resulted in a 14% decrease in mean ribavirin AUCtf. The clinical relevance of results from this single-dose study is unknown.

TABLE 1. Mean (% CV) Pharmacokinetic Parameters for INTRON A and REBETOL When Administered Individually to Adults with Chronic Hepatitis C

Parameter INTRON A (N=12) REBETOL (N=12)
Single Dose
3 MIU
Multiple Dose
3 MIU TIW
Single Dose
600 mg
Multiple Dose
600 mg BID
Tmax (hr) 7 (44) 5 (37) 1.7 (46) *** 3 (60)
Cmax * 13.9 (32) 29.7 (33) 782 (37) 3680 (85)
AUCtf ** 142 (43) 333 (39) 13400 (48) 228000 (25)
T½ (hr) 6.8 (24) 6.5 (29) 43.6 (47) 298 (30)
Apparent Volume of Distribution(L)     2825 (9)†  
Apparent Clearance (L/hr) 14.3 (17)   38.2 (40)  
Absolute Bioavailability     64% (44)† †  
* IU/mL for INTRON A and ng/mL for REBETOL
** IU.hr/mL for INTRON A and ng.hr/mL for REBETOL
† data obtained from a single-dose pharmacokinetic study using 14C labeled ribavirin; N = 5
† † N = 6
*** N = 11

Ribavirin transport into nonplasma compartments has been most extensively studied in red blood cells, and has been identified to be primarily via an es -type equilibrative nucleoside transporter. This type of transporter is present on virtually all cell types and may account for the extensive volume of distribution. Ribavirin does not bind to plasma proteins.

Ribavirin has two pathways of metabolism: (i) a reversible phosphorylation pathway in nucleated cells; and (ii) a degradative pathway involving deribosylation and amide hydrolysis to yield a triazole carboxylic acid metabolite. Ribavirin and its triazole carboxamide and triazole carboxylic acid metabolites are excreted renally. After oral administration of 600 mg of 14C-ribavirin, approximately 61% and 12% of the radioactivity was eliminated in the urine and feces, respectively, in 336 hours. Unchanged ribavirin accounted for 17% of the administered dose.

Results of in vitro studies using both human and rat liver microsome preparations indicated little or no cytochrome P450 enzyme-mediated metabolism of ribavirin, with minimal potential for P450 enzyme-based drug interactions.

No pharmacokinetic interactions were noted between INTRON A Injection and REBETOL Capsules in a multiple-dose pharmacokinetic study.

Special Populations

Renal Dysfunction

The pharmacokinetics of ribavirin were assessed after administration of a single oral dose (400 mg) of ribavirin to subjects with varying degrees of renal dysfunction. The mean AUCtf value was threefold greater in subjects with creatinine clearance values between 10 to 30 mL/min when compared to control subjects (creatinine clearance > 90 mL/min). This appears to be due to reduction of apparent clearance in these patients. Ribavirin was not removed by hemodialysis. Patients with creatinine clearance < 50 mL/min should not be treated with REBETOL (see WARNINGS).

Hepatic Dysfunction

The effect of hepatic dysfunction was assessed after a single oral dose of ribavirin (600 mg). The mean AUCtf values were not significantly different in subjects with mild, moderate, or severe hepatic dysfunction (Child-Pugh Classification A, B, or C), when compared to control subjects. However, the mean Cmax values increased with severity of hepatic dysfunction and was twofold greater in subjects with severe hepatic dysfunction when compared to control subjects.

Pediatric Patients

Multiple-dose pharmacokinetic properties for ribavirin in pediatric patients with chronic hepatitis C between 5 and 16 years of age are summarized in TABLE 2.

TABLE 2. Mean (% CV) Pharmacokinetic Parameters for REBETOL When Administered to Pediatric Patients with Chronic Hepatitis C

Parameter 12 mg/kg/day as 2 divided doses
(n=19)
15 mg/kg/day as 2 divided doses
(n=19)
Tmax (hr) 1.4 (60) 1.9 (81)
Cmax (ng/mL) 2705 (17) 3243 (24)
AUC12 (ng*hr/mL) 25049 (16) 29620 (25)
Apparent Clearance (L/hr/kg) 0.25 (16) 0.27 (25)
Elderly Patients

Pharmacokinetic evaluations for elderly subjects have not been performed.

Gender

There were no clinically significant pharmacokinetic differences noted in a single-dose study of eighteen male and eighteen female subjects.

* In this section of the label, numbers in parenthesis indicate % coefficient of variation.

Description of Clinical Studies

Previously Untreated Patients

Adults with compensated chronic hepatitis C and detectable HCV RNA (assessed by a central laboratory using a research-based RT-PCR assay) who were previously untreated with alpha interferon therapy were enrolled into two multicenter, double-blind trials (US and International) and randomized to receive REBETOL Capsules 1200 mg/day (1000 mg/day for patients weighing ≤ 75 kg) plus INTRON A Injection 3 MIU TIW or INTRON A Injection plus placebo for 24 or 48 weeks followed by 24 weeks of off-therapy follow-up. The International study did not contain a 24-week INTRON A plus placebo treatment arm. The US study enrolled 912 patients who, at baseline, were 67% male, 89% caucasian with a mean Knodell HAI score (I+II+III) of 7.5, and 72% genotype 1. The International study, conducted in Europe, Israel, Canada, and Australia, enrolled 799 patients (65% male, 95% caucasian, mean Knodell score 6.8, and 58% genotype 1).

Study results are summarized in TABLE 3.

TABLE 3. Virologic and Histologic Responses: Previously Untreated Patients*

View Enlarged Table

Of patients who had not achieved HCV RNA below the limit of detection of the research based assay by week 24 of REBETOL/INTRON A treatment, less than 5% responded to an additional 24 weeks of combination treatment.

Among patients with HCV genotype 1 treated with REBETOL/INTRON A therapy who achieved HCV RNA below the detection limit of the research-based assay by 24 weeks, those randomized to 48 weeks of treatment had higher virologic responses compared to those in the 24-week treatment group. There was no observed increase in response rates for patients with HCV nongenotype 1 randomized to REBETOL/INTRON A therapy for 48 weeks compared to 24 weeks.

Relapse Patients

Patients with compensated chronic hepatitis C and detectable HCV RNA (assessed by a central laboratory using a research based RT-PCR assay) who had relapsed following one or two courses of interferon therapy (defined as abnormal serum ALT levels) were enrolled into two multicenter, double-blind trials (US and International) and randomized to receive REBETOL 1200 mg/day (1000 mg/day for patients weighing ≤ 75 kg) plus INTRON A 3 MIU TIW or INTRON A plus placebo for 24 weeks followed by 24 weeks of off-therapy follow-up. The US study enrolled 153 patients who, at baseline, were 67% male, 92% caucasian with a mean Knodell HAI score (I+II+III) of 6.8, and 58% genotype 1. The International study, conducted in Europe, Israel, Canada, and Australia, enrolled 192 patients (64% male, 95% caucasian, mean Knodell score 6.6, and 56% genotype 1). Study results are summarized in TABLE 4.

TABLE 4. Virologic and Histologic Responses: Relapse Patients*

  US Study International Study
INTRON A
plus REBETOL
N=77
INTRON A
plus Placebo
N=76
INTRON A
plus REBETOL
N=96
INTRON A
plus Placebo
N=96
Virologic Response
   -Responder1 33(43) 3(4) 46(48) 5(5)
   -Nonresponder 36(47) 66(87) 45(47) 91(95)
   -Missing Data 8(10) 7(9) 5(5) 0(0)
Histologic Response
   -Improvement2 38(49) 27(36) 49(51) 30(31)
   -No improvement 23(30) 37(49) 29(30) 44(46)
   -Missing Data 16(21) 12(16) 18(19) 22(23)
* Number (%) of Patients.
1 Defined as HCV RNA below limit of detection using a research based RT-PCR assay at end of treatment and during follow-up period.
2 Defined as posttreatment (end of follow-up) minus pretreatment liver biopsy Knodell HAI score (I+II+III) improvement of ≥ 2 points.

Virologic and histologic responses were similar among male and female patients in both the previously untreated and relapse studies.

Animal Toxicology

Long-term studies in the mouse and rat (18 - 24 months; doses of 20 - 75 and 10 - 40 mg/kg/day, respectively [estimated human equivalent doses of 1.67 - 6.25 and 1.43 - 5.71 mg/kg/day, respectively, based on body surface area adjustment for a 60 kg adult; approximately 0.1 - 0.4 X the maximum human 24-hour dose of ribavirin]) have demonstrated a relationship between chronic ribavirin exposure and increased incidences of vascular lesions (microscopic hemorrhages) in mice. In rats, retinal degeneration occurred in controls, but the incidence was increased in ribavirin-treated rats.

This monograph has been modified to include the generic and brand name in many instances.

Patient Information

MEDICATION GUIDE

REBETRON Combination Therapy containing REBETOL (ribavirin, USP) Capsules INTRON A (interferon alfa-2b, recombinant) Injection

REBETRON (rebetol and intron a combination therapy) (REB-eh-tron) is the name for the combination of REBETOL (REB-eh-tole) and INTRON A (IN-tron aye). Read this medication guide carefully before you begin taking REBETRON (rebetol and intron a combination therapy) Combination Therapy, and each time you refill your prescription in case there is new information. This summary does not tell you everything about REBETRON (rebetol and intron a combination therapy) Combination Therapy. Your health care provider is the best source of information about these medicines. After reading this medication guide, talk with your health care provider if you have any questions about this treatment.

What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • REBETRON (rebetol and intron a combination therapy) Combination Therapy may cause birth defects and/or death of an unborn child. Therefore, if you are pregnant, you must not take REBETRON (rebetol and intron a combination therapy) Combination Therapy. If you could become pregnant, you must not become pregnant during therapy and for six months after you have stopped therapy. During this time you must use two forms of birth control, and you must have pregnancy tests that show that you are not pregnant.
    Female sexual partners of male patients being treated with REBETOL must not become pregnant during treatment and for six months after treatment has stopped. Therefore, two forms of birth control must be used during this time.
    If pregnancy occurs, report the pregnancy to your healthcare provider right away.
  • Treatment with REBETOL and INTRON A products can cause a dangerous drop in your blood cell counts.
    REBETRON (rebetol and intron a combination therapy) Combination Therapy
    can cause anemia, which is a decrease in the number of red blood cells. This can be dangerous, especially if you have heart or breathing problems. Tell your health care provider before taking REBETRON (rebetol and intron a combination therapy) Combination Therapy if you have ever had any of these problems. Your health care provider should check your red blood cell count before starting therapy and often during the first 4 weeks of therapy. Your red blood cell count may be checked more often if you have heart or breathing problems.
  • REBETRON (rebetol and intron a combination therapy) Combination Therapy can cause a dangerous drop in the number of cells that help fight infections and stop bleeding, which might cause you to have an infection or abnormal bleeding.
  • Serious mental problems: REBETRON (rebetol and intron a combination therapy) Combination Therapy may cause or worsen mood or behavioral problems. These can include irritability (getting easily upset) and depression (feeling low, feeling bad about yourself). Some patients, including some children, think about hurting or killing themselves or other people, and some have killed themselves (suicide) or hurt themselves or others. If you experience any of these thoughts or symptoms you should tell your health care provider right away. See “What are the possible side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?” for important information on signs of mental problems.
  • You should not take REBETOL Capsules alone to treat your hepatitis C virus infection. REBETOL Capsules should be used only in combination with interferon alfa-2b (INTRON A) for the treatment of chronic hepatitis C infection; the combination is called REBETRON (rebetol and intron a combination therapy) Combination Therapy.

What is REBETRON (rebetol and intron a combination therapy) Combination Therapy?

REBETRON (rebetol and intron a combination therapy) Combination Therapy is a treatment for some people who have chronic hepatitis C infection. It consists of two separate medicines, REBETOL Capsules (ribavirin) and INTRON A Injection (interferon), used in combination. INTRON A helps the body's immune system fight infections. “REBETOL” is the name given to the antiviral drug ribavirin made by Schering. It is not known how REBETOL and INTRON A work together to fight hepatitis C infection. REBETOL should not be used alone to treat chronic hepatitis C infection.

It is not known if treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy will cure hepatitis C virus infections or prevent cirrhosis, liver failure, or liver cancer that can be caused by hepatitis C virus infections. It is not known if treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy will prevent you from infecting another person with the hepatitis C virus.

You should use REBETRON (rebetol and intron a combination therapy) Combination Therapy only if you have never been treated or your hepatitis C has returned after interferon therapy.

Who should not take REBETRON (rebetol and intron a combination therapy) Combination Therapy?

Do not use these medicines if:

  • You are a female and you are pregnant or plan to become pregnant at any time during your treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after your treatment has ended.
  • You are a male patient with a female sexual partner who is pregnant or plans to become pregnant at any time while you are being treated during treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after your treatment has ended. Please see “What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.
  • You are breastfeeding. REBETOL and INTRON A products may pass through your milk and harm your baby. Talk with your health care provider about whether you should stop breast-feeding.
  • You have autoimmune hepatitis (hepatitis caused by cells in your body attacking each other) because treatment with REBETOL and INTRON A can make this kind of liver problem worse.
  • You are allergic to any of the ingredients in REBETOL Capsules or INTRON A Injection, or to any alpha interferon. (See ingredients listed at the end of this Medication Guide).

Tell your health care provider before starting REBETRON (rebetol and intron a combination therapy) Combination Therapy if you have any of the following medical conditions or other serious medical problems:

  • mental health problems, such as depression or anxiety. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make them worse. Tell your health care provider if you are being treated for a mental illness or had treatment in the past for any mental problems, including depression, suicidal behavior, or psychosis. Psychosis is loss of contact with reality, such as hearing voices or seeing things that are not there.
  • high blood pressure, other heart problems, or have had a heart attack. The medicines in REBETRON (rebetol and intron a combination therapy) Combination Therapy may worsen heart problems. Patients who have had certain heart problems should not take REBETRON (rebetol and intron a combination therapy) Combination Therapy.
  • blood disorders, including anemia (low red blood cell count), thalassemia (Mediterranean anemia), and sickle-cell anemia. REBETRON (rebetol and intron a combination therapy) Combination Therapy can reduce the number of red blood cells you have. This may make you feel dizzy or weak and could worsen any heart problems you might have.
  • kidney problems. If your kidneys do not work well, you may get worse side effects from REBETRON (rebetol and intron a combination therapy) Combination Therapy and need a dose adjustment.
  • liver problems (other than hepatitis C infection)
  • organ transplant, and are taking medicine that keeps your body from rejecting your transplant (suppresses your immune system)
  • thyroid disease. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make your thyroid disease worse or harder to treat. REBETRON (rebetol and intron a combination therapy) Combination Therapy may be stopped if you develop thyroid abnormalities that cannot be controlled by medication.
  • lung problems. REBETRON (rebetol and intron a combination therapy) Combination Therapy can cause breathing problems or worsen breathing problems you already have.
  • alcoholism or drug abuse or addiction
  • cancer
  • infection with hepatitis B virus or human immunodeficiency virus (HIV), the virus that causes AIDS.
  • diabetes. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make your diabetes worse or harder to treat.
  • past interferon treatment for hepatitis C virus infection that did not work for you.

How should I take REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Your health care provider has determined the correct doses of REBETOL and INTRON A. Your doses of REBETOL and INTRON A may be lowered if you have side effects.
  • Under no circumstances should REBETOL capsules be opened, crushed or broken.

The recommended dose of INTRON A Injection and REBETOL Capsules are shown in the table below.

 

If your weight is: Take this many REBETOL Capsules each day: Inject this amount of INTRON A under your skin (subcutaneously)
165 pounds or less 2 capsules in the AM
3 capsules in the PM
3 million international units
3times a week
More than 165 pounds 3 capsules in the AM
3 capsules in the PM
3 million international units
3times a week

Ask your health care provider about the right amount of INTRON A Injection and REBETOL Capsules needed to treat a child with hepatitis C. This amount will depend on a child's weight.

  • You can take your REBETOL Capsules with or without food, but you should take it the same way every day.
  • It is important to follow your dosing schedule and your health care provider's instructions on how to take your medicines.
  • Take the medicines for as long as they are prescribed, and do not take more than the recommended doses.
  • If you miss a dose of REBETOL Capsules, take the missed dose as soon as possible during the same day. If an entire day has gone by, check with your health care provider about what to do. Do not double the next dose.
  • If you miss a dose of INTRON A, take the missed dose as soon as possible during the same day or on the next day, and continue your regular dosing schedule. If several days go by without taking INTRON A, check with your health care provider about what to do. Do not double the next dose.
  • Tell your health care provider if you are taking or planning to take other prescription or non-prescription medicines, including vitamin and mineral supplements and herbal medicines.

Instructions on how to inject INTRON A are at the end of this Medication Guide.

What should I avoid while taking REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Pregnancy: If you or your sexual partner becomes pregnant, tell your health care provider right away. (See “What is the most important information I should know about therapy with Rebetron (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.)

Talk with your health care provider about how to avoid pregnancy. If you or your sexual partner becomes pregnant while being treated with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after treatment ends, you must report the pregnancy to your health care provider right away. Your health care provider should call toll-free 1-800-727-7064. Your health care provider will be asked to give follow-up information about the pregnancy. Any information about your pregnancy that is reported about you will be confidential.

  • Breastfeeding. The medicine may pass through your milk and harm the baby.
  • Drinking alcohol, including beer, wine and liquor because this may make your liver disease worse.
  • Do not inject yourself with Intron A if it is discolored or contains particles.
  • Taking any medicines other than those prescribed or approved by your health care provider
  • Ask your health care provider if there are other things you should avoid, in addition to alcohol (beer, wine, liquor), prescription and nonprescription drugs, and alternative medications (herbal medicine).

What are the possible side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?

Harm to unborn children. REBETRON (rebetol and intron a combination therapy) Combination Therapy can harm your unborn child. It can cause birth defects and may kill your unborn child. (For more details, see “What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.)

  • Anemia. REBETRON (rebetol and intron a combination therapy) Combination Therapy causes anemia (a reduction in the number of red blood cells you have) which can be dangerous, especially if you have heart, or breathing problems. Tell your health care provider right away if you feel tired, have chest pain or shortness of breath. These may be signs of low red blood counts.
  • Infections. INTRON A therapy may lower your white blood cell count, making it easier for you to get serious infections. You must have your blood tested regularly during treatment to check for this problem.
  • Mental Problems. Tell your health care provider if you have ever had any mental illness, including depression, suicidal behavior, or psychosis (loss of contact with reality such as hearing voices or seeing things that are not there). Also, tell your health care provider if you are taking any medications for these problems. Tell your health care provider right away if you have the following:
    • Start to feel unusually sad or have crying spells
    • Lose interest in your usual activities
    • Have changes in your normal sleep patterns
    • Become more irritable than usual
    • Lose your appetite
    • Become unusually tired
    • Have trouble concentrating
    • Withdraw from family and friends
    • Have thoughts about hurting yourself or others.

Tell your health care provider right away if you have any of the following symptoms. They may be signs of a serious side effect:

  • trouble breathing, hives or swelling
  • chest pain
  • severe stomach or lower back pain
  • bloody diarrhea or bloody stools (bowel movements). These may appear to be black and tarry.
  • high fever
  • bruising
  • bleeding
  • decreased vision

What are the most common side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Flu-like” symptoms. These include headache, feeling very tired (fatigue), muscle aches, and fever. These get better as treatment continues. You can reduce some of these flu-like symptoms by injecting your INTRON A about 2 hours before bedtime. Some health care providers suggest taking non-prescription pain and fever reducers, such as acetaminophen or ibuprofen before taking INTRON A. This may be helpful to prevent or relieve the fever and headache.
  • Feeling tired
  • Hair thinning
  • Rash and itching
  • Nausea and appetite loss
  • Abdominal pain with nausea and vomiting
  • Trouble breathing
  • Trouble with your vision
  • Trouble sleeping at night

This summary does not include all possible side effects of combination therapy. You should talk to your health care provider, if you do not feel well while taking REBETOL and INTRON A. Your health care provider can give you more information about managing your side effects.

What should I know about the hepatitis C virus?

Hepatitis C infection is a disease caused by a virus that infects the liver. This liver infection becomes a continuing (chronic) condition in most patients. Patients with chronic hepatitis C infection may develop cirrhosis, liver cancer, and liver failure. The virus is spread from one person to another by contact with the infected person's blood. You should talk to your health care provider about ways to prevent you from infecting others.

How do I Inject INTRON A?

  • When you have been trained to do it properly. If you have any questions, contact your health care provider before injecting INTRON A.
  • Use the sterile technique taught by your health care provider. Use disposable needles after each use, and throw them away properly as directed by your health care provider, nurse, or pharmacist.
  • If someone else gives you your injection, that person should be trained in the use of sterile technique and how to avoid an accidental needle stick.

Preparing the INTRON A Dose

IMPORTANT: Before each use, the liquid in the vial (small bottle) should be clear, colorless to light yellow, and without particles. Do not use the medicine if you see particles or the color is not correct. Call your doctor, nurse, or pharmacist to find out what to do if this happens.

1. Check the date printed on the INTRON A carton to make sure that the expiration date has not passed.

2. Wash your hands well and remove the protective plastic cap from the top of the INTRON A vial.

3. Remove the protective plastic wrapper from the syringe provided (Figure A). The safety sleeve should be tight against the flange for use and moved over the needle only when ready for disposal, as instructed in step 6.

Figure A

Syringe - Illustration

4. Clean the rubber stopper on the top of the INTRON A vial with an alcohol swab.

5. Remove the protective cap from the syringe needle. Ensure safety sleeve is pushed firmly against the syringe flange so that the needle is fully exposed. Fill the syringe with air by pulling the plunger to the level that represents your correct dose. (Figure B).

Figure B

Fill the syringe with air - Illustration

6. Hold the INTRON A vial upright without touching the cleaned top of the vial with your hands (Figure C).

Figure C

Hold the INTRON A vial upright - Illustration

7. Insert the needle into the vial containing the INTRON A solution and inject the air into the vial (Figure D).

Figure D

Insert the needle into the vial - Illustration

8. Turn vial and syringe upside down in one hand. Be sure tip of needle is in the INTRON A solution. Your other hand will be free to move the plunger. Pull back on plunger slowly to draw the correct dose into syringe (Figure E).

Figure E

Pull back on plunger slowly - Illustration

9. Remove the needle from the vial (Figure F) and check for air bubbles in the syringe. If you see any bubbles, tap the syringe gently. Then, with the needle pointing up, push the plunger slowly until the bubbles disappear.

Figure F

Remove the needle from the vial - Illustration

10. Replace the needle cap. If the solution is cold, warm the syringe between your hands. Lay the syringe down on a flat surface so that needle does not touch anything.

Subcutaneous (under the skin) Injection

1. Select the site for injection

  • The best sites for injection are tissues with a layer of fat between skin and muscle, such as the
    • thigh
    • outer surface of the upper arm
    • abdomen (stomach area), except the navel (belly button) or waistline
  • If you are very thin, use only the thigh or outer surface of the arm for injection.
  • Do not inject INTRON A solution in the same place repeatedly. Change your injection site in a regular pattern.

 

Select the site - Illustration

Use an alcohol swab to cleanse the skin where the injection is to be made. Wait for area to dry.

2. Remove the cap from the needle. Ensure the safety sleeve is pushed firmly against the syringe flange so that the needle is fully exposed. Hold the syringe with one hand, as you would hold a pencil. With the other hand, pinch approximately a 2-inch fold of loose skin.

3. With a quick dart-like motion, push the needle about 1/4 inch into the pinched skin at an angle of 45° to 90 °.

 

Push the needle about 1/4 inch into the pinched skin - Illustration

After the needle is in, remove hand used to pinch skin and use it to hold syringe barrel. Pull back the plunger very slightly with one hand. If blood comes into the syringe, the needle has entered a blood vessel. Do not inject. Withdraw and discard needle and syringe as instructed in step 6 below. Prepare a new syringe and inject at a new site. (Follow steps 2 and 3.)

4. If blood does not appear in the syringe, gently push the plunger all the way down.

5. Hold an alcohol swab near the needle and pull the needle straight out of the skin. Press the alcohol swab over the injection site for several seconds. Do not massage (rub) the injection site. If there is bleeding, cover the area with an adhesive bandage.

6. After use, firmly grasp the safety sleeve and pull over the exposed needle until you hear a click, and the green stripe on the safety sleeve covers the red stripe on the needle.

 

Pull over the exposed needle - Illustration

7. Use disposable syringe only once to ensure sterility of syringe and needle. Dispose of syringe and needle as directed.

Your health care professional should tell you about the proper handling and disposal of all syringes and needles and the importance of not reusing any syringes or needles.

Your health care professional should give you a container for throwing away used needles and syringes. Throw away the full container according to directions provided by your doctor.

8. After 2 hours, check injection site for signs of inflammation, such as redness, swelling, or tenderness. If there are signs of inflammation, contact your doctor.

Instructional leaflet and video are available through your health care provider.

How do I store my medications?

STORAGE OF REBETOL CAPSULES

REBETOL capsules should be stored in the refrigerator between 36° and 46° F (2° and 8° C) or at room temperature 77° F (25° C).

STORAGE OF INTRON A INJECTION VIAL

INTRON A Injection vial should be stored in the refrigerator between 36° and 46° F (2° and 8° C), not in the freezer.

General advice about prescription medicines

Do not use REBETOL Capsules or INTRON A for conditions for which they were not prescribed. If you have any concern about REBETRON (rebetol and intron a combination therapy) Combination Therapy, ask your health care provider. Your health care provider or pharmacist can give you information about REBETRON (rebetol and intron a combination therapy) Combination Therapy that was written for health care professionals. Do not give these medicines to other people, even if they have the same condition you have.

Ingredients:

REBETOL capsules contain ribavirin and the inactive ingredients microcrystalline cellulose, lactose monohydrate, croscarmellose sodium, and magnesium stearate. The capsule shell consists of gelatin and titanium dioxide. The capsule is printed with edible blue pharmaceutical ink which is made of shellac, anhydrous ethyl alcohol, isopropyl alcohol, n-butyl alcohol, propylene glycol, ammonium hydroxide, and FD&C Blue #2 aluminum lake. INTRON A contains interferon alfa-2b recombinant, sodium chloride, dibasic sodium phosphate, monobasic sodium phosphate, edetate disodium, polysorbate 80, m-cresol (as a preservative).

This Medication Guide has been approved by the U.S. Food and Drug Administration.

Combination Therapy containing REBETOL (ribavirin, USP) Capsules INTRON A (interferon alfa-2b, recombinant) Injection

REBETRON (rebetol and intron a combination therapy) (REB-eh-tron) is the name for the combination of REBETOL (REB-eh-tole) and INTRON A (IN-tron aye). Read this medication guide carefully before you begin taking REBETRON (rebetol and intron a combination therapy) Combination Therapy, and each time you refill your prescription in case there is new information. This summary does not tell you everything about REBETRON (rebetol and intron a combination therapy) Combination Therapy. Your health care provider is the best source of information about these medicines. After reading this medication guide, talk with your health care provider if you have any questions about this treatment.

What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • REBETRON (rebetol and intron a combination therapy) Combination Therapy may cause birth defects and/or death of an unborn child. Therefore, if you are pregnant, you must not take REBETRON (rebetol and intron a combination therapy) Combination Therapy. If you could become pregnant, you must not become pregnant during therapy and for six months after you have stopped therapy. During this time you must use two forms of birth control, and you must have pregnancy tests that show that you are not pregnant.
    Female sexual partners of male patients being treated with REBETOL must not become pregnant during treatment and for six months after treatment has stopped. Therefore, two forms of birth control must be used during this time.
    If pregnancy occurs, report the pregnancy to your healthcare provider right away.
  • Treatment with REBETOL and INTRON A products can cause a dangerous drop in your blood cell counts.
    REBETRON (rebetol and intron a combination therapy) Combination Therapy
    can cause anemia, which is a decrease in the number of red blood cells. This can be dangerous, especially if you have heart or breathing problems. Tell your health care provider before taking REBETRON (rebetol and intron a combination therapy) Combination Therapy if you have ever had any of these problems. Your health care provider should check your red blood cell count before starting therapy and often during the first 4 weeks of therapy. Your red blood cell count may be checked more often if you have heart or breathing problems.
  • REBETRON (rebetol and intron a combination therapy) Combination Therapy can cause a dangerous drop in the number of cells that help fight infections and stop bleeding, which might cause you to have an infection or abnormal bleeding.
  • Serious mental problems: REBETRON (rebetol and intron a combination therapy) Combination Therapy may cause or worsen mood or behavioral problems. These can include irritability (getting easily upset) and depression (feeling low, feeling bad about yourself). Some patients think about hurting or killing themselves or other people, and some have killed themselves (suicide) or hurt themselves or others. If you experience any of these thoughts or symptoms you should tell your health care provider right away. See “What are the possible side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?” for important information on signs of mental problems.
  • You should not take REBETOL Capsules alone to treat your hepatitis C virus infection. REBETOL Capsules should be used only in combination with interferon alfa-2b (INTRON A) for the treatment of chronic hepatitis C infection; the combination is called REBETRON (rebetol and intron a combination therapy) Combination Therapy.

What is REBETRON (rebetol and intron a combination therapy) Combination Therapy?

REBETRON (rebetol and intron a combination therapy) Combination Therapy is a treatment for some people who have chronic hepatitis C infection. It consists of two separate medicines, REBETOL Capsules (ribavirin) and INTRON A Injection (interferon), used in combination. INTRON A helps the body's immune system fight infections. “REBETOL” is the name given to the antiviral drug ribavirin made by Schering. It is not known how REBETOL and INTRON A work together to fight hepatitis C infection. REBETOL should not be used alone to treat chronic hepatitis C infection.

It is not known if treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy will cure hepatitis C virus infections or prevent cirrhosis, liver failure, or liver cancer that can be caused by hepatitis C virus infections. It is not known if treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy will prevent you from infecting another person with the hepatitis C virus.

You should use REBETRON (rebetol and intron a combination therapy) Combination Therapy only if you have never been treated or your hepatitis C has returned after interferon therapy.

Who should not take REBETRON (rebetol and intron a combination therapy) Combination Therapy?

Do not use these medicines if:

  • You are a female and you are pregnant or plan to become pregnant at any time during your treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after your treatment has ended.
  • You are a male patient with a female sexual partner who is pregnant or plans to become pregnant at any time while you are being treated during treatment with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after your treatment has ended. Please see “What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.
  • You are breastfeeding. REBETOL and INTRON A products may pass through your milk and harm your baby. Talk with your health care provider about whether you should stop breast-feeding.
  • You have autoimmune hepatitis (hepatitis caused by cells in your body attacking each other) because treatment with REBETOL and INTRON A can make this kind of liver problem worse.
  • You are allergic to any of the ingredients in REBETOL Capsules or INTRON A Injection, or to any alpha interferon. (See ingredients listed at the end of this Medication Guide).

Tell your health care provider before starting REBETRON (rebetol and intron a combination therapy) Combination Therapy if you have any of the following medical conditions or other serious medical problems:

  • mental health problems, such as depression or anxiety. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make them worse. Tell your health care provider if you are being treated for a mental illness or had treatment in the past for any mental problems, including depression, suicidal behavior, or psychosis. Psychosis is loss of contact with reality, such as hearing voices or seeing things that are not there.
  • high blood pressure, other heart problems, or have had a heart attack. The medicines in REBETRON (rebetol and intron a combination therapy) Combination Therapy may worsen heart problems. Patients who have had certain heart problems should not take REBETRON (rebetol and intron a combination therapy) Combination Therapy.
  • blood disorders, including anemia (low red blood cell count), thalassemia (Mediterranean anemia), and sickle-cell anemia. REBETRON (rebetol and intron a combination therapy) Combination Therapy can reduce the number of red blood cells you have. This may make you feel dizzy or weak and could worsen any heart problems you might have.
  • kidney problems. If your kidneys do not work well, you may get worse side effects from REBETRON (rebetol and intron a combination therapy) Combination Therapy and need a dose adjustment.
  • liver problems (other than hepatitis C infection)
  • organ transplant, and are taking medicine that keeps your body from rejecting your transplant (suppresses your immune system)
  • thyroid disease. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make your thyroid disease worse or harder to treat. REBETRON (rebetol and intron a combination therapy) Combination Therapy may be stopped if you develop thyroid abnormalities that cannot be controlled by medication.
  • lung problems. REBETRON (rebetol and intron a combination therapy) Combination Therapy can cause breathing problems or worsen breathing problems you already have.
  • alcoholism or drug abuse or addiction
  • cancer
  • infection with hepatitis B virus or human immunodeficiency virus (HIV), the virus that causes AIDS.
  • diabetes. REBETRON (rebetol and intron a combination therapy) Combination Therapy may make your diabetes worse or harder to treat.
  • past interferon treatment for hepatitis C virus infection that did not work for you.

How should I take REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Your health care provider has determined the correct doses of REBETOL and INTRON A. Your doses of REBETOL and INTRON A may be lowered if you have side effects. The recommended dose of INTRON A Injection and REBETOL Capsules are shown in the table below.

 

If your weight is: Take this many REBETOL
Capsules each day:
Inject this amount of INTRON A
under your skin
(subcutaneously)
165 pounds or less 2 capsules in the AM
3 capsules in the PM
3 million international units
3times a week
More than 165 pounds 3 capsules in the AM
3 capsules in the PM
3 million international units
3times a week
  • You can take your REBETOL Capsules with or without food, but you should take it the same way every day.
  • It is important to follow your dosing schedule and your health care provider's instructions on how to take your medicines.
  • Take the medicines for as long as they are prescribed, and do not take more than the recommended doses.
  • If you miss a dose of REBETOL Capsules, take the missed dose as soon as possible during the same day. If an entire day has gone by, check with your health care provider about what to do. Do not double the next dose.
  • If you miss a dose of INTRON A, take the missed dose as soon as possible during the same day or on the next day, and continue your regular dosing schedule. If several days go by without taking INTRON A, check with your health care provider about what to do. Do not double the next dose.
  • Tell your health care provider if you are taking or planning to take other prescription or non-prescription medicines, including vitamin and mineral supplements and herbal medicines.

Instructions on how to inject INTRON A are at the end of this Medication Guide.

What should I avoid while taking REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Pregnancy: If you or your sexual partner becomes pregnant, tell your health care provider right away. (See “What is the most important information I should know about therapy with Rebetron (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.)

Talk with your health care provider about how to avoid pregnancy. If you or your sexual partner becomes pregnant while being treated with REBETRON (rebetol and intron a combination therapy) Combination Therapy or during the 6 months after treatment ends, you must report the pregnancy to your health care provider right away. Your health care provider should call toll-free 1-800-727-7064. Your health care provider will be asked to give follow-up information about the pregnancy. Any information about your pregnancy that is reported about you will be confidential.

  • Breastfeeding. The medicine may pass through your milk and harm the baby.
  • Drinking alcohol, including beer, wine and liquor because this may make your liver disease worse.
  • Do not inject yourself with Intron A if it is discolored or contains particles.
  • Taking any medicines other than those prescribed or approved by your health care provider
  • Ask your health care provider if there are other things you should avoid, in addition to alcohol (beer, wine, liquor), prescription and nonprescription drugs, and alternative medications (herbal medicine).

What are the possible side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?

Harm to unborn children. REBETRON (rebetol and intron a combination therapy) Combination Therapy can harm your unborn child. It can cause birth defects and may kill your unborn child. (For more details, see “What is the most important information I should know about REBETRON (rebetol and intron a combination therapy) Combination Therapy?” at the beginning of this Medication Guide.)

  • Anemia. REBETRON (rebetol and intron a combination therapy) Combination Therapy causes anemia (a reduction in the number of red blood cells you have) which can be dangerous, especially if you have heart, or breathing problems. Tell your health care provider right away if you feel tired, have chest pain or shortness of breath. These may be signs of low red blood counts.
  • Infections. INTRON A therapy may lower your white blood cell count, making it easier for you to get serious infections. You must have your blood tested regularly during treatment to check for this problem.
  • Mental Problems. Tell your health care provider if you have ever had any mental illness, including depression, suicidal behavior, or psychosis (loss of contact with reality such as hearing voices or seeing things that are not there). Also, tell your health care provider if you are taking any medications for these problems. Tell your health care provider right away if you have the following:
    • Start to feel unusually sad or have crying spells
    • Lose interest in your usual activities
    • Have changes in your normal sleep patterns
    • Become more irritable than usual
    • Lose your appetite
    • Become unusually tired
    • Have trouble concentrating
    • Withdraw from family and friends
    • Have thoughts about hurting yourself or others.

Tell your health care provider right away if you have any of the following symptoms. They may be signs of a serious side effect:

  • trouble breathing, hives or swelling
  • chest pain
  • severe stomach or lower back pain
  • bloody diarrhea or bloody stools (bowel movements). These may appear to be black and tarry.
  • high fever
  • bruising
  • bleeding
  • decreased vision

What are the most common side effects of REBETRON (rebetol and intron a combination therapy) Combination Therapy?

  • Flu-like“ symptoms. These include headache, feeling very tired (fatigue), muscle aches, and fever. These get better as treatment continues. You can reduce some of these flu-like symptoms by injecting your INTRON A about 2 hours before bedtime. Some health care providers suggest taking non-prescription pain and fever reducers, such as acetaminophen or ibuprofen before taking INTRON A. This may be helpful to prevent or relieve the fever and headache.
  • Feeling tired
  • Hair thinning
  • Rash and itching
  • Nausea and appetite loss
  • Abdominal pain with nausea and vomiting
  • Trouble breathing
  • Trouble with your vision
  • Trouble sleeping at night

This summary does not include all possible side effects of combination therapy. You should talk to your health care provider, if you do not feel well while taking REBETOL and INTRON A. Your health care provider can give you more information about managing your side effects.

What should I know about the hepatitis C virus?

Hepatitis C infection is a disease caused by a virus that infects the liver. This liver infection becomes a continuing (chronic) condition in most patients. Patients with chronic hepatitis C infection may develop cirrhosis, liver cancer, and liver failure. The virus is spread from one person to another by contact with the infected person's blood. You should talk to your health care provider about ways to prevent you from infecting others.

How do I Inject INTRON A?

  • When you have been trained to do it properly. If you have any questions, contact your health care provider before injecting INTRON A.
  • Use the sterile technique taught by your health care provider. Use disposable needles after each use, and throw them away properly as directed by your health care provider, nurse, or pharmacist.
  • If someone else gives you your injection, that person should be trained in the use of sterile technique and how to avoid an accidental needle stick.

The INTRON A Injection multidose pen (INTRON A multidose pen) is a pre-filled multidose syringe containing six doses of INTRON A (interferon alfa-2b, recombinant). This multidose pen is specially designed to deliver six doses of 3 MIU of INTRON A. If necessary, it can also be used to deliver different doses (i.e. if your health care provider wants you to increase or decrease your dose). The different doses that it can deliver are 1.5 MIU, 3 MIU, 4.5 MIU and 6 MIU. Six MIU is the maximum dose that this pen can give at one time.

Please note the following important points BEFORE using your INTRON A multidose pen:

  • The INTRON A multidose pen should ONLY be used with the enclosed Novofine* needles. The use of other needles may result in the pen not working properly and/or the wrong dose of INTRON A solution delivered.
  • ALWAYS discard needles and used pens carefully; NEVER discard the pen with a needle attached.
  • Use the INTRON A multidose pen ONLY in accordance with these instructions. DO NOT allow the INTRON A multidose pen to be handled roughly or otherwise misused. To avoid possible transmission of disease, DO NOT share your multidose pen with anyone; it is for you and you alone.
  • KEEP out of reach of children.
  • When not in use you should STORE the INTRON A multidose pen in the REFRIGERATOR at 36° -46° F (2° to 8° C) (not too near the freezer compartment).
  • ALWAYS check that INTRON A IS CLEAR in appearance prior to use. If it DOES NOT have a clear uniform appearance DO NOT USE. Please consult your health care provider or pharmacist.
  • ALWAYS check the expiration date; NEVER use after the expiration date.

Description of your INTRON A multidose pen

Diagrams A and B show you all the different parts of the pen and the Novofine* needle. The most important parts to note are as follows:

  • The push button scale tells you what dose has been set.
  • The color coding strip and the push button are at the bottom of the pen as it is held cap up. (The six doses of 3 MIU multidose pen have a brown coding strip)
  • The INTRON A multidose pen can only be fully capped when the triangle on the cap scale is aligned with the dosage indicator on the barrel.

Diagram A

INTRON A multidose pen - Illustration

Diagram B

Parts of Pen - Illustration

HOW TO USE YOUR INTRON A Multidose Pen

When you are ready to give your injection prepare your pen as follows. (NOTE: Boldface print indicates ACTION STEPS):

1. First check that you have the correct INTRON A multidose pen as prescribed by your health care provider, (i.e. the six doses of 3 MIU INTRON A multidose pen which have a brown push button and a brown color coding strip).

2. Pull off the cap of the pen and disinfect the rubber membrane (see Diagram C) with one alcohol wipe.

Diagram C

How to use a Multi dose Pen - Illustration 1

3.Remove the protective tab from the Novofine* needle. Note that the rear portion of the needle is revealed once the protective tab is removed (see Diagram D).

Diagram D

How to use a Multi dose Pen - Illustration 2

4. Gently push the Novofine* needle onto the pen as shown in Diagram E. (Notice that the rear portion of the needle described in Step 3 will pierce through the rubber membrane that you disinfected previously.) Now screw the needle onto the INTRON A multidose pen securely by turning it in a clockwise direction (see Diagram F).

Diagram E

Gently push the Novofine* needle - Illustration

Diagram F

Now screw the needle onto the INTRON A multidose pen - Illustration

5. First, pull off the outer needle cap (Diagram G). Then, pull off the inner needle cap carefully, bearing in mind that the needle will now be exposed (Diagram H). Keep the outer needle cap for later use.

Diagram G

pull off the outer needle cap - Illustration

Diagram H

Needle will now be exposed - Illustration

The pen is now ready to use. Since a small amount of air may collect in the needle and reservoir during storage, the next step is to remove any air bubbles.

6. Hold the INTRON A multidose pen with the needle point upwards.

7. Tap the reservoir with your finger so that any air bubbles rise to the top of the reservoir, just below the needle (Diagram I).

Diagram I

Tap the reservoir with your finger - Illustration

8. Hold the pen by the barrel and turn the reservoir in the direction as indicated by the arrow in Diagram J (clockwise) until you feel it click.

Diagram J

Hold the pen by the barrel - Illustration

9. Keeping the pen pointing upwards, press the push button up fully and see if a drop of INTRON A solution appears at the needle tip (notice the drop at the tip of needle in Diagram K).

Diagram K

Press the push button up fully - Illustration

10. If no drop appears then repeat Steps 7, 8, and 9 until a drop appears at the needle tip. Note: Some air may still remain in the pen, but this is not important as you have removed the air from the needle and the dose will be accurate.

11. Replace the INTRON A multidose pen cap with the ‘triangle' opposite the dosage indicator as seen in Diagram L.

Diagram L

Replace the INTRON A multidose pen cap - Illustration

The pen is now ready to set the dose. For the next step hold the pen in the middle of the barrel. This will allow the push button to move freely, ensuring that the correct dose is set.

12. To set the required dose, hold the pen horizontally by the barrel with one hand. With the other hand, turn the cap in a clockwise direction indicated by the arrow in Diagram M. You will observe the push button rising, indicating the dose set. To set a 3 MIU dose, turn the cap 2 full turns (10 clicks) = 3.0 MIU.

Diagram M

Turn the cap in a clockwise direction indicated by the arrow - Illustration

Note: If your health care provider has prescribed a dose other than 3 MIU, the correct dose can be set by turning the cap as many times as indicated as follows:

1 full turn (5 clicks) = 1.5 MIU
3 full turns (15 clicks) = 4.5 MIU
4 full turns (20 clicks) = 6.0 MIU

The push button scale will show you the dose set (see Diagram N). At that point check that you have the correct dose.

Diagram N

The push button scale will show you the dose set - Illustration

13. After each complete turn make sure that the triangle is opposite the dosage indicator (see Diagram O). If you have set a wrong dose, simply turn the cap back (counter-clockwise) as far as you can until the push button is fully home and start again. Once the correct dose is set, you are ready to give the injection.

Diagram O

After each complete turn make sure that the triangle is opposite the dosage indicator - Illustration

14. To give the injection, remove the pen cap from the needle. With one hand, pinch a 2-inch fold of loose skin.

15. With your other hand, pick up the pen and hold it as you would a pencil. Insert the needle into the pinched skin at an angle of approximately 45° (see Diagram P) then press the push button down fully.

If blood comes into the pen, do not inject. Withdraw the needle and consult your physician or pharmacist.

Diagram P

Insert the needle into the pinched skin - Illustration

16. Leave the needle in place for a few seconds, while holding down the push button, to allow the INTRON A Solution to distribute under the skin.

17. Slowly release the push button, then remove the needle.

18. Carefully replace the outer needle cap using a scooping motion (See Diagram Q).

Diagram Q

Carefully replace the outer needle cap - Illustration

19. Completely unscrew the needle assembly using a counter-clockwise turning motion as show in Diagram R. Then carefully lift it off the pen and discard the capped needle (see Diagram S).

Diagram R

Completely unscrew the needle - Illustration

Diagram S

Carefully lift it off the pen - Illustration

20. Replace the pen cap with the triangle once again opposite the dosage indicator as shown in Diagram T.

Diagram T

Replace the pen cap - Illustration

Instructional leaflet and video are available through your health care provider.

How do I store my medications?

STORAGE OF REBETOL CAPSULES

REBETOL capsules should be stored in the refrigerator between 36° and 46° F (2° and 8° C) or at room temperature 77° F (25° C).

STORAGE OF INTRON A INJECTION MULTIDOSE PEN

INTRON A Injection multidose pen should be stored in the refrigerator between 36° and 46° F (2° and 8° C), not in the freezer.

Consumer Overview Uses

No Information Available!

Consumer Overview Side Effect

No Information Available!

Consumer Overview Missed Dose

No Information Available!

Patient Detailed Side Effect

Brand Names: Rebetron

Generic Name: interferon alfa-2b and ribavirin (Pronunciation: in ter FEAR on AL fa 2b and RYE ba VYE rin)

  • What is interferon alfa-2b and ribavirin (Rebetron)?
  • What are the possible side effects of interferon alfa-2b and ribavirin (Rebetron)?
  • What is the most important information I should know about interferon alfa-2b and ribavirin (Rebetron)?
  • What should I discuss with my healthcare provider before using interferon alfa-2b and ribavirin (Rebetron)?
  • How should I use interferon alfa-2b and ribavirin (Rebetron)?
  • What happens if I miss a dose (Rebetron)?
  • What happens if I overdose (Rebetron)?
  • What should I avoid while using interferon alfa-2b and ribavirin (Rebetron)?
  • What other drugs will affect interferon alfa-2b and ribavirin (Rebetron)?
  • Where can I get more information?

What is interferon alfa-2b and ribavirin (Rebetron)?

Interferon alfa-2b is made from human proteins that help the body fight viral infections.

Ribavirin is an antiviral medication.

Interferon alfa-2b and ribavirin are packaged together as a capsule and injection kit to treat chronic hepatitis C. These medications must be used together.

Interferon alfa-2b and ribavirin may also be used for other purposes not listed in this medication guide.

What are the possible side effects of interferon alfa-2b and ribavirin (Rebetron)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Stop using this medication and call your doctor at once if you have any of these serious side effects:

  • pale or yellowed skin, dark colored urine;
  • fever, chills, body aches, flu symptoms, easy bruising or bleeding, unusual weakness;
  • confusion, severe depression or anxiety, aggression, thoughts of hurting yourself or others;
  • vision problems;
  • high fever with severe stomach pain and bloody diarrhea.
  • cough, stabbing chest pain, feeling short of breath, uneven heartbeats;
  • severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate; or
  • worsening psoriasis or other autoimmune disorder.

Less serious side effects may include:

  • dizziness, tired feeling, headache, joint or muscle pain;
  • mild nausea, loss of appetite, weight loss;
  • sleep problems (insomnia);
  • feeling mildly anxious, depressed, or irritable; or
  • pain, redness, swelling, or irritation where the medicine was injected.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Read the Rebetron (rebetol and intron a combination therapy) Side Effects Center for a complete guide to possible side effects

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What is the most important information I should know about interferon alfa-2b and ribavirin (Rebetron)?

You should not use this medication if you are allergic to interferon alfa-2b (Intron A) or ribavirin (Copegus, Rebetol), or if you have autoimmune hepatitis, severe liver or kidney disease, or a hemoglobin blood cell disorder such as sickle-cell anemia or thalassemia.

Do not use interferon alfa-2b and ribavirin if you are pregnant, or if you are a man and your female sexual partner is pregnant.

Use at least 2 effective forms of birth control while either sexual partner is using interferon alfa-2b and ribavirin. Keep using 2 forms of birth control for at least 6 months after treatment ends.

Before using interferon alfa-2b and ribavirin, tell your doctor about all of your medical conditions, especially kidney disease, liver problems other than hepatitis, heart disease or high blood pressure, a thyroid disorder, eye problems, HIV or AIDS, a blood cell disorder, an autoimmune disorder such as lupus or psoriasis, or a history of heart attack, stroke, organ transplant, depression, mental illness, drug or alcohol addiction, or suicidal thoughts or behaviors.

Also tell your doctor if you have ever used an interferon to treat hepatitis in the past and it did not work.

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Patient Detailed How Take

What should I discuss with my healthcare provider before using interferon alfa-2b and ribavirin (Rebetron)?

You should not use this medication if you are allergic to interferon alfa-2b (Intron A) or ribavirin (Copegus, Rebetol), or if you have:

  • autoimmune hepatitis;
  • liver failure;
  • severe kidney disease;
  • a hemoglobin blood cell disorder such as sickle-cell anemia or thalassemia;
  • if you are pregnant or breast-feeding; or
  • if you are a man and your female sexual partner is pregnant.

If you have any of these other conditions, you may need a dose adjustment or special tests to safely use interferon alfa-2b and ribavirin:

  • lung disease;
  • kidney disease (or if you are on dialysis);
  • hepatitis B, or liver problems other than hepatitis;
  • a thyroid disorder;
  • uncontrolled diabetes;
  • new or worsening problems with your eyes;
  • cancer;
  • HIV or AIDS;
  • high cholesterol or triglycerides;
  • heart disease or high blood pressure, history of heart attack, or stroke;
  • history of organ transplant;
  • any blood cell disorder causing bleeding episodes, infections, or fever-related illness;
  • an autoimmune disorder such as rheumatoid arthritis, systemic lupus erythematosus (SLE), or psoriasis;
  • a history of drug or alcohol addiction, depression, anxiety, or suicidal thoughts or behaviors; or
  • if you have ever used an interferon to treat hepatitis in the past and it did not work.

FDA pregnancy category X. Ribavirin is known to cause birth defects or death in an unborn baby. Do not use interferon alfa-2b and ribavirin if you are pregnant. You may need to have a negative pregnancy test before using this medication and every month during your treatment.

  • If you are a woman, do not use interferon alfa-2b and ribavirin if you are pregnant.
  • If you are a man, do not use interferon alfa-2b and ribavirin if your female sexual partner is pregnant. An unborn baby could also be harmed if a man fathers the child while he is taking ribavirin.
  • Use at least 2 effective forms of birth control while either sexual partner is using interferon alfa-2b and ribavirin. Keep using 2 forms of birth control for at least 6 months after treatment ends.
  • Tell your doctor right away if a pregnancy occurs while either the mother or the father is using interferon alfa-2b and ribavirin.

Interferon alfa-2b and ribavirin may pass into breast milk and could harm a nursing baby. Do not use this medication if you are breast-feeding a baby.

Interferon alfa-2b and ribavirin can affect growth in children. Talk with your doctor if you think your child is not growing at a normal rate while using this medication.

The powder form of interferon alfa-2b contains albumin, but the solution (liquid) form does not. Albumin comes from human plasma (part of the blood) and may contain viruses and other infectious agents that can cause disease. Although donated human plasma is screened, tested, and treated to reduce the risk of it containing anything that could cause disease, there is still a small possibility it could transmit disease. Talk with your doctor about the risks and benefits of using this medication.

How should I use interferon alfa-2b and ribavirin (Rebetron)?

Interferon alfa-2b is given as an injection under the skin. Your doctor, nurse, or other healthcare provider will give you this injection. You may be shown how to inject your medicine at home. Do not self-inject this medicine if you do not fully understand how to give the injection and properly dispose of used needles and syringes.

Do not use the medication if it has changed colors or has any particles in it. Call your doctor for a new prescription.

Use a different place on your arm, stomach, or thigh each time you give yourself an injection. Your care provider will show you the places on your body where you can safely inject the medication. Do not inject into the same place two times in a row.

Use each disposable needle only one time. Throw away used needles in a puncture-proof container (ask your pharmacist where you can get one and how to dispose of it). Keep this container out of the reach of children and pets.

The interferon alfa-2b injection is usually given 3 times per week. The ribavirin capsule is usually taken twice daily. You may take the capsules with or without food but take them the same way each time. Follow your doctor's instructions. Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Your ribavirin dose needs may change if you gain weight. Tell your doctor if your weight increases to 165 pounds or above.

To be sure this medication is helping your condition and not causing harmful effects, your blood may need to be tested on a regular basis. You may also need regular eye exams. Do not miss any scheduled appointments.

Store both the ribavirin capsules and the interferon alfa-2b vials (bottles) or injection pens in the refrigerator. Do not allow the medicine to freeze.

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Patient Detailed Avoid Taking

What happens if I miss a dose (Rebetron)?

Use the medicine as soon as you remember the missed dose, then go back to your regular schedule on the day your next dose is due. If you are more than 2 days late in using your injection, call your doctor for instructions. Do not use extra medicine to make up a missed dose.

What happens if I overdose (Rebetron)?

Seek emergency medical attention if you think you have used too much of this medicine. Symptoms of an interferon alfa-2b and ribavirin overdose are not known.

What should I avoid while using interferon alfa-2b and ribavirin (Rebetron)?

Avoid drinking alcohol. Alcohol may increase your risk of liver damage.

Treatment with this medication does not prevent spread of the hepatitis virus to other people. Follow your doctor's instructions about how to prevent passing the disease to another person.

What other drugs will affect interferon alfa-2b and ribavirin (Rebetron)?

Tell your doctor about all other medications you use, especially HIV or AIDS medications such as :

  • abacavir (Ziagen);
  • didanosine (Videx);
  • efavirenz (Sustiva, Atripla);
  • emtricitabine (Emtriva);
  • etravine (Intelence);
  • lamivudine (Epivir, Epzicom, Combivir, Trizivir);
  • stavudine (Zerit);
  • tenofovir (Truvada, Viread); or
  • zidovudine (Retrovir).

This list is not complete and there may be other drugs that can interact with interferon alfa-2b and ribavirin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

Where can I get more information?

Your pharmacist can provide more information about interferon alfa-2b and ribavirin.


Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2013 Cerner Multum, Inc. Version: 7.03. Revision date: 12/15/2010.

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