Metoject pen 7.5 mg solution for injection in Pre-filled pen, Metex pen 7.5 mg solution for injection in Pre-filled pen, Methotrexate 7.5 mg solution for injection in Pre-filled pen – patient leaflet, side effects, dosage

1. What Metoject PEN is and what it is used for

Metoject PEN is indicated for the treatment of

• active rheumatoid arthritis in adult patients.
• polyarthritic forms of severe, active juvenile idiopathic arthritis, when the response to nonsteroidal anti-inflammatory drugs (NSAIDs) has been inadequate.
• moderate to severe psoriasis in adult patients, and severe psoriatic arthritis in adults.
• mild to moderate Crohn’s disease in adult patients when adequate treatment with other medicines is not possible.

Rheumatoid arthritis (RA) is a chronic collagen disease, characterised by inflammation of the synovial membranes (joint membranes). These membranes produce a fluid which acts as a lubricant for many joints. The inflammation causes thickening of the membrane and swelling of the joint.

Juvenile arthritis concerns children and adolescents less than 16 years. Polyarthritic forms are indicated if 5 or more joints are affected within the first 6 months of the disease.

Psoriasis is a common chronic skin disease, characterised by red patches covered by thick, dry, silvery, adherent scales.

Psoriatic arthritis is a kind of arthritis with psoriatic lesions of the skin and nails, especially at the joints of fingers and toes.

Metoject PEN modifies and slows down the progression of the disease.

Crohn’s disease is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract causing symptoms such as abdominal pain, diarrhoea, vomiting or weight loss.

2. What you need to know before you use Metoject PEN

Do not use Metoject PEN:

• if you are allergic to methotrexate or any of the other ingredients of this medicine (listed in section 6).
• if you suffer from liver or severe kidney diseases or blood diseases.
• if you regularly drink large amounts of alcohol.
• if you suffer from a severe infection, such as tuberculosis, HIV or other immunodeficiency syndromes.
• if you suffer from mouth ulcers, stomach ulcer or intestinal ulcer.
• if you are pregnant or breast-feeding (see section “Pregnancy, breast-feeding and fertility”).
• if you receive vaccinations with live vaccines at the same time.

Warnings and precautions

Talk to your doctor or pharmacist before taking Metoject PEN if:

• you are elderly or if you feel generally unwell and weak.
• you have problems with the way your liver works.

• you suffer from dehydration (water loss).

  Instructions for use

  Recommendations

  • Carefully read the instructions below before starting your injection.
  • Always use the injection technique advised by your doctor, pharmacist or nurse.

Additional information

The manner of handling and throwing away of the medicine and pre-filled pen must be in accordance with local requirements. Pregnant healthcare personnel should not handle and/or administer Metoject PEN.

Methotrexate should not come into contact with the surface of the skin or mucosa. In the event of contamination, the affected area must be rinsed immediately with plenty of water.

Metoject PEN pre-filled pen components:

1. a) With cap before injection
2. b) After cap removal before injection
3. c) After injection

What you need to do before administering your injection

1. 1. Wash your hands very carefully.
2. 2. Remove the system from its packaging.
3. 3.

   Check the Metoject PEN pre-filled pen before using it:

   If the Metoject PEN pre-filled pen appears to be damaged do not use it. Use another one and contact your doctor, pharmacist or nurse.

   In case a small air bubble is visible through the transparent control zone, this will not affect your dose nor will it harm you.

If you are not able to see or to check the system correctly prior to injection, ask someone around you for assistance.

1. 4. Set the Metoject PEN pre-filled pen on a clean flat surface (such as a table).

Where you should administer the injection

The most appropriate zones for your injection are:

• upper thighs,
• abdomen except around the navel.

• If someone around you administers the injection for you, the person may also use the top of the zone at the back of the arm, just below the shoulder.

  • Change the injection area with each injection. This will minimise any reactions at the injection site.
  • Never inject into areas where the skin is tender, bruised, red or hard or where you have scars or stretch marks. If you have psoriasis, you should not try to inject directly into any raised, thick, red or scaly skin patches or lesions.

How to prepare the injection

1. 5.

   Choose an injection site and clean the area of and around the chosen injection site.

   Injection button

   Handling area

   Transparent control zone

   Cap

• Do not remove the cap before you are ready to administer the injection
• Hold the pen with one hand in the handling area with the cap pointing upwards. Use your other hand to gently pull the cap straight off (do not bend or twist the cap). The cap has a small needle shield that should come off with the cap automatically. If the needle shield does not come off, use another pen and contact your doctor, pharmacist or nurse.
• If you are unable to remove the cap, ask someone around you for assistance.

Note: Once you have removed the cap, perform your injection without delay.

1. 7.

   With your free hand, build a skin

   1. fold by gently squeezing the area of
   2. the cleaned skin at the injection
   3. site.
2. •

   The fold must be held pinched until

   1. the Metoject PEN pre-filled pen is
   2. removed from the skin after the
   3. injection.

1. 8.

   Position the uncapped transparent

   1. end of Metoject PEN pre-filled pen
   2. perpendicular to the fold of skin.
2. 9.

   Without pressing the button, push

   1. the Metoject PEN pre-filled pen
   2. firmly onto your skin in order to
   3. unlock the button.
3. •

   If you are unable to push the

   1. Metoject PEN pre-filled pen to the
   2. stop-point, ask someone around you
   3. for assistance.

How to administer the injection:

1. 10.

   While holding the Metoject PEN

   1. pre-filled pen firmly against the skin,
   2. now press the button with your
   3. thumb.
2. 11.

   You will hear a click which indicates

   1. the start of the injection. Keep
   2. holding the pen against the raised
   3. skin until all of the medicine is
   4. injected. This can take up to 5
   5. seconds.

Note:

Do not remove the Metoject PEN pre-filled pen from the skin before the end of the injection to avoid incomplete injection.

If the injection is not triggered, release the button, make sure that the Metoject PEN pre-filled pen is pressed firmly against the skin and push hard on the button.

If you have troubles with your hearing, count 5 seconds from the moment you have pressed the button and then lift the Metoject PEN pre-filled pen from the injection site.

1. 12.

   Remove the Metoject PEN pre-

   1. filled pen from the injection site,
   2. perpendicular to the skin (pull up).
2. 13.

   The protective shield automatically

   1. moves into place over the needle.
   2. The protective shield is then
   3. locked and the needle is protected.
3. 14.

   In case of a slight bleeding use a

   1. plaster.

Before throwing away the Metoject PEN pre-filled pen, check visually that there is no liquid left in the pen, at the bottom of the transparent control zone. If there is liquid left in the pen, not all of the medicine has been injected correctly and you should consult your doctor.

Note

To avoid any injury, never insert your fingers in the opening of the protective tube covering the needle. Do not destroy the pen.

Whom should you contact in case of need

• For any problem or question, contact your doctor, pharmacist or nurse.
• If you or someone around you is injured by the needle, consult your doctor immediately and throw away the Metoject PEN pre-filled pen.

Product Licence holder

Procured from within the EU and repackaged by the Product Licence holder: S&M Medical Ltd., Chemilines House, Alperton Lane, Wembley, HA0 1DX.

Leaflet revision date: 17 March 2022

Special precautionary measures for treatment with Metoject PEN

Methotrexate temporarily affects sperm and egg production, which is reversible in most cases. Methotrexate can cause miscarriage and severe birth defects. You must avoid becoming pregnant when using methotrexate and for at least six months after treatment has stopped. See also section “Pregnancy, breast-feeding and fertility”.

Recommended follow-up examinations and safety measures

Even when Metoject PEN is administered in low doses, severe side effects can occur. In order to detect them in time, check-ups and laboratory tests have to be carried out by your doctor.

Before therapy

Before starting the treatment, blood samples will be taken in order to check that you have enough blood cells, tests to check your liver function, serum albumin (a protein in the blood) and kidney function. Your doctor will also check if you suffer from tuberculosis (infectious disease in combination with little nodules in the affected tissue) and a chest X-ray will be taken.

During therapy

You will have the following tests at least once a month during the first six months and at least every three months thereafter:

• Examination of the mouth and throat for changes of the mucosa.
• Blood tests.
• Check of liver function.
• Check of kidney function.
• Check of respiratory system and if necessary lung function test.

Acute bleeding from the lungs in patients with underlying rheumatologic disease has been reported with methotrexate. If you experience symptoms of spitting or coughing up blood you should contact your doctor immediately.

Methotrexate may affect your immune system and vaccination results. It may also affect the result of immunological tests. Inactive, chronic infections (such as herpes zoster [shingles], tuberculosis, hepatitis B or C) may flare up. During therapy with Metoject PEN you must not be vaccinated with live vaccines.

Radiation-induced dermatitis and sun-burn can reappear under methotrexate therapy (recall-reaction). Psoriatic lesions can exacerbate during UV-irradiation and simultaneous administration of methotrexate.

Enlarged lymph nodes (lymphoma) may occur and if this is the case, therapy must be stopped.

Diarrhoea can be a possible side effect of Metoject PEN and requires an interruption of therapy. If you suffer from diarrhoea please speak to your doctor.

Certain brain disorders (encephalopathy/leukoencephalopathy) have been reported in cancer patients receiving methotrexate. Such side effects cannot be excluded when methotrexate is used to treat other diseases.

Other medicines and Metoject PEN

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. Please note that this also applies to medicines that you will take in the future.

The effect of the treatment may be affected if Metoject PEN is administered at the same time as certain other medicines:

• Antibiotics such as: tetracyclines, chloramphenicol, non-absorbable broad-spectrum antibiotics, penicillines, glycopeptides, sulphonamides, ciprofloxacin and cefalotin (medicines to prevent/fight certain infections).
• Non-steroidal anti-inflammatory drugs or salicylates (medicines against pain and/or inflammation such as acetylsalicylic acid, diclofenac and ibuprofen or pyrazole).
• Probenecid (medicine against gout).
• Weak organic acids like loop diuretics (“water tablets”).
• Medicines, which may have adverse effects on the bone marrow, such as trimethoprim-sulphamethoxazole (an antibiotic) and pyrimethamine.
• Other medicines used to treat rheumatoid arthritis such as leflunomide, sulphasalazine and azathioprine.
• Mercaptopurine (a cytostatic medicine).
• Retinoids (medicine against psoriasis and other dermatological diseases).
• Theophylline (medicine against bronchial asthma and other lung diseases).
• Some medicines against stomach trouble such as omeprazole and pantoprazole.
• Hypoglycaemics (medicines that are used to lower the blood sugar).

Vitamins containing folic acid may impair the effect of your treatment and should only be taken when advised by your doctor.

Vaccination with live vaccine must be avoided.

Metoject PEN with food, drink and alcohol

Alcohol as well as large amounts of coffee, caffeine-containing soft drinks and black tea should be avoided during treatment with Metoject PEN.

Pregnancy, breast-feeding and fertility

Pregnancy

Do not use Metoject PEN during pregnancy or if you are trying to become pregnant. Methotrexate can cause birth defects, harm the unborn child or cause miscarriage. It is associated with malformations of the skull, face, heart and blood vessels, brain and limbs. Therefore, it is very important that methotrexate is not given to pregnant patients or patients planning to become pregnant.

In women of child-bearing age, any possibility of pregnancy must be excluded with appropriate measures, e.g. pregnancy test before starting treatment. You must avoid becoming pregnant whilst taking methotrexate and for at least 6 months after treatment is stopped by using reliable contraception throughout this time (see also section “Warnings and precautions”). If you do become pregnant during treatment or suspect you might be pregnant, speak to your doctor as soon as possible. You should be offered advice regarding the risk of harmful effects on the child through treatment.

If you wish to become pregnant you should consult your doctor, who may refer you for specialist advice before the planned start of treatment.

Breast-feeding

Stop breast-feeding prior to and during treatment with Metoject PEN.

Male fertility

The available evidence does not indicate an increased risk of malformations or miscarriage if the father takes methotrexate less than 30 mg/week. However, a risk cannot be completely excluded. Methotrexate may be genotoxic. This means that the medicine may cause genetic mutation. Methotrexate can affect sperm production with the potential to cause birth defects. Therefore, you should avoid fathering a child or to donate semen whilst taking methotrexate and for at least 6 months after treatment is stopped.

Driving and using machines

Treatment with Metoject PEN may cause adverse reactions affecting the central nervous system, such as tiredness and dizziness. Thus the ability to drive a vehicle and/or to operate machines may, in certain cases, be compromised. If you feel tired or drowsy do not drive or use machines.

Metoject PEN contains sodium

This medicine contains less than 1 mmol sodium (23 mg) per dose; that is to say essentially “sodium-free”.

1. 3. How to use Metoject PEN

Always use this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.

Your doctor decides on the dose, which is adjusted individually to you. Usually it takes 4 – 8 weeks before there is any effect of the treatment.

Metoject PEN is administered subcutaneously (under the skin) by or under the supervision of a physician or healthcare staff as an injection once a week only. Together with your doctor you decide on a suitable weekday each week on which you receive your injection.

Use in children and adolescents

The doctor decides on the appropriate dose in children and adolescents with polyarthritic forms of juvenile idiopathic arthritis.

Metoject PEN is not recommended in children less than 3 years of age due to insufficient experience in this age group.

Method and duration of administration

Metoject PEN is injected once weekly!

The duration of the treatment is determined by the treating physician. Treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis vulgaris, psoriatic arthritis and Crohn’s disease with Metoject PEN is a long-term treatment.

At the start of your treatment, Metoject PEN may be injected by medical staff. However, your doctor may decide that you can learn how to inject Metoject PEN yourself. You will then receive appropriate training for you to do this.

Under no circumstances should you attempt to inject yourself, unless you have been trained to do so.

You can also find guidance on how to use Metoject PEN in the section “Instructions for use” at the end of this leaflet.

Please note that all of the contents have to be used.

The manner of handling and throwing away of the medicine and pre-filled pen must be in accordance with local requirements. Pregnant healthcare personnel should not handle and/or administer Metoject PEN.

Methotrexate should not come into contact with the surface of the skin or mucosa. In the event of contamination, the affected area must be rinsed immediately with plenty of water.

If you use more Metoject PEN than you should

If you use more Metoject PEN than you should, talk to your doctor immediately.

If you forget to use Metoject PEN

Do not take a double dose to make up for a forgotten dose.

If you stop using Metoject PEN

If you stop using Metoject PEN, talk to your doctor immediately.

If you have the impression that the effect of Metoject PEN is too strong or too weak, talk to your doctor or pharmacist.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

The frequency as well as the degree of severity of the side effects depends on the dosage level and the frequency of administration. As severe side effects may occur even at low dosage, it is important that you are monitored regularly by your doctor. Your doctor will do tests to check for abnormalities developing in the blood (such as low white blood cells, low platelets, lymphoma) and changes in the kidneys and the liver.

Tell your doctor immediately if you experience any of the following symptoms, as these may indicate a serious, potentially life-threatening side effect, which require urgent specific treatment:

• persistent dry, non-productive cough, shortness of breath and fever; these may be signs of an inflammation of the lungs [common]
• spitting or coughing blood; these might be signs of bleeding from the lungs [not known]
• symptoms of liver damage such as yellowing of the skin and whites of the eyes; methotrexate can cause chronic liver damage (liver cirrhosis), formation of scar tissue in the liver (liver fibrosis), fatty degeneration of the liver [all uncommon], inflammation of the liver (acute hepatitis) [rare] and liver failure [very rare]
• allergy symptoms such as skin rash including red itchy skin, swelling of the hands, feet, ankles, face, lips, mouth or throat (which may cause difficulty in swallowing or breathing) and feeling you are going to faint; these may be signs of severe allergic reactions or an anaphylactic shock [rare]
• symptoms of kidney damage such as swelling of the hands, ankles or feet or changes in frequency of urination or decrease (oliguria) or absence of urine (anuria); these may be signs of kidney failure [rare]
• symptoms of infections, e.g. fever, chills, achiness, sore throat; methotrexate can make you more susceptible to infections. Severe infections like a certain type of pneumonia (Pneumocystis jirovecii pneumonia) or blood poisoning (sepsis) may occur [rare]
• symptoms such as weakness of one side of the body (stroke) or pain, swelling, redness and unusual warmth in one of your legs (deep vein thrombosis); This may happen when a dislodged blood clot causes a blockage of a blood vessel (thromboembolic event) [rare]
• fever and serious deterioration of your general condition, or sudden fever accompanied by a sore throat or mouth, or urinary problems; methotrexate can cause a sharp fall in certain white blood cells (agranulocytosis) and severe bone marrow suppression [very rare]
• unexpected bleeding, e.g. bleeding gums, blood in the urine, vomiting blood or bruising, these can be signs of a severely reduced number of blood platelets caused by severe courses of bone marrow depression [very rare]
• symptoms such as severe headache often in combination with fever, neck stiffness, feeling sick, vomiting, disorientation and sensitivity to light may indicate an inflammation of the membranes of the brain (acute aseptic meningitis) [very rare]
• certain brain disorders (encephalopathy/ leukoencephalopathy) have been reported in cancer patients receiving methotrexate. Such side effects cannot be excluded when methotrexate therapy is used to treat other diseases. Signs of this kind of brain disorders may be altered mental state, movement disorders (ataxia), visual disturbances or disturbances of memory [not known]
• severe skin rash or blistering of the skin (this can also affect your mouth, eyes and genitals); these may be signs of conditions called Stevens Johnson syndrome or burned skin syndrome (toxic epidermal necrolysis/Lyell’s syndrome) [very rare]

In the following, please find the other side effects that may occur:

Very common: may affect more than 1 in 10 people

• Inflammation of the mouth lining, indigestion, feeling sick, loss of appetite, abdominal pain.
• Abnormal liver function test (ASAT, ALAT, bilirubin, alkaline phosphatase).

Important warning about the dose of Metoject PEN (methotrexate):

Use Metoject PEN only once a week for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis and psoriatic arthritis, and Crohn’s disease. Using too much of Metoject PEN (methotrexate) may be fatal. Please read section 3 of this leaflet very carefully. If you have any questions, please talk to your doctor or pharmacist before you take this medicine.

5. How to store Metoject PEN

• KEEP OUT OF THE SIGHT AND REACH OF CHILDREN.
• Do not store above 25°C.
• Keep the pre-filled pens in the outer carton in order to protect from light.
• Do not use this medicine after the expiry date stated on the carton and pre-filled pen after EXP. The expiry date refers to the last day of that month.
• Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.
• If your pre-filled pen shows any signs of deterioration, consult your doctor or pharmacist who will tell you what to do.

6. Contents of the pack and other information

What Metoject PEN contains

• The active substance is methotrexate.

  1 pre-filled pen with 0.15 ml solution contains 7.5 mg methotrexate.

  1 pre-filled pen with 0.2 ml solution contains 10 mg methotrexate.

  1 pre-filled pen with 0.25 ml solution contains 12.5 mg methotrexate.

  1 pre-filled pen with 0.3 ml solution contains 15 mg methotrexate.

  1 pre-filled pen with 0.35 ml solution contains 17.5 mg methotrexate.

• The other ingredients are sodium chloride, sodium hydroxide and hydrochloric acid for pH adjustment and water for injections.

What Metoject PEN looks like and contents of the pack

One pre-filled pen containing a clear, yellow-brown solution in pre-filled glass syringe with chlorobutyl rubber plunger stopper and embedded injection needle.

Metoject PEN is available in packs of 1 pre-filled pen.

Product Licence holder

Procured from within the EU and repackaged by the Product Licence holder: S&M Medical Ltd., Chemilines House, Alperton Lane, Wembley, HA0 1DX.

Manufacturer

This product is manufactured by medac Gesellschaft für klinische Spezialpräparate mbH, Theaterstr. 6, 22880 Wedel, Germany.

POM

PL: 19488/1796 Metoject^® PEN 7.5 mg solution for injection in pre-filled pen

PL: 19488/1797 Metoject^® PEN 10 mg solution for injection in pre-filled pen

PL: 19488/1798 Metoject^® PEN 12.5 mg solution for injection in pre-filled pen

PL: 19488/1799 Metoject^® PEN 15 mg solution for injection in pre-filled pen

PL: 19488/1800 Metoject^® PEN 17.5 mg solution for injection in pre-filled pen

Leaflet revision date: 17 March 2022

Blind or partially sighted? Is this leaflet hard to see or read? Call 02087997607 to obtain the leaflet in large print, tape, CD or Braille.

Metoject^® is a registered trade mark of medac Gesellschaft für klinische Spezialpräparate mbH, Germany.

S1796-1800 LEAFLET Metoject 20220317