|Trade names||Copegus, Rebetol, Virazole, other|
|by mouth, solution for inhalation|
|Metabolism||liver and intracellularly|
|Biological half-life||298 hours (multiple dose); 43.6 hours (single dose)|
|Excretion||Urine (61%), faeces (12%)|
|Chemical and physical data|
|3D model (Jmol)|
Ribavirin, also known as tribavirin, is an anti-viral medication used to treat RSV infection, hepatitis C, and viral hemorrhagic fever. For hepatitis C it is used with other medications such as simeprevir, sofosbuvir, peginterferon alfa-2b or peginterferon alfa-2a. Among the viral hemorrhagic fevers it is used for Lassa fever, Crimean–Congo hemorrhagic fever, and Hantavirus infection but not Ebola or Marburg. Ribavirin is taken by mouth or inhaled.
Common side effects include feeling tired, headache, nausea, fever, muscle pains, and an irritable mood. Serious side effects include red blood cell breakdown, liver problems, and allergic reactions. Use during pregnancy results in harm to the baby. Effective birth control is recommended for both males and females for 7 months after use. The mechanism of action of ribavirin is not entirely clear.
Ribavirin was patented in 1971 and approved for medical use in 1986. It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. It is available as a generic medication. In the United States a course of treatment costs more than 200 USD.
Ribavirin is used primarily to treat hepatitis C and viral hemorrhagic fevers (which is an orphan indication in most countries). In this former indication the oral (capsule or tablet) form of ribavirin is used in combination with pegylated interferon alfa. Including in people coinfected with hepatitis B, HIV and in the pediatric population. Statins may improve this combination's efficacy in treating hepatitis C. Ribavirin is the only known treatment for a variety of viral hemorrhagic fevers, including Lassa fever, Crimean-Congo hemorrhagic fever, Venezuelan hemorrhagic fever, and Hantavirus infection, although data regarding these infections are scarce and the drug might be effective only in early stages. It is noted by the USAMRIID that "Ribavirin has poor in vitro and in vivo activity against the filoviruses (Ebola and Marburg) and the flaviviruses (dengue, yellow fever, Omsk hemorrhagic fever, and Kyasanur forest disease)" The aerosol form has been used in the past to treat respiratory syncytial virus-related diseases in children, although the evidence to support this is rather weak.
Experimental data indicate that ribavirin may have useful activity against Canine distemper. Ribavirin has also been used as a treatment for herpes simplex virus. One small study found that ribavirin treatment reduced the severity of herpes outbreaks and promoted recovery, as compared with placebo treatment. Another study found that ribavirin potentiated the antiviral effect of acyclovir.
The medication has two FDA "black box" warnings. One for its teratogenic and embryocidal effects and a statement that women of child bearing should use two forms of birth control when taking the drug, and for 6 months. The same applies the men who are sexual contacts of women of child bearing potential. Second, a hemolytic anemia commonly develops with the drug, which can be dangerous in those with other illness. Blood counts and dosage adjustments must be made during the administration of this drug.;
Ribavirin should not be given with zidovudine because of the increased risk of anemia; concurrent use with didanosine should likewise be avoided because of an increased risk of mitochondrial toxicity.
Mechanisms of action
It is a guanosine (ribonucleic) analog used to stop viral RNA synthesis and viral mRNA capping, thus, it is a nucleoside inhibitor. Ribavirin is a prodrug, which when metabolized resembles purine RNA nucleotides. In this form it interferes with RNA metabolism required for viral replication. How it exactly affects viral replication is unknown; many mechanisms have been proposed for this but none of these has been proven to date. Multiple mechanisms may be responsible for its mechanism of action.
Ribavirin's carboxamide group can make the native nucleoside drug resemble adenosine or guanosine, depending on its rotation. For this reason, when ribavirin is incorporated into RNA, as a base analog of either adenine or guanine, it pairs equally well with either uracil or cytosine, inducing mutations in RNA-dependent replication in RNA viruses. Such hypermutation can be lethal to RNA viruses.
Neither of these mechanisms explains ribavirin's effect on many DNA viruses, which is more of a mystery, especially given the complete inactivity of ribavirin's 2' deoxyribose analogue, which suggests that the drug functions only as an RNA nucleoside mimic, and never a DNA nucleoside mimic. Ribavirin 5'-monophosphate inhibits cellular inosine monophosphate dehydrogenase, thereby depleting intracellular pools of GTP.
It was reported that ribavirin was active against a variety of RNA and DNA viruses in culture and in animals, without undue toxicity.
Ribavirin is possibly best viewed as a ribosyl purine analogue with an incomplete purine 6-membered ring. This structural resemblance historically prompted replacement of the 2' nitrogen of the triazole with a carbon (which becomes the 5' carbon in an imidazole), in an attempt to partly "fill out" the second ring--- but to no great effect. Such 5' imidazole riboside derivatives show antiviral activity with 5' hydrogen or halide, but the larger the substituent, the smaller the activity, and all proved less active than ribavirin. Note that two natural products were already known with this imidazole riboside structure: substitution at the 5' carbon with OH results in pyrazomycin/pyrazofurin, an antibiotic with antiviral properties but unacceptable toxicity, and replacement with an amino group results in the natural purine synthetic precursor 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranoside (AICAR), which has only modest antiviral properties.
The most successful ribavirin derivative to date is the 3-carboxamidine derivative of the parent 3-carboxamide, first reported in 1973 by J.T.Witkowski et al., and now called taribavirin (former names viramidine and ribamidine). This drug shows a similar spectrum of antiviral activity to ribavirin, which is not surprising as it is now known to be a pro-drug for ribavirin. Viramidine, however, has useful properties of less erythrocyte-trapping and better liver-targeting than ribavirin. The first property is due to viramidine's basic amidine group which inhibits drug entry into RBCs, and the second property is probably due to increased concentration of the enzymes which convert amidine to amide, in liver tissue. Viramidine is in phase III human trials and may one day be used in place of ribavirin, at least against certain kinds of viral hepatitis. Viramidine's slightly superior toxicological properties may eventually cause it to replace ribavirin in all uses of ribavirin.
- "Ribavirin". The American Society of Health-System Pharmacists. Retrieved 8 December 2016.
- "PRODUCT INFORMATION REBETOL® (RIBAVIRIN) CAPSULES" (PDF). TGA eBusiness Services. Merck Sharp & Dohme (Australia) Pty Limited. 29 April 2013. Retrieved 23 February 2014.
- WHO Model Formulary 2008 (PDF). World Health Organization. 2009. p. 177. ISBN 9789241547659. Retrieved 8 December 2016.
- Fischer, Janos; Ganellin, C. Robin (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 504. ISBN 9783527607495.
- "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Retrieved 8 December 2016.
- Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 79. ISBN 9781284057560.
- "Rebetol, Ribasphere (ribavirin) dosing, indications, interactions, adverse effects, and more". Medscape Reference. WebMD. Retrieved 23 February 2014.
- Paeshuyse J, Dallmeier K, Neyts J (December 2011). "Ribavirin for the treatment of chronic hepatitis C virus infection: a review of the proposed mechanisms of action". Current Opinion in Virology. 1 (6): 590–8. doi:10.1016/j.coviro.2011.10.030. PMID 22440916.
- Flori N, Funakoshi N, Duny Y, Valats JC, Bismuth M, Christophorou D, Daurès JP, Blanc P (March 2013). "Pegylated interferon-α2a and ribavirin versus pegylated interferon-α2b and ribavirin in chronic hepatitis C : a meta-analysis". Drugs. 73 (3): 263–77. doi:10.1007/s40265-013-0027-1. PMID 23436591.
- Druyts E, Thorlund K, Wu P, Kanters S, Yaya S, Cooper CL, Mills EJ (April 2013). "Efficacy and safety of pegylated interferon alfa-2a or alfa-2b plus ribavirin for the treatment of chronic hepatitis C in children and adolescents: a systematic review and meta-analysis". Clinical Infectious Diseases. 56 (7): 961–7. doi:10.1093/cid/cis1031. PMID 23243171.
- Zeuzem S, Poordad F (July 2010). "Pegylated-interferon plus ribavirin therapy in the treatment of CHC: individualization of treatment duration according to on-treatment virologic response". Current Medical Research and Opinion. 26 (7): 1733–43. doi:10.1185/03007995.2010.487038. PMID 20482242.
- Liu JY, Sheng YJ, Hu HD, Zhong Q, Wang J, Tong SW, Zhou Z, Zhang DZ, Hu P, Ren H (September 2012). "The influence of hepatitis B virus on antiviral treatment with interferon and ribavirin in Asian patients with hepatitis C virus/hepatitis B virus coinfection: a meta-analysis". Virology Journal. 9: 186. doi:10.1186/1743-422X-9-186. PMC . PMID 22950520.
- Basso M, Parisi SG, Mengoli C, Gentilini V, Menegotto N, Monticelli J, Nicolè S, Cruciani M, Palù G (July–August 2013). "Sustained virological response and baseline predictors in HIV-HCV coinfected patients retreated with pegylated interferon and ribavirin after failing a previous interferon-based therapy: systematic review and meta-analysis". HIV Clinical Trials. 14 (4): 127–39. doi:10.1310/hct1404-127. PMID 23924585.
- Zhu Q, Li N, Han Q, Zhang P, Yang C, Zeng X, Chen Y, Lv Y, Liu X, Liu Z (June 2013). "Statin therapy improves response to interferon alfa and ribavirin in chronic hepatitis C: a systematic review and meta-analysis". Antiviral Research. 98 (3): 373–9. doi:10.1016/j.antiviral.2013.04.009. PMID 23603497.
- Steckbriefe seltener und importierter Infektionskrankheiten [Characteristics of rare and imported infectious diseases] (PDF). Berlin: Robert Koch Institute. 2006. ISBN 3-89606-095-3.
- Ascioglu S, Leblebicioglu H, Vahaboglu H, Chan KA (June 2011). "Ribavirin for patients with Crimean-Congo haemorrhagic fever: a systematic review and meta-analysis" (PDF). The Journal of Antimicrobial Chemotherapy. 66 (6): 1215–22. doi:10.1093/jac/dkr136. PMID 21482564.
- Bausch DG, Hadi CM, Khan SH, Lertora JJ (December 2010). "Review of the literature and proposed guidelines for the use of oral ribavirin as postexposure prophylaxis for Lassa fever" (PDF). Clinical Infectious Diseases. 51 (12): 1435–41. doi:10.1086/657315. PMID 21058912.
- Soares-Weiser K, Thomas S, Thomson G, Garner P (July 2010). "Ribavirin for Crimean-Congo hemorrhagic fever: systematic review and meta-analysis". BMC Infectious Diseases. 10: 207. doi:10.1186/1471-2334-10-207. PMC . PMID 20626907.
- Goeijenbier M, van Kampen JJ, Reusken CB, Koopmans MP, van Gorp EC (November 2014). "Ebola virus disease: a review on epidemiology, symptoms, treatment and pathogenesis". The Netherlands Journal of Medicine. 72 (9): 442–8. PMID 25387613.
- Medical Management of Biological Casualties Handbook. United States Government Printing Office. 2011. p. 115. ISBN 978-0-16-090015-0.
- Ventre K, Randolph AG (January 2007). "Ribavirin for respiratory syncytial virus infection of the lower respiratory tract in infants and young children" (PDF). The Cochrane Database of Systematic Reviews (1): CD000181. doi:10.1002/14651858.CD000181.pub3. PMID 17253446.
- Hemachudha T, Ugolini G, Wacharapluesadee S, Sungkarat W, Shuangshoti S, Laothamatas J (May 2013). "Human rabies: neuropathogenesis, diagnosis, and management". The Lancet. Neurology. 12 (5): 498–513. doi:10.1016/S1474-4422(13)70038-3. PMID 23602163.
- Elia G, Belloli C, Cirone F, Lucente MS, Caruso M, Martella V, Decaro N, Buonavoglia C, Ormas P (February 2008). "In vitro efficacy of ribavirin against canine distemper virus". Antiviral Research. 77 (2): 108–13. doi:10.1016/j.antiviral.2007.09.004. PMID 17949825.
- Bierman SM, Kirkpatrick W, Fernandez H (1981). "Clinical efficacy of ribavirin in the treatment of genital herpes simplex virus infection". Chemotherapy. 27 (2): 139–45. doi:10.1159/000237969. PMID 7009087.
- Pancheva SN (September 1991). "Potentiating effect of ribavirin on the anti-herpes activity of acyclovir". Antiviral Research. 16 (2): 151–61. doi:10.1016/0166-3542(91)90021-I. PMID 1665959.
- Kast RE (November–December 2002). "Ribavirin in cancer immunotherapies: controlling nitric oxide helps generate cytotoxic lymphocyte" (PDF). Cancer Biology & Therapy. 1 (6): 626–30. doi:10.4161/cbt.310. PMID 12642684.
- Borden KL, Culjkovic-Kraljacic B (October 2010). "Ribavirin as an anti-cancer therapy: acute myeloid leukemia and beyond?". Leukemia & Lymphoma. 51 (10): 1805–15. doi:10.3109/10428194.2010.496506. PMC . PMID 20629523.
- Alvarez D, Dieterich DT, Brau N, Moorehead L, Ball L, Sulkowski MS (October 2006). "Zidovudine use but not weight-based ribavirin dosing impacts anaemia during HCV treatment in HIV-infected persons". Journal of Viral Hepatitis. 13 (10): 683–9. doi:10.1111/j.1365-2893.2006.00749.x. PMID 16970600.
- Bani-Sadr F, Carrat F, Pol S, Hor R, Rosenthal E, Goujard C, Morand P, Lunel-Fabiani F, Salmon-Ceron D, Piroth L, Pialoux G, Bentata M, Cacoub P, Perronne C (September 2005). "Risk factors for symptomatic mitochondrial toxicity in HIV/hepatitis C virus-coinfected patients during interferon plus ribavirin-based therapy". Journal of Acquired Immune Deficiency Syndromes. 40 (1): 47–52. doi:10.1097/01.qai.0000174649.51084.46. PMID 16123681.
- Ortega-Prieto AM, Sheldon J, Grande-Pérez A, Tejero H, Gregori J, Quer J, Esteban JI, Domingo E, Perales C (2013). Vartanian J, ed. "Extinction of hepatitis C virus by ribavirin in hepatoma cells involves lethal mutagenesis". PloS One. 8 (8): e71039. doi:10.1371/journal.pone.0071039. PMC . PMID 23976977.
- Crotty S, Cameron C, Andino R (February 2002). "Ribavirin's antiviral mechanism of action: lethal mutagenesis?". Journal of Molecular Medicine. 80 (2): 86–95. doi:10.1007/s00109-001-0308-0. PMID 11907645.
- Leyssen P, De Clercq E, Neyts J (April 2006). "The anti-yellow fever virus activity of ribavirin is independent of error-prone replication". Molecular Pharmacology. 69 (4): 1461–7. doi:10.1124/mol.105.020057. PMID 16421290.
- Snell NJ (August 2001). "Ribavirin--current status of a broad spectrum antiviral agent". Expert Opinion on Pharmacotherapy. 2 (8): 1317–24. doi:10.1517/146565184.108.40.2067. PMID 11585000.
- "Ribavirin History". News-Medical.net. Retrieved 2016-02-19.
- Sidwell RW, Huffman JH, Khare GP, Allen LB, Witkowski JT, Robins RK (August 1972). "Broad-spectrum antiviral activity of Virazole: 1-beta-D-ribofuranosyl-1,2,4-triazole-3-carboxamide". Science. 177 (4050): 705–6. doi:10.1126/science.177.4050.705. PMID 4340949.
- Smith RA & Kirkpatrick W (eds.) (1980). "Ribavirin: structure and antiviral activity relationships". Ribavirin: A Broad Spectrum Antiviral Agent. New York: Academic Press. pp. 1–21.
- Witkowski JT, Robins RK, Khare GP, Sidwell RW (August 1973). "Synthesis and antiviral activity of 1,2,4-triazole-3-thiocarboxamide and 1,2,4-triazole-3-carboxamidine ribonucleosides". Journal of Medicinal Chemistry. 16 (8): 935–7. doi:10.1021/jm00266a014. PMID 4355593.
- Sidwell RW, Bailey KW, Wong MH, Barnard DL, Smee DF (October 2005). "In vitro and in vivo influenza virus-inhibitory effects of viramidine". Antiviral Research. 68 (1): 10–7. doi:10.1016/j.antiviral.2005.06.003. PMID 16087250.
- Information on Ribavirin