Version July 2025
Use of ribavirin in patients requiring mechanical ventilator assistance should be undertaken only by health care providers and support staff familiar with this mode of administration and the specific ventilator being used. Strict attention must be paid to procedures that have been shown to minimize the accumulation of drug precipitate, which can result in mechanical ventilator dysfunction and associated increases in pulmonary pressures.
Sudden deterioration of respiratory function has been associated with the initiation of ribavirin use in infants. Carefully monitor respiratory function during treatment. If the initiation of ribavirin treatment appears to produce sudden deterioration of respiratory function, stop treatment and reinstitute only with extreme caution, continuous monitoring, and consideration of coadministration of bronchodilators.
Aerosolized ribavirin is not indicated for use in adults. Be aware that ribavirin has been shown to produce testicular lesions in rodents and to be teratogenic in all animal species in which adequate studies have been conducted (rodents and rabbits).
Respiratory syncytial virus (RSV) infection: Note: Due to lack of clinically significant effect on outcomes, the AAP recommends against routine use of ribavirin to treat RSV. Additionally, concerns exist regarding cost and potential toxicity in exposed health care personnel (Ref).
Aerosol inhalation: Note: Dose actually delivered to the patient will depend on patient's minute ventilation.
Continuous aerosolization: Infants and Children: 6 g administered over 12 to 18 hours/day for 3 to 7 days using Bausch Health small particle aerosol generator (SPAG-2).
Intermittent aerosolization: Very limited data available: Infants, Children, and Adolescents: 2,000 mg over 2 to 3 hours 3 times daily for 2 to 10 days has been used to permit easier accessibility for patient care and limit environmental exposure of health care workers (Ref). Utilization of the SPAG-2 is the most common method of administration; however, use of a vibrating mesh micropump nebulizer (Aerogen Solo) has also been described (Ref).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
(For additional information see "Ribavirin (oral inhalation): Drug information")
Respiratory syncytial virus infection in hematopoietic cell or heart/lung transplant recipients (off-label use): Note: May use in combination with intravenous immune globulin (IVIG), methylprednisolone, and palivizumab. Dosage and protocol may be institution-specific (Ref). Pretreatment with albuterol may be necessary (Ref).
Oral inhalation:
Mechanically ventilated: Continuous dosing: 6 g over 12 to 18 hours daily (Ref)
Non-mechanically ventilated: Intermittent dosing: 2 g (over 2 to 4 hours) every 8 hours (Ref) or 6 g (over 2 to 6 hours) every 6 to 8 hours via a small particle aerosol generator (SPAG-2) nebulizer (mask or hood) (Ref)
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined:
Cardiovascular: Bigeminy, bradycardia, chest pain, hypotension, tachycardia
Dermatologic: Skin rash
Ophthalmic: Conjunctivitis
Respiratory: Apnea, atelectasis, bacterial pneumonia, bronchospasm, cyanosis, dyspnea, hypoventilation, pneumothorax, pulmonary complications (ventilator dependence), pulmonary edema, severe dyspnea (worsening of respiratory status)
<1%, postmarketing, and/or case reports: Anemia, hemolytic anemia, reticulocytosis
Hypersensitivity to ribavirin or any component of the formulation; patients who are pregnant or may become pregnant
Other warnings/precautions:
• Use with mechanical ventilators: Strictly adhere to procedures to prevent ventilator dysfunction (eg, use of bacteria filters, verification that ribavirin crystals are not accumulating in the ventilator circuitry, frequent suctioning and monitoring of the patient).
Sudden respiratory deterioration has been observed during the initiation of aerosolized ribavirin in infants; carefully monitor infants. If deterioration of respiratory function occurs, stop treatment; reinstitute with extreme caution, continuous monitoring, and consider concomitant administration of bronchodilators.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution Reconstituted, Inhalation:
Generic: 6 g (1 ea)
Solution Reconstituted, Inhalation [preservative free]:
Virazole: 6 g (1 ea [DSC])
Generic: 6 g (1 ea)
Yes
Solution (reconstituted) (Ribavirin Inhalation)
6 g (per each): $24,000.00 - $27,600.00
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Inhalation:
Virazole: 6 g (1 ea)
Inhalation: Aerosolize with Bausch Health small particle aerosol generator (SPAG-2). Ribavirin should be administered in negative-pressure or other well-ventilated rooms (at least 6 air changes/hour). Additional precautions to limit exposure to health care personnel include the use of scavenging devices or respirator masks and turning off the aerosolizer for 5 to 10 minutes prior to prolonged patient contact. Solutions in SPAG-2 unit should be discarded at least every 24 hours and when the liquid level is low before adding newly reconstituted solution. Should not be mixed with other aerosolized medication.
The manufacturer recommends that pregnant health care workers take precautions to limit exposure to ribavirin aerosol.
Continuous inhalation:
Non-mechanically ventilated patients: Administer via an infant oxygen hood; if not available, may use an oxygen tent or face mask.
Mechanically ventilated patients: Ribavirin can potentially be deposited in the ventilator delivery system, which can lead to mechanical ventilator dysfunction and increased pulmonary pressures. To minimize accumulation of drug precipitate, use and frequently change (every 4 hours) filters in the expiratory line, use water column pressure release valves, frequently monitor devices, and verify that ribavirin crystals have not accumulated within circuit. Endotracheal tubes should be suctioned every 1 to 2 hours and pulmonary pressures should be monitored every 2 to 4 hours.
Intermittent inhalation: Utilization of the SPAG-2 as described above is the most common method of administration; however, use of a vibrating mesh micropump nebulizer (Aerogen Solo) has also been described (Ref).
Oral inhalation: Ribavirin should be administered in well-ventilated rooms (at least 6 air changes/hour). In mechanically ventilated patients, ribavirin can potentially be deposited in the ventilator delivery system depending on temperature, humidity, and electrostatic forces; this deposition and drug precipitation can lead to malfunction or obstruction of the expiratory valve, resulting in inadvertently high positive end-expiratory pressures. The use of one-way valves in the inspiratory lines, a breathing circuit filter in the expiratory line, and frequent monitoring and filter replacement have been effective in preventing these problems. Solutions in SPAG-2 unit should be discarded at least every 24 hours and when the liquid level is low before adding newly reconstituted solution. Should not be mixed with other aerosolized medications. Environmental services/infection control should be notified of ribavirin inhaled administration to any patient. The manufacturer recommends that pregnant health care workers take precautions to limit exposure to ribavirin aerosol.
Hazardous agent (NIOSH 2024 [table 2]).
Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2023; NIOSH 2024; USP-NF 2020).
Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.
Store vials in a dry place at 15°C to 30°C (59°F to 86°F). Reconstituted solution is stable for 24 hours at room temperature.
Treatment of hospitalized patients with severe lower respiratory tract respiratory syncytial virus (RSV) infections (FDA approved in infants and young children). Note: The AAP recommends against routine use of ribavirin to treat RSV because it has no clinically significant impact on outcomes (Red Book [AAP 2018]).
Ribavirin may be confused with riboflavin, rifampin, Robaxin.
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs (contraindicated in pregnancy) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Community/Ambulatory Care Settings).
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
AzaTHIOprine: Ribavirin (Oral Inhalation) may increase active metabolite exposure of AzaTHIOprine. Specifically, concentrations of potentially myelotoxic methylated metabolites may be increased, while concentrations of active 6-thioguanine nucleotides may be decreased. Management: Consider using alternative agent(s) when possible. When these drugs are used in combination, monitor patients extra closely for signs/symptoms of myelosuppression. Risk D: Consider Therapy Modification
Didanosine: Ribavirin (Oral Inhalation) may increase adverse/toxic effects of Didanosine. Ribavirin (Oral Inhalation) may increase active metabolite exposure of Didanosine. Risk X: Avoid
Influenza Virus Vaccine (Live/Attenuated): Antiviral Agents (Influenza A and B) may decrease therapeutic effects of Influenza Virus Vaccine (Live/Attenuated). Management: Avoid administration of live influenza virus vaccine (LAIV) within 2 weeks before or 48 hours after administration of antiviral agents. Consider avoiding LAIV if peramivir was given within the last 5 days or baloxavir was given within the last 17 days. Risk D: Consider Therapy Modification
Interferons (Alfa): May increase adverse/toxic effects of Ribavirin (Oral Inhalation). Hemolytic anemia has been observed. Risk C: Monitor
Zidovudine: May increase adverse/toxic effects of Ribavirin (Oral Inhalation). Specifically, the risk/severity of anemia may be increased. Management: Due to significantly increased risk of anemia, consider even closer monitoring for anemia than routinely recommended. Alternative therapies should be considered when clinically possible, particularly for patients with other risk factors. Risk D: Consider Therapy Modification
Use is contraindicated in females who may become pregnant.
Use is contraindicated in females who are pregnant. [US Boxed Warning]: Aerosolized ribavirin is not indicated for use in adults. Be aware that ribavirin has been shown to produce testicular lesions in rodents and to be teratogenic in all animal species in which adequate studies have been conducted (rodents and rabbits). The manufacturer recommends that pregnant health care workers take precautions to limit exposure to ribavirin aerosol; potential occupational exposure may be greatest if administration is via oxygen tent or hood, and lower if administered via mechanical ventilation. The minimum interval following exposure to ribavirin inhalation prior to pregnancy is not known.
Respiratory function, CBC with differential (hemoglobin, reticulocyte count).
Inhibits replication of RNA and DNA viruses; inhibits influenza virus RNA polymerase activity and inhibits the initiation and elongation of RNA fragments resulting in inhibition of viral protein synthesis
Absorption: Inhalation: Systemic; dependent upon respiratory factors and method of drug delivery; maximal absorption occurs with the use of aerosol generator via endotracheal tube; highest concentrations in respiratory tract and erythrocytes
Metabolism: Occurs intracellularly and may be necessary for drug action; metabolized hepatically to deribosylated ribavirin (active metabolite)
Bioavailability: Oral: 64%
Half-life elimination:
Respiratory tract secretions: Infants and Children 6 weeks to 7 years: ~2 hours (Englund 1990)
Plasma: Infants and Children: Inhalation: 9.5 hours
Time to peak, serum: Inhalation: At end of inhalation period
Excretion: Inhalation: Urine (40% as unchanged drug and metabolites)
