1. Name Of The Medicinal Product
EVRA transdermal patch
2. Qualitative And Quantitative Composition
Each 20 cm2 transdermal patch contains 6 mg norelgestromin (NGMN) and 600 micrograms ethinyl estradiol (EE).
Each transdermal patch releases an average of 203 micrograms of NGMN and 33.9 micrograms of EE per 24 hours. Medicinal product exposure is more appropriately characterized by the pharmacokinetic profile (see section 5.2).
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Transdermal patch.
EVRA is a thin, matrix-type transdermal patch consisting of three layers.
The outside of the backing layer is beige and heat-stamped “EVRA”.
4. Clinical Particulars
4.1 Therapeutic Indications
Female contraception
EVRA is intended for women of fertile age. The safety and efficacy has been established in women aged 18 to 45 years.
4.2 Posology And Method Of Administration
Posology
To achieve maximum contraceptive effectiveness, patients must be advised to use EVRA exactly as directed. For initiation instructions see 'How to start EVRA' below.
Only one patch is to be worn at a time.
Each used patch is removed and immediately replaced with a new one on the same day of the week (Change Day) on Day 8 and Day 15 of the cycle. Patch changes may occur at any time on the scheduled Change Day. The fourth week is patch-free starting on Day 22.
A new contraceptive cycle begins on the next day following patch-free week; the next EVRA patch should be applied even if there has been no bleeding or if bleeding has not yet stopped.
Under no circumstances should there be more than a 7-day patch-free interval between dosing cycles. If there are more than 7 patch-free days, the user may not be protected against pregnancy. A non-hormonal contraceptive must then be used concurrently for 7 days. As with combined oral contraceptives, the risk of ovulation increases with each day beyond the recommended contraceptive-free period. If intercourse has occurred during such an extended patch-free interval, the possibility of fertilisation should be considered.
Method of administration
EVRA should be applied to clean, dry, hairless, intact healthy skin on the buttock, abdomen, upper outer arm or upper torso, in a place where it will not be rubbed by tight clothing. EVRA should not be placed on the breasts or on skin that is red, irritated or cut. Each consecutive patch should be applied to a different place on the skin to help avoid potential irritation, although they may be kept within the same anatomic site.
The patch should be pressed down firmly until the edges stick well.
To prevent interference with the adhesive properties of the patch, no make-up, creams, lotions, powders or other topical products should be applied to the skin area where the patch is placed or where it will be applied shortly.
It is recommended that users visually check their patch daily to ensure continued proper adhesion.
Used patches should be discarded carefully in accordance with the instructions given in section 6.6.
How to start EVRA
When there has been no hormonal contraceptive use in the preceding cycle
Contraception with EVRA begins on the first day of menses. A single patch is applied and worn for one full week (7 days). The day the first patch is applied (Day 1/Start Day) determines the subsequent Change Days. The patch Change Day will be on this day every week (cycle Days 8, 15, 22 and Day 1 of the next cycle) The fourth week is patch-free starting on Day 22.
If Cycle 1 therapy starts after first day of the menstrual cycle, a non-hormonal contraceptive should be used concurrently for the first 7 consecutive days of the first treatment cycle only.
When switching from an oral combined contraceptive
Treatment with EVRA should begin on the first day of withdrawal bleeding. If there is no withdrawal bleeding within 5 days of the last active (hormone containing) tablet, pregnancy must be ruled out prior to the start of treatment with EVRA. If therapy starts after the first day of withdrawal bleeding, a non-hormonal contraceptive must be used concurrently for 7 days.
If more than 7 days elapse after taking the last active oral contraceptive tablet, the woman may have ovulated and should, therefore, be advised to consult a physician before initiating treatment with EVRA. If intercourse has occurred during such an extended pill-free interval, the possibility of pregnancy should be considered.
When changing from a progestogen-only-method
The woman may switch any day from the minipill (from an implant on the day of its removal, from an injectable when the next injection would be due), but a back-up barrier method of birth control must be used during the first 7 days.
Following abortion or miscarriage
After an abortion or miscarriage that occurs before 20 weeks gestation, EVRA may be started immediately. An additional method of contraception is not needed if EVRA is started immediately. Be advised that ovulation may occur within 10 days of an abortion or miscarriage.
After an abortion or miscarriage that occurs at or after 20 weeks gestation, EVRA may be started either on Day 21 post-abortion or on the first day of the first spontaneous menstruation, whichever comes first. The incidence of ovulation on Day 21 post abortion (at 20 weeks gestation) is not known.
Following delivery
Users who choose not to breast-feed should start contraceptive therapy with EVRA no sooner than 4 weeks after child-birth. When starting later, the woman should be advised to additionally use a barrier method for the first 7 days. However, if intercourse has already occurred, pregnancy should be excluded before the actual start of EVRA or the woman has to wait for her first menstrual period.
For breast-feeding women, see section 4.6.
What to do if the patch comes off or partly detaches
If the EVRA patch partly or completely detaches and remains detached, insufficient medicinal product delivery occurs.
If EVRA remains even partly detached:
- for less than one day (up to 24 hours): it should be re-applied to the same place or replaced with a new EVRA patch immediately. No additional contraceptive is needed. The next EVRA patch should be applied on the usual “Change Day”.
- for more than one day (24 hours or more) or if the user is not aware when the patch has lifted or become detached: the user may not be protected from pregnancy: The user should stop the current contraceptive cycle and start a new cycle immediately by applying a new EVRA patch. There is now a new “Day 1” and a new “Change Day”. A non-hormonal contraceptive must be used concurrently for the first 7 days of the new cycle only.
A patch should not be reapplied if it is no longer sticky; a new patch should be applied immediately. Supplemental adhesives or bandages should not be used to hold the EVRA patch in place.
If subsequent EVRA patch change days are delayed
At the start of any patch cycle (Week One/Day 1):
The user may not be protected from pregnancy. The user should apply the first patch of the new cycle as soon as remembered. There is now a new patch “Change Day” and a new “Day 1”. A non-hormonal contraceptive must be used concurrently for the first 7 days of the new cycle. If intercourse has occurred during such an extended patch-free interval, the possibility of fertilisation should be considered.
In the middle of the cycle (Week Two/Day 8 or Week Three/Day 15):
- for one or two days (up to 48 hours): The user should apply a new EVRA patch immediately. The next EVRA patch should be applied on the usual “Change Day”. If during the 7 days preceding the first skipped day of patch application, the patch was worn correctly, no additional contraceptive use is required.
- for more than two days (48 hours or more): The user may not be protected from pregnancy. The user should stop the current contraceptive cycle and start a new four-week cycle immediately by putting on a new EVRA patch. There is now a new “Day 1” and a new “Change Day”. A non-hormonal contraceptive must be used concurrently for the first 7 consecutive days of the new cycle.
- at the end of the cycle (Week Four/Day 22): If the EVRA patch is not removed at the beginning of Week 4 (Day 22), it should be removed as soon as possible. The next cycle should begin on the usual “Change Day”, which is the day after Day 28. No additional contraceptive use is required.
Change Day adjustment
In order to postpone a menstrual period for one cycle, the woman must apply another patch at the beginning of Week 4 (Day 22) thus not observing the patch free interval. Breakthrough bleeding or spotting may occur. After 6 consecutive weeks of patch wear, there should be a patch free interval of 7 days. Following this, the regular application of EVRA is resumed.
If the user wishes to move the Change Day the current cycle should be completed, removing the third EVRA patch on the correct day. During the patch-free week a new Change Day may be selected by applying the first EVRA patch of the next cycle on the first occurrence of the desired day. In no case should there be more than 7 consecutive patch-free days. The shorter the patch-free interval, the higher the risk that the user does not have a withdrawal bleed and may experience breakthrough bleeding and spotting during the subsequent treatment cycle.
In case of minor skin irritation
If patch use results in uncomfortable irritation, a new patch may be applied to a new location until the next Change Day. Only one patch should be worn at a time.
Special populations
Body weight equal or greater than 90 kg: contraceptive efficacy may be decreased in women weighing equal or greater than 90 kg.
Renal impairment: EVRA has not been studied in women with renal impairment. No dose adjustment is necessary but as there is a suggestion in the literature that the unbound fraction of ethinyl estradiol is higher, EVRA should be used with supervision in this population.
Hepatic impairment: EVRA has not been studied in women with hepatic impairment. EVRA is contraindicated in women with hepatic impairment (see section 4.3).
Post-menopausal women: EVRA is not intended for use as hormonal replacement therapy.
Children and adolescents: EVRA is not recommended for use in children and adolescents under age 18 due to insufficient data on safety and efficacy.
4.3 Contraindications
EVRA should not be used in the presence of one of the following disorders. If one of these disorders occurs during the use of EVRA, EVRA must be discontinued immediately.
- Hypersensitivity to the active substances or to any of the excipients
- Presence or history of venous thrombosis, with or without the involvement of pulmonary embolism
- Presence or history of arterial thrombosis (e.g., cerebrovascular accident, myocardial infarction, retinal thrombosis) or prodrome of a thrombosis (e.g., angina pectoris or transient ischaemic attack)
- Migraine with focal aura
- The presence of serious or multiple risk factor(s) for the occurrence of arterial thrombosis:
- Severe hypertension (Persistent blood pressure values of
- Diabetes Mellitus with vascular involvement
- Hereditary dyslipoproteinemia
- Possible hereditary predisposition for venous or arterial thrombosis, such as activated protein C (APC-) resistance, antithrombin-III deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinemia, and antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant)
- Known or suspected carcinoma of the breast
- Carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia
- Abnormal liver function related to acute or chronic hepatocellular disease
- Hepatic adenomas or carcinomas
- Undiagnosed abnormal genital bleeding
4.4 Special Warnings And Precautions For Use
There is no clinical evidence indicating that a transdermal patch is, in any aspect, safer than combined oral contraceptives.
EVRA is not indicated during pregnancy (see section 4.6).
If any of the conditions/risk factors mentioned below is present, the benefits of the use of EVRA should be weighed against the possible risks for each individual woman and discussed with the woman before she decides to start using EVRA. In the event of aggravation, exacerbation or first appearance of any of these conditions or risk factors, the woman should be emphatically told to contact her physician who will decide on whether its use should be discontinued.
Thromboembolic and other vascular disorders
The use of any combined hormonal contraceptive, including EVRA, carries an increased risk of venous thromboembolism (deep vein thrombosis, pulmonary embolism) compared to no use. Epidemiological studies have shown that the incidence of venous thromboembolism (VTE) in women with no other risk factors for VTE who use low dose oestrogen (<50 micrograms ethinyl estradiol) combined contraceptives ranges from about 20 to 40 cases per 100,000 women-years, but this risk estimate varies according to the type of progestagen. This compares with 5 to 10 cases per 100,000 women-years for non-users and 60 cases per 100,000 pregnancies. VTE is fatal in 1%-2% of cases.
Data from a retrospective cohort study in women aged 15 to 44 years have suggested that the incidence of VTE in women who used EVRA is increased in comparison with users of a levonorgestrel-containing OC (so-called “second generation” OC).
The incidence was 1.4 fold (95% CI 0.9-2.3) increased in women with or without other risk factors for VTE and 1.5 fold (95% CI 0.8-2.7) increased in women with no other risk factors for VTE.
Epidemiological studies have also associated the use of combined oral contraceptives (COCs) with an increased risk for arterial (myocardial infarction, transient ischaemic attack, stroke) thromboembolism.
Extremely rarely, thrombosis has been reported to occur in other blood vessels e.g., hepatic, mesenteric, renal, cerebral or retinal veins and arteries, in COC users. There is no consensus as to whether the occurrence of these events is associated with the use of COCs.
Symptoms of venous or arterial thrombosis can include:
- Unilateral leg pain, and/or swelling
- Sudden severe pain in the chest with possible radiation to the left arm
- Sudden breathlessness, sudden onset of coughing without a clear cause
- Any unusual, severe, prolonged headache
- Sudden partial or complete loss of vision
- Diplopia
- Slurred speech or aphasia
- Vertigo; collapse with or without focal seizure
- Weakness or very marked numbness suddenly affecting one side or one part of the body
- Motor disturbances
- 'Acute' abdominal pain
The risk of venous thromboembolism in combined contraceptives users increases with:
- Increasing age
- A positive family history (i.e. venous thromboembolism ever in a sibling or parent at relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any hormonal contraceptive use
- Prolonged immobilisation, major surgery to the legs, or major trauma. In these situations it is advisable to discontinue use (in the case of elective surgery at least 4 weeks in advance) and not to resume until two weeks after complete remobilisation
- Obesity (body mass index over 30 kg/m²)
- Possibly also with superficial thrombophlebitis and varicose veins. There is no consensus about the possible role of these conditions in the aetiology of venous thrombosis.
The risk of arterial thromboembolic complications in combined contraceptives users increases with:
- Increasing age;
- Smoking (with heavier smoking and increasing age the risk further increases, especially in women over 35 years of age);
- Dyslipoproteiniaemia;
- Obesity (body mass index over 30 kg/m²);
- Hypertension;
- Valvular heart disease;
- Atrial fibrillation;
- A positive family history (arterial thrombosis ever in a sibling or parent at a relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any hormonal contraceptive use.
Biochemical factors that may be indicative of hereditary or acquired predisposition for venous or arterial thrombosis include Activated Protein C (APC) resistance, hyper homocysteinaemia, antithrombin-III deficiency, protein C deficiency, protein S deficiency, antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant).
Other medical conditions, which have been associated with adverse circulatory events, included diabetes mellitus, systemic lupus erythematosus, haemolytic uraemic syndrome, chronic inflammatory bowel disease (e.g., Crohn's disease or ulcerative colitis).
The increased risk for thromboembolism in the puerperium must be considered (see section 4.6).
An increase in frequency or severity of headache (which may be prodromal of a cerebrovascular event) may be a reason for immediate discontinuation of combination contraceptives.
Women using combined contraceptives should be emphatically advised to contact their physician in case of possible symptoms of thrombosis. In case of suspected or confirmed thrombosis, hormonal contraceptive use should be discontinued. Adequate contraception should be initiated because of the teratogenicity of anti-coagulant therapy (coumarins).
Tumours
An increased risk of cervical cancer in long-term users of COCs has been reported in some epidemiological studies, but there continues to be controversy about the extent to which this finding is attributable to the compounding effects of sexual behaviour and other factors such as human papilloma virus (HPV).
A meta-analysis of 54 epidemiological studies reported that there is a slightly increased risk (RR = 1.24) of having breast cancer diagnosed in women who are currently using COCs. The excess risk gradually disappears during the course of the 10 years after cessation of COC use. Because breast cancer is rare in women under 40 years of age, the excess number of breast cancer diagnoses in current and recent COC users is small in relation to the overall risk of breast cancer. The breast cancers diagnosed in ever-users tend to be less advanced clinically than the cancers diagnosed in never-users. The observed pattern of increased risk may be due to an earlier diagnosis of breast cancer in COC users, the biological effects of COCs or a combination of both.
In rare cases, benign liver tumours, and even more rarely, malignant liver tumours have been reported in users of COCs. In isolated cases, these tumours have led to life-threatening intra-abdominal haemorrhages. Therefore a hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal haemorrhage occur in women using EVRA.
Other conditions
- Contraceptive efficacy may be reduced in women weighing equal or greater than 90 kg (see sections 4.2 and 5.1).
- Women with hypertriglyceridaemia, or a family history thereof, may be at an increased risk of pancreatitis when using combination hormonal contraceptives.
- Although small increases of blood pressure have been reported in many women using hormonal contraceptives, clinically relevant increases are rare. A definitive relationship between hormonal contraceptive use and clinical hypertension has not been established. If, during the use of a combination hormonal contraceptive in pre-existing hypertension, constantly elevated blood pressure values or a significant increase in blood pressure do not respond adequately to antihypertensive treatment, the combination hormonal contraceptive must be withdrawn. Combination hormonal contraceptive use may be resumed if normotensive values can be achieved with antihypertensive therapy.
- The following conditions have been reported to occur or deteriorate with both pregnancy and COC use, but the evidence of an association with COC use is inconclusive: Jaundice and/or pruritus related to cholestasis; gallstones; porphyria; systemic erythematosus; haemolytic ureamic syndrome; Sydenham's chorea; herpes gestationis; otosclerosis-related hearing loss.
- Acute or chronic disturbances of liver function may necessitate the discontinuation of combination hormonal contraceptives until markers of liver function return to normal. Recurrence of cholestatic-related pruritus, which occurred during a previous pregnancy or previous use of sex steroids necessitates the discontinuation of combination hormonal contraceptives.
- Although combined hormonal contraceptives may have an effect on peripheral insulin resistance and glucose tolerance there is no evidence for a need to alter the therapeutic regimen in diabetes during use of combined hormonal contraception. However, diabetic women should be carefully observed, particularly in the early stage of EVRA use.
- Worsening of endogenous depression, of epilepsy, of Crohn's disease and of ulcerative colitis has been reported during COC use.
- Chloasma may occasionally occur with the use of hormonal contraception, especially in users with a history of chloasma gravidarum. Users with a tendency to chloasma should avoid exposure to the sun or ultraviolet radiation while using EVRA. Chloasma is often not fully reversible.
Medical examination/consultation
Prior to the initiation or reinstitution of EVRA a complete medical history (including family history) should be taken and pregnancy should be ruled out. Blood pressure should be measured and a physical examination should be performed guided by the contraindications (see section 4.3) and warnings (see section 4.4). The woman should also be instructed to carefully read the package leaflet and to adhere to the advice given.
The frequency and nature of subsequent examinations should be based on established guidelines and be adapted to the individual woman on the basis of clinical impression.
Women should be advised that hormonal contraceptives do not protect against HIV infections (AIDS) and other sexually transmissible diseases.
Bleeding irregularities
With all combination hormonal contraceptives, irregular blood loss (spotting or breakthrough bleeding) can occur, especially during the initial months of usage. For this reason, a medical opinion on irregular blood loss will only be useful after an adjustment period of approximately three cycles. If breakthrough bleeding persists, or breakthrough bleeding occurs after previously regular cycles, while EVRA has been used according the recommended regimen, a cause other than EVRA should be considered. Non-hormonal causes should be considered and, if necessary, adequate diagnostic measures taken to rule out organic disease or pregnancy. This may include curettage. In some women withdrawal bleeding may not occur during this patch free period. If EVRA has been taken according to the directions described in section 4.2, it is unlikely that the woman is pregnant. However, if EVRA has not been taken according to these directions prior to the first missed withdrawal bleed or if two withdrawal bleeds are missed, pregnancy must be ruled out before EVRA use is continued.
Some users may experience amenorrhoea or oligomenorrhoea after discontinuing hormonal contraception, especially when such a condition was pre-existent.
Herbal preparations containing St John's Wort (Hypericum perforatum) should not be used while taking EVRA (see section 4.5)
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Note: The prescribing information of concomitant medications should be consulted to identify potential interactions.
• Influence of other medicinal products on EVRA
Interactions between oral contraceptives and other medicinal products may lead to breakthrough bleeding and/or contraceptive failure. The following interactions have been reported in the literature.
Hepatic metabolism
Interactions can occur with drugs that induce hepatic enzymes which can result in increased clearance of sex hormones (e.g. phenytoin, barbiturates, primidone, carbamazepine, rifampicin, bosentan and HIV-medication (e.g. ritonavir, nevirapine) and possibly also oxcarbazepine, topiramate, felbamate, griseofulvin and products containing the herbal remedy St. John's Wort (hypericum perforatum)). Maximal enzyme induction is generally seen in about 10 days but may then be sustained for at least 4 weeks after the cessation of drug therapy.
Interference with Enterohepatic Circulation
Contraceptive failures have also been reported with antibiotics, such as penicillins and tetracyclines. The mechanism of this effect has not been elucidated. In a pharmacokinetic interaction study, oral administration of tetracycline hydrochloride, 500 mg four times daily for 3 days prior to and 7 days during wear of EVRA, did not significantly affect the pharmacokinetics of norelgestromin or EE.
Management
Women on short-term treatment with any of the above-mentioned classes of medicinal products or individual active substances (hepatic enzyme-inducing medicine) besides rifampicin should temporarily use a barrier method in addition to EVRA, i.e. during the time of concomitant medicinal product administration and for 7 days after their discontinuation.
For women on rifampicin a barrier method should be used in addition to EVRA during the time of rifampicin administration and for 28 days after its discontinuation.
In women on long-term treatment with hepatic enzyme-inducing active substances, another reliable, non-hormonal, method of contraception is recommended.
Women on treatment with antibiotics (besides rifampicin, see above) should use the barrier method until 7 days after discontinuation.
If concomitant medicinal product administration runs beyond the end of the one-week wear period, the next patch should be applied without the usual patch-free interval.
• Influence of EVRA on other medicinal products
Hormonal contraceptives may affect the metabolism of certain other active substances. Accordingly, plasma and tissue concentrations may either increase (e.g. ciclosporin) or decrease (e.g. lamotrigine).
• Laboratory tests
The use of contraceptive steroids may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, plasma levels of (carrier) proteins, e.g. corticosteroid-binding globulin and lipid/lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. Changes generally remain within the normal laboratory range.
4.6 Pregnancy And Lactation
EVRA is not indicated during pregnancy.
Epidemiological studies indicate no increased risk of birth defects in children born to women who used hormonal contraceptives prior to pregnancy. The majority of recent studies also do not indicate a teratogenic effect when hormonal contraceptives are used inadvertently during early pregnancy.
For EVRA there are no clinical data on exposed pregnancies, which allow conclusions about its safety during pregnancy.
Studies in animals have shown reproductive toxicity (see section 5.3). On the basis of available data, a potential risk of masculinisation as a consequence of an exaggerated hormonal action cannot be excluded.
If pregnancy occurs during use of EVRA, EVRA should be stopped immediately.
Lactation may be influenced by combination hormonal contraceptives as they may reduce the quantity and change the composition of breast milk. Therefore, the use of EVRA is not to be recommended until the breast-feeding mother has completely weaned her child.
4.7 Effects On Ability To Drive And Use Machines
EVRA has no or negligible influence on the ability to drive and use machines.
4.8 Undesirable Effects
4.8.1 Clinical Trial Data
The most commonly reported adverse drug reactions (ADRs) in clinical trials were headache, nausea, and breast tenderness, occurring in approximately 21.0%, 16.6%, and 15.9% of patients, respectively.
Frequency estimate: very common (
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4.8.2 Postmarketing Data
Additional adverse drug reactions first identified during postmarketing experience with EVRA are listed below:
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