Esme 21: Uses, Side Effects and Dosage

ABOUT THIS MEDICATION

What the medication is used for:

• To prevent pregnancy

• To treat moderate acne in women 14 years of age and

  older who are able to use birth control pills, desire birth control and have achieved menarche. Your first menstrual period is referred to as menarche.

What it does:

ESME is a birth control pill (oral contraceptive) that contains two female sex hormones (levonorgestrel and ethinyl estradiol). It has been shown to be highly effective in preventing pregnancy when taken as prescribed by your doctor. Pregnancy is always more risky than taking birth control pills except in smokers older than age 35.

Birth control pills work in two ways:

1. 1.

   They inhibit the monthly release of an egg by the

   ovaries.

2. 2.

   They change the mucus produced by the cervix

   (narrow outer end of the womb). This slows the movement of the sperm through the mucus and through the uterus (womb).

Effectiveness of Birth Control Pills

Combination birth control pills are more than 99 percent effective in preventing pregnancy when:

• the pill is TAKEN AS DIRECTED, and
• the amount of estrogen is 20 micrograms or more.

A 99 percent effectiveness rate means that if 100 women used birth control pills for one year, one woman in the group would get pregnant.

The chance of becoming pregnant increases with incorrect use.

Other Ways to Prevent Pregnancy

Other methods of birth control are available to you. They are usually less effective than birth control pills. When used properly, however, other methods of birth control are effective enough for many women.

The following table gives reported pregnancy rates for various forms of birth control, including no birth control. The reported rates represent the number of women out of 100 who would become pregnant in one year.

Reported Pregnancies per 100 Women per Year:

Combination pill less than 1 to 2 Intrauterine device (IUD) less than 1 to 6 Condom with spermicidal

foam or gel

1 to 6

Mini-pill 3 to 6

Condom 2 to 12

Diaphragm with spermicidal

foam or gel

3 to 18

Spermicide 3 to 21

Sponge with spermicide 3 to 28

Cervical cap with spermicide 5 to 18

Periodic abstinence (rhythm),

all types

2 to 20

No birth control 60 to 85

Pregnancy rates vary widely because people differ in how carefully and regularly they use each method. (This does not apply to IUDs since they are implanted in the uterus). Regular users may achieve pregnancy rates in the lower ranges. Others may expect pregnancy rates more in the middle ranges.

The effective use of birth control methods other than birth control pills and IUDs requires more effort than taking a single pill every day. It is an effort that many couples undertake successfully.

When it should not be used:

The birth control pill is not suitable for every woman. In a small number of women, serious side effects may occur. Your doctor can advise you if you have any conditions that would pose a risk to you. If you see a different doctor, inform him/her that you are taking birth control pills. Tell the doctor that your birth control pills are ESME. The use of the birth control pill should always be supervised by your doctor.

You should not use ESME if you have or have had any of the following conditions:

IMPORTANT: PLEASE READ

• History of or actual heart attack, chest pain (angina

  pectoris) or stroke;

• Blood clots in the legs (thrombophlebitis), lungs

  (pulmonary embolism), eyes or elsewhere;

• Hereditary or acquired blood clotting disorders;

• Known or suspected cancer of the breast, sex organs,

  or certain estrogen-dependent cancers;

• Unexplained vaginal bleeding (until a diagnosis is

  reached by your doctor);

• Partial or complete loss of vision or other vision

  problems caused by vascular disease (blood vessel disease of the eye);

• History of or actual liver disease or history of or actual

  benign or malignant liver tumor;

• Jaundice (yellowing of the skin and eyes) or liver

  disease if still present;

• Heart valve or heart rhythm disorders that may be

  associated with formation of blood clots;

• Diabetes affecting your circulation;

• Migraines (current or history) with neurological

  symptoms such as aura (visual or sensory disturbance);

• Uncontrolled high blood pressure;

• Hypersensitivity(allergy) to any of the components of

  ESME (levonorgestrel and ethinyl estradiol tablets) (see What the nonmedicinal ingredients are);

• Known or suspected pregnancy. Birth control pills

  should never be taken if you think you are pregnant. They will not prevent the pregnancy from continuing. There is no conclusive evidence, however, that the pill can damage a developing child when taken inadvertently during early pregnancy.

• Pancreatitis associated with severe

  hypertriglyceridemia (current or history). Pancreatitis is the inflammation of the pancreas, marked by abdominal pain, whereas severe hypertriglyceridemia is a very high level of triglycerides in the blood, and may show no symptoms.

• Are using anti-viral medications to treat Hepatitis C

  Virus (HCV) which contain combination of ombitasvir, paritaprevir, ritonavir and dasabuvir with or without ribavirin.

What the medicinal ingredients are:

Levonorgestrel and Ethinyl Estradiol

What the nonmedicinal ingredients are:

Each pink, round flat tablet with beveled edges, debossed with “405” on one side and plain on the other side contains croscarmellose sodium, ferric oxide red, lactose monohydrate, magnesium stearate, microcrystalline cellulose, povidone and sodium lauryl sulfate.

Each inactive green, round, flat tablet with beveled edges, debossed with “471” on one side and plain on the other

side (in ESME 28) contains croscarmellose sodium, FD&C Blue No. 1 aluminum lake (aluminium chloride, aluminium hydroxide, brilliant blue), ferric oxide (yellow), lactose monohydrate, magnesium stearate, microcrystalline cellulose and povidone.

What dosage forms it comes in:

ESME (levonorgestrel and ethinyl estradiol tablets) are available in a 21-day regimen (ESME 21) and a 28-day regimen (ESME 28).

ESME 21: Each package contains 21 pink tablets. Each pink tablet contains 100 mcg levonorgestrel and 20 mcg ethinyl estradiol.

ESME 28: Each blister pack contains 21 pink and 7 green, tablets. Each pink tablet contains 100 mcg levonorgestrel and 20 mcg ethinyl estradiol. The green tablets are inactive (do not contain hormones).

WARNINGS AND PRECAUTIONS

Serious Warnings and Precautions

Cigarette smoking increases the risk of serious adverse effects on the heart and blood vessels. This risk increases with age and becomes significant in birth control pill users over 35 years of age. Women who use birth control pills should not smoke.

Birth control pills DO NOT PROTECT against sexually transmitted infections (STIs), including HIV/AIDS.

For protection against STIs, it is advisable to use latex or polyurethane condoms IN COMBINATION WITH birth control pills.

There are also conditions that your doctor will want to watch closely or that might cause your doctor to recommend a method of contraception other than birth control pills.

BEFORE you use ESME talk to your doctor or pharmacist if the following apply to you:

• Breast conditions

  • A strong family history of breast cancer
  • Breast disorders including pain, discharge from the nipples, thickenings, or lumps. In some circumstances, benefit may be derived from taking the pill; in other cases, adverse effects may follow.
• Diabetes
• High blood pressure

• Abnormal levels of fats in the bloodstream (high

  cholesterol or triglycerides)

• Cigarette Smoking
• Heart or kidney disease
• Epilepsy/seizures
• History of Depression
• Fibroid tumours of the uterus
• Gallbladder or pancreatic disease
• History of liver disease or jaundice

• Family history of blood clots, heart attacks or

  strokes.

• May be pregnant or breast feeding
• Have systemic lupus erythmatosus

• Have inflammatory bowel disease such as

  Crohn’s disease or ulcerative colitis

• Have haemolytic uremic syndrome
• Have sickle cell disease

• Have problems with the valves in your heart

  and/or have irregular heart rhythm

• Wear contact lenses
• Have Hepatitis C

If you see a different doctor, inform him or her that you are using ESME.

Tell your doctor if you are scheduled for any laboratory tests since certain blood tests may be affected by hormonal contraceptives.

Also tell your doctor if you are scheduled for MAJOR surgery, recent delivery, or second-trimester abortion. You should consult your doctor about stopping the use of ESME four weeks before major surgery and not using ESME for a time period after surgery or during prolonged bed rest.

ESME should be used only under the supervision of a doctor, with regular follow-up to identify side effects associated with its use. Your visits may include a blood pressure check, a breast exam, an abdominal exam and a pelvic exam, including a Pap smear. Visit your doctor three months or sooner after the initial examination. Afterward, visit your doctor at least once a year.

Use ESME only on the advice of your doctor and carefully follow all directions given to you. You must use the birth control pill exactly as prescribed. Otherwise, you may become pregnant. If you and your doctor decide that, for you, the benefits of ESME outweigh the risks, you should be aware of the following:

THE RISKS OF USING BIRTH CONTROL PILLS

1. 1.

   Circulatory disorders (including blood clot in legs, lungs, heart, eyes or brain)

   Women who use hormonal contraceptives have a higher incidence of blood clots. Blood clots are the most common serious side effects of birth control pills. The risk of developing clots is especially high during the first year a woman ever uses a hormonal contraceptive. Clots can occur in many areas of the body.

   Be alert for the following symptoms and signs of serious adverse effects. Call your doctor immediately if they occur:

   • Sharp pain in the chest, coughing blood, or sudden shortness of breath. These symptoms could indicate a possible blood clot in the lung;
   • Pain and/or swelling in the calf. These symptoms could indicate a possible clot in the leg;

   • Crushing chest pain or heaviness. These

     symptoms could indicate a possible heart attack;

   • Sudden severe or worsening headache or vomiting, dizziness or fainting, disturbances of vision or speech, or weakness or numbness in an arm or leg. These symptoms could indicate a possible stroke;
   • Sudden partial or complete loss of vision. This symptom could indicate a blood clot in the eye.

Any of these conditions can cause death or disability. Clots also occur rarely in the blood vessels of the eye, resulting in blindness or impaired vision or in a blood vessel leading to an arm or leg, resulting in damage to or loss of a limb.

The risk of clotting seems to increase with higher estrogen doses. It is important, therefore, to use as low a dosage of estrogen as possible.

1. 2.

   Breast cancer

   The most significant risk factors for breast cancer are increasing age and a strong history of breast cancer in the family (mother or sister). Other established risk factors include obesity, never having children, and having your first full-term pregnancy at a late age.

   Some women who use birth control pills may be at increased risk of developing breast cancer before menopause, which occurs around age 50. These women may be long-term users of birth control pills (more than eight years) or women who start using birth control pills at an early age. In a few women, the use of birth control pills may accelerate the growth of an existing but undiagnosed breast cancer. Early diagnosis, however, can reduce the effect of breast cancer on a woman’s life expectancy. The potential risks related to birth control pills seem to be small,

however; a yearly breast examination by a doctor is recommended for all women.

ASK YOUR DOCTOR FOR ADVICE AND INSTRUCTIONS ON REGULAR SELF-EXAMINATION OF YOUR BREASTS.

1. 3.

   Cervical cancer

   Some studies have found an increase of cancer of the cervix in women who use hormonal contraceptives, although this finding may be related to factors other than the use of oral contraceptives. However, there is insufficient evidence to rule out the possibility that oral contraceptives may cause such cancers.

   Chronic infection with the Human Papilloma Virus (HPV) is believed to be the most important risk factor for cervical cancer. In women who use COCs for a long time the chance of getting cervical cancer may be slightly higher. This finding may not be caused by the Pill itself but may be related to sexual behavior and other factors.

2. 4.

   Liver tumors

   The short and long-term use of birth control pills have also been linked with the growth of liver tumors or liver injury (e.g., hepatitis, hepatic function abnormal). Such injury or tumors are extremely rare.

   Contact your doctor immediately if you experience nausea, vomiting, severe pain or a lump in the abdomen.

3. 5.

   Gallbladder disease

   Users of birth control pills have a greater risk of developing gallbladder disease requiring surgery within the first year of use. The risk may double after four or five years of use.

4. 6.

   Use in pregnancy

   Birth control pills should not be taken by pregnant women. They will not prevent the pregnancy from continuing. There is no evidence, however, that the birth control pill can damage a developing child. You should check with your doctor about risks to your unborn child from any medication taken during pregnancy.

   1. 7.

      Use after pregnancy, miscarriage or an abortion

      Your doctor will advise you of the appropriate time to start the use of ESME after childbirth, miscarriage, or therapeutic abortion.

   2. 8.

      Pregnancy after stopping ESME

      You will have a menstrual period when you stop using ESME. You should delay pregnancy until another menstrual period occurs within four to six weeks. In this way the pregnancy can be more accurately dated. Contact your doctor for recommendations on alternate methods of contraception during this time.

   3. 9.

      Use while breast feeding

      If you are breast-feeding, consult your doctor before starting the birth control pill. The hormones in birth control pills are known to appear in breast milk. Adverse effects on the child have been reported, including yellowing of the skin (jaundice) and breast enlargement. You should use another method of contraception. The use of oral contraceptives is generally not recommended until the nursing mother has completely weaned her child.

INTERACTIONS WITH THIS MEDICATION

Certain drugs may interact with birth-control pills to make them less effective in preventing pregnancy or cause an increase in breakthrough bleeding. You may also need to use a nonhormonal method of contraception during any cycle in which you take drugs that can make oral contraceptives less effective.

Drugs that may interact with ESME include:

• drugs used for epilepsy such as barbiturates (e.g. phenobarbital) and phenytoin, primidone, topiramate, carbamazepine
• certain drugs used in the treatment of tuberculosis (eg. rifampicin, rifabutin)
• drugs used for HIV or AIDS such as ritonavir
• herbal products containing St. John’s Wort (Hypericum perforatum)
• antibiotics (e.g. penicillins, tetracyclines) for infectious diseases
• cyclosporine
• antifungals (griseofulvin)
• cholesterol-lowering drugs (eg. clofibrate)
• antihypertensive drugs (for high blood pressure)
• antidiabetic drugs and insulin (for diabetes)
• prednisone

• sedatives and hypnotics (eg, benzodiazepines, barbiturates, chloral hydrate, glutethimide, meprobamate)
• antidepressants (e.g. clomipramine)
• other drugs such as phenylbutazone, analgesics, modafinil, troleandomycin, Vitamin E and Vitamin B₁₂.
• anti-viral hepatitis C virus (HCV) medicinal products such as ombitasvir, paritaprevir, ritonavir and dasabuvir, with or without ribavirin.

Please inform your doctor and pharmacist if you are taking or have recently taken any other drugs or herbal products, even those without a prescription. Also tell any other doctor or dentist who prescribes another drug (or the dispensing pharmacist) that you use ESME. They can tell you if you need to use an additional method of contraception and if so, for how long.

This is not a complete list of possible drug interactions with ESME. Talk to your doctor for more information about drug interactions.

PROPER USE OF THIS MEDICATION

Usual dose:

HOW TO TAKE ESME:

1. 1.

   READ THESE DIRECTIONS

   • Before you start taking your pills, and
   • Any time you are not sure what to do.
2. 2.

   LOOK AT YOUR PILL PACK to see if it has 21 or 28 pills:

   • 21-Pill Pack: 21 active pills (with hormones)

     taken daily for three weeks, and then no pills taken for one week;

or

• 28-Pill Pack: 21 active pills (with hormones)

  taken daily for three weeks, and then seven "reminder" pills (no hormones) taken daily for one week.

  1. 3.

     You may wish to use a second method of birth control

     (e.g. latex condoms and spermicidal foam or gel) for the first seven days of the first cycle of pill use. This will provide a back-up in case pills are forgotten while you are getting used to taking them.

  2. 4. When receiving any medical treatment, be sure to tell your doctor that you are using birth control pills.
  3. 5.

     MANY WOMEN HAVE SPOTTING OR LIGHT

     BLEEDING, OR MAY FEEL SICK TO THEIR STOMACH DURING THE FIRST THREE MONTHS ON THE PILL. If you do feel sick, do not stop taking ESME. The problem will usually go away. If it does not go away, check with your doctor or clinic.

  4. 6.

     MISSING PILLS ALSO CAN CAUSE SOME

     SPOTTING OR LIGHT BLEEDING, even if you make up the missed pills. You also could feel a little sick to your stomach on the days you take two pills to make up for missed pills.

  5. 7.

     IF YOU MISS PILLS AT ANY TIME, YOU COULD

     GET PREGNANT. THE GREATEST RISKS FOR PREGNANCY ARE:

     • when you start a pack late or
     • when you miss pills at the beginning or at the very end of the pack.
  6. 8.

     ALWAYS BE SURE YOU HAVE READY:

     • ANOTHER KIND OF BIRTH CONTROL (such as latex condoms and spermicidal foam or gel) to use as a back-up in case you miss pills, and
     • AN EXTRA PACK OF PILLS.
  7. 9.

     IF YOU EXPERIENCE VOMITING OR

     DIARRHEA, OR IF YOU TAKE CERTAIN MEDICINES, such as antibiotics, your pills may not

work as well. Use a back-up method, such as latex condoms and spermicidal foam or gel, until you can check with your doctor or clinic.

1. 10.

   IF YOU FORGOT MORE THAN ONE PILL TWO

   MONTHS IN A ROW, talk to your doctor or clinic about how to make pill-taking easier or about using another method of birth control.

2. 11.

   IF YOUR QUESTIONS ARE NOT ANSWERED

   HERE, CALL YOUR DOCTOR OR CLINIC.

WHEN TO START THE FIRST PACK OF PILLS

BE SURE TO READ THESE INSTRUCTIONS:

• before you start taking your pills, and
• any time you are not sure what to do.

Decide with your doctor or clinic what is the best day for you to start taking your first pack of pills. Your pills may be either a 21-day or a 28-day type.

A. 21-DAY COMBINATION

With this type of birth control pill, you are on pills for 21 days and off pills for seven days. You must not be off the pills for more than seven days in a row.

1. 1.

   THE FIRST DAY OF YOUR MENSTRUAL

   PERIOD (BLEEDING) IS DAY 1 OF YOUR CYCLE. Your doctor may advise you to start taking the pills on Day 1, on Day 5, or on the first Sunday after your period begins. If your period starts on Sunday, start that same day. If ESME tablets administration is initiated after Day 1 of the first menstrual cycle or postpartum, contraceptive reliance should not be placed on ESME until after the first seven active tablets have been taken for seven consecutive days. Nonhormonal methods of contraception (such as latex condoms and spermicidal foam or gel) should be used for the first 7 days of tablet taking.

2. 2.

   Take one pill at approximately the same time every

   day for 21 days, THEN TAKE NO PILLS FOR SEVEN DAYS. Start a new pack on the eighth day. You will probably have a period during the seven days off the pill. (This bleeding may be lighter and shorter than your usual period).

TWO WAYS TO REMEMBER IN WHAT ORDER TO TAKE THE PILLS

1. 1. Follow the days of the week (as shown above the pills).
2. 2.

   Always finish the pink tablets before going on to the week when you are off pills.

   B. 28-DAY COMBINATION

   With this type of birth control pill, you take 21 pills that contain hormones and seven pills that contain no hormones.

   1. 1.

      THE FIRST DAY OF YOUR MENSTRUAL

      PERIOD (BLEEDING) IS DAY 1 OF YOUR CYCLE. Your doctor may advise you to start taking the pills on Day 1, on Day 5, or on the first Sunday after your period begins. If your period starts on Sunday, start that same day. If ESME tablets administration is initiated after Day 1 of the first menstrual cycle or postpartum, contraceptive reliance should not be placed on ESME until after the first seven active tablets have been taken for seven consecutive days. Nonhormonal methods of contraception (such as latex condoms and spermicidal foam or gel) should be used for the first 7 days of tablet taking.

   2. 2. Take one pill at approximately the same time every day for 28 days. Begin a new pack the next day, NOT MISSING ANY DAYS. Your period should occur during the last seven days of using that pill pack.

TWO WAYS TO REMEMBER IN WHAT ORDER TO TAKE THE PILLS

1. 1. Follow the days of the week (as shown above the pills).
2. 2. Always finish the pink tablets before going on to the green pills in week 4 row.

INSTRUCTIONS FOR USING YOUR PACKAGE.

FOLLOW THESE INSTRUCTIONS CAREFULLY:

1.For Day 1 or Day 5 start: Label the Package by selecting the day label sticker that corresponds with Day 1 (or Day 5) of your menstrual period (the first day of menstruation is Day 1). For example, if your first day of menstruation is Tuesday, select and peel off the day label that begins with TUE/MAR.

OR For Sunday start: No day label is required. The Package is printed for a Sunday start.

2.Place the day label sticker over the existing days of the week printed on the package. Having the Package labelled with the days of the week will help remind you to take your pill every day.

3.To begin taking your pills, start with the pill next to the word START. This pill should correspond to the day of the week that you are taking your first pill. To remove the pill, push through the back of the Package.

4.On the following day, take the next pill in the same row, always proceeding from left to right (→). Each row will always begin on the same day of the week.

WHAT TO DO DURING THE MONTH

1. 1.

   TAKE A PILL AT APPROXIMATELY THE SAME

   TIME EVERY DAY UNTIL THE PACK IS EMPTY.

2. 2.

   Try to associate taking your pill with some regular

   activity such as eating a meal or going to bed.

3. 3.

   Do not skip pills even if you have bleeding between

   monthly periods or feel sick to your stomach (nausea).

4. 4. Do not skip pills even if you do not have sex very often.
5. 5.

   WHEN YOU FINISH A PACK

   • 21 PILLS

WAIT SEVEN DAYS to start the next pack. You will have your period during that week.

• 28 PILLS

Start the next pack ON THE NEXT DAY. Take one pill every day. Do not wait any days between packs.

Overdose:

Overdosage may cause nausea, vomiting, breast tenderness, dizziness, abdominal pain, and fatigue/ drowsiness. Withdrawal bleeding may occur in females.

If you think you have taken too much ESME, contact your healthcare professional, hospital emergency department or regional Poison Controls Centre immediately, even if there are no symptoms.

Missed Dose:

WHAT TO DO IF YOU MISS PILLS

Birth control pills may not be as effective if you miss pills. The following chart outlines the actions you should take if you miss one or more of your birth control pills. Match the number of pills missed with the appropriate starting time for your type of pill pack.

NOTE: 28-DAY PACK - If you forget any of the seven "reminder" pills (without hormones) in Week 4, just safely dispose of the pills you missed. Then keep taking one pill each day until the pack is empty. You do not need to use a back-up method.

Always be sure you have on hand:

• a non-hormonal back-up method of birth control

  (such as latex condoms and spermicidal foam or gel) in case you miss pills, and

• an extra, full pack of pills.

IF YOU FORGET MORE THAN ONE PILL TWO MONTHS IN A ROW, TALK TO YOUR DOCTOR OR CLINIC about ways to make pill-taking easier or about using another method of birth control.

Non-Contraceptive Benefits of Birth Control Pills:

Several health advantages have been linked to the use of birth control pills.

• Combination estrogen and progestin birth control

  pills reduce the incidence of cancer of the uterus and ovaries.

• Birth control pills reduce the likelihood of

  developing benign (non-cancerous) breast disease and ovarian cysts.

• Users of birth control pills lose less menstrual blood

  and have more regular cycles. The risk of developing iron deficiency anemia is thus reduced.

• There may be a decrease in painful menstruation

  and premenstrual syndrome (PMS).

• Acne, excessive hair growth and male hormone-

  related disorders also may be improved.

SIDE EFFECTS AND WHAT TO DO ABOUT THEM

Some users of birth control pills have unpleasant side effects. Most side effects are temporary and are not hazardous to the health.

There may be tenderness of the breast, nausea, and vomiting. Some users will experience weight gain or loss. Many of these side effects occurred with high-dose combination birth control pills. These side effects are less common with the low-dose pills prescribed today.

Unexpected vaginal bleeding or spotting and changes in the usual menstrual period may also occur. These side effects usually disappear after the first few cycles. They are not an indication to stop taking birth control pills. Unless more significant complications occur, a decision to stop using the pill or to change the brand of pill should be made only after three consecutive months of use. Occasionally, users develop high blood pressure that may require stopping the use of birth control pills.

Other side effects may include

• growth of pre-existing fibroid tumours of the uterus;

• an increase or decrease in hair growth, sex drive and

  appetite;

• skin pigmentation;
• headaches;

• abnormal liver test, nausea, vomiting, severe pain or

  lump in the abdomen;

  • rash; and/or
  • vaginal infections.

Infrequently, there is a need to change contact lens prescription or an inability to use contact lenses.

A woman's menstrual period may be delayed after stopping birth control pills. There is no evidence that the use of the pill leads to a decrease in fertility. As mentioned, it is wise to delay starting a pregnancy for one menstrual period after stopping birth control pills.

This is not a complete list of side effects. For any unexpected effects while taking ESME, contact your doctor or pharmacist.

HOW TO STORE IT

Store at room temperature (15°C-30°C).

ESME 21 AND ESME 28 should be protected from light once opened using the protective covering provided. Keep out of reach of children and pets.

Reporting Side Effects

You can report any suspected side effects associated with the use of health products to Health Canada by:

• Visiting the Web page on Adverse Reaction

  Reporting (https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/adverse-reaction-reporting.html) for information on how to report online, by mail or by fax; or

• Calling toll-free at 1-866-234-2345.

NOTE: Contact your health professional if you need information about how to manage your side effects. The Canada Vigilance Program does not provide medical advice.

MORE INFORMATION

This document can be found at: www.mylan.ca.

The full product monograph prepared for health professionals can be obtained by contacting the Canadian distributor, Mylan Pharmaceuticals ULC, at: 1-844-596-9526.

Revised on: August 16, 2018

Mylan Pharmaceuticals ULC

Etobicoke, ON M8Z 2S6

1-844-596-9526

www.mylan.ca