EVOREL^® SEQUI

International non-proprietary names

estradiol

norethisterone acetate

EVOREL^® SEQUI is a transdermal therapy comprising

EVOREL^® SEQUI is composed of EVOREL^® 50 and EVOREL^® CONTI. Both EVOREL^® 50 and EVOREL^® CONTI are a Transdermal Delivery System (TDS), or transdermal patch, composed of a flat two-layer laminate which is 0.1 mm in thickness. The first layer is a flexible, translucent, and nearly colourless backing film. The second layer is a monolayer adhesive film (matrix) composed of acrylic adhesive and guar gum and contains the hormones. This system is protected by a polyester foil release liner, which is affixed to the adhesive matrix and is removed prior to application of the patch to the skin. The polyester foil used is coated with silicone on both sides. The release liner has an S-shaped opening to facilitate its removal prior to use. Each TDS is enclosed in a protective, hermetically-sealed sachet.

EVOREL^® CONTI has a surface area of 16 sq cm and contains 3.2 mg of estradiol corresponding to a nominal release of 50 micrograms of estradiol per 24 hours and 11.2 mg of norethisterone acetate corresponding to a nominal release of 170 micrograms of norethisterone acetate per 24 hours. Each EVOREL Conti patch is marked in the centre of the lower margin on the outside of the backing film: CENI.

EVOREL^® 50 has a surface area of 16 sq cm and contains 3.2 mg of estradiol corresponding to a nominal release of 50 micrograms of estradiol per 24 hours. The release liner of EVOREL^® 50 is aluminised on one side. Each EVOREL 50 patch is marked in the centre of the lower margin of the outside of the backing film: CE50.

Hormone replacement therapy (HRT) for oestrogen deficiency symptoms in peri- and post-menopausal women.

Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis. (See also Section 4.4)

The experience treating women older than 65 years is limited.

Adults

Evorel Sequi is a continuous sequential HRT preparation. Patches are applied to the skin twice weekly.

One Evorel Sequi patch should be worn at all times, without interruptions. For initiation and continuation of treatment of menopausal symptoms, the lowest effective dose for the shortest duration (see also Section 4.4) should be used.

Guidance on how to start therapy:

Any previous therapy with HRT must be stopped prior to starting Evorel Sequi.

Post-menopausal women currently not on HRT may start Evorel Sequi at any time.

Peri-menopausal women who are still having regular menstrual cycles and are not currently on HRT should start Evorel Sequi within 5 days of the start of bleeding. Peri-menopausal women with irregular menstrual cycles, for whom pregnancy has been excluded, can start Evorel Sequi at any time.

Switching from other HRT

Women on a continuous combined regimen wishing to switch from another oestrogen to Evorel Sequi may do so at any time.

Women on a cyclic or continuous sequential regimen wishing to switch from a sequential combined HRT preparation to Evorel Sequi may do so at the end of a cycle of the current therapy or after a 7 day hormone free interval.

Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women.

Method of Administration

A treatment cycle with Evorel Sequi is 28 days. During the first 14 days, one estradiol-only (Evorel 50) patch should be worn at all times, without interruption. During days 15-28, one estradiol + norethisterone (Evorel Conti) patch should be worn at all times, without interruption. A subsequent treatment cycle should follow immediately, without a treatment free interval.

Patches should be applied to the trunk, below the waist. Patches should be changed twice a week, i.e. every three to four days. Application of a new patch should be to a site different from the previous application site. The patch should not be applied on or near the breasts.

Evorel should remain in place during bathing and showering. Should it fall off during bathing or showering the patient should wait until cutaneous vasodilation ceases before applying a replacement patch to avoid potential excessive absorption. Should a patch fall off at other times it should be replaced immediately.

Missed dose

If the patient forgets to change their patch, they should change it as soon as possible and apply the next one at the normal time. However, if it is almost time for the next patch, the patient should skip the missed one and go back to their regular schedule. Only one patch should be applied at a time.

Wearing a patch for more than 4 days by mistake or any period without a patch may increase the likelihood of breakthrough bleeding or spotting.

Children

Evorel Sequi is not indicated in children.

Elderly

Data are insufficient in regard to the use of Evorel Sequi in the elderly (>65 years old).

Route of administration

Transdermal use.

Known, past or suspected breast cancer

Known or suspected estrogen-dependent malignant tumours (eg endometrial cancer)

Undiagnosed genital bleeding

Untreated endometrial hyperplasia

Previous idiopathic or current venous thrombo-embolism (deep venous thrombosis, pulmonary embolism)

Active or recent arterial thrombo-embolic disease (eg angina, myocardial infarction)

Acute liver disease, or a history of liver disease as long as liver function tests have failed to return to normal

Known hypersensitivity to the active substances or to any of the excipients

Porphyria

For the treatment of menopausal symptoms, HRT should only be initiated for symptoms that adversely affect quality of life. In all cases, a careful appraisal of the risks and benefits should be undertaken at least annually and HRT should only be continued as long as the benefit outweighs the risk

Medical examination/follow-up

Before initiating or re-instituting HRT, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contra-indications and warnings for use. During treatment, periodic check-ups are recommended of a frequency and nature adapted to the individual woman. Women should be advised what changes in their breasts should be reported to their doctor or nurse (see 'Breast cancer' below). Investigations, including mammography, should be carried out in accordance with currently accepted screening practices, modified to the clinical needs of the individual.

Conditions which need supervision

If any of the following conditions are present, have occurred previously, and/or have been aggravated during pregnancy or previous hormone treatment, the patient should be closely supervised. It should be taken into account that these conditions may recur or be aggravated during treatment with Evorel Sequi, in particular:

Leiomyoma (uterine fibroids) or endometriosis

A history of, or risk factors for, thrombo-embolic disorders (see below)

Risk factors for oestrogen dependent tumours, eg 1^st degree heredity for breast cancer

Hypertension

Liver disorders (eg liver adenoma)

Diabetes mellitus with or without vascular involvement

Cholelithiasis

Migraine or (severe) headache

Systemic lupus erythematosus

A history of endometrial hyperplasia (see below)

Epilepsy

Asthma

Otosclerosis

Hereditary angiodema

Reasons for immediate withdrawal of therapy:

Therapy should be discontinued if a contra-indication is discovered and in the following situations:

Jaundice or deterioration in liver function

Significant increase in blood pressure

New onset of migraine-type headache

Pregnancy

Endometrial hyperplasia

The risk of endometrial hyperplasia and carcinoma is increased when oestrogens are administered alone for prolonged periods (see Section 4.8). The addition of a progestogen for at least 12 days per cycle in non-hysterectomised women greatly reduces this risk.

Break-through bleeding and spotting may occur during the first months of treatment. If break-through bleeding or spotting appears after some time on therapy, or continues after treatment has been discontinued, the reason should be investigated, which may include endometrial biopsy to exclude endometrial malignancy.

Breast cancer

A randomised placebo-controlled trial, the Women's Health Initiative (WHI) and epidemiological studies, including the Million Women Study (MWS) have reported an increased risk of breast cancer in women taking oestrogens or oestrogen-progestogen combinations or tibolone for HRT for several years (see Section 4.8). For all HRT, an excess risk becomes apparent within a few years of use and increases with duration of intake but returns to baseline within a few (at most five) years after stopping treatment.

In the MWS, the relative risk of breast cancer with conjugated equine oestrogens (CEE) or estradiol (E2) was greater when a progestogen was added, either sequentially or continuously, and regardless of type of progestogen. There was no evidence of a difference in risk between the different routes of administration.

In the WHI study, the continuous combined conjugated equine estrogen and medroxyprogesterone acetate (CEE + MPA) product used was associated with breast cancers that were slightly larger in size and more frequently had local lymph node metastases compared to placebo.

HRT, especially oestrogen-progestogen combined treatment, increases the density of mammographic images which may adversely affect the radiological detection of breast cancer.

Venous thrombo-embolism

HRT is associated with a higher relative risk of developing venous thrombo-embolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. One randomised controlled trial and epidemiological studies found a two- to threefold higher risk for users compared with non-users. For non-users it is estimated that the number of cases of VTE that will occur over a 5 year period is about 3 per 1000 women aged 50-59 years and 8 per 1000 women aged 60-69 years. It is estimated that in healthy women who use HRT for 5 years, the number of additional cases of VTE over a 5 year period will be between 2 and 6 (best estimate =4) per 1000 women aged 50-59 years and between 5 and 15 (best estimate =9) per 1000 women aged 60-69 years. The occurrence of such an event is more likely in the first year of HRT than later.

Generally recognised risk factors for VTE include a personal history or family history, severe obesity (BMI > 30 kg/m²) and systemic lupus erythematosus (SLE). There is no consensus about the possible role of varicose veins in VTE.

Patients with a history of VTE or known thrombophilic states have an increased risk of VTE. HRT may add to this risk. Personal or strong family history of thrombo-embolism or recurrent spontaneous abortion should be investigated in order to exclude a thrombophilic predisposition. Until a thorough evaluation of thrombophilic factors has been made or anticoagulant treatment initiated, use of HRT in such patients should be viewed as contra-indicated. The women already on anticoagulant treatment require careful consideration of the benefit-risk of use of HRT.

The risk of VTE may be temporarily increased with prolonged immobilisation, major trauma or major surgery. As in all postoperative patients, scrupulous attention should be given to prophylactic measures to prevent VTE following surgery. Where prolonged immobilisation is liable to follow elective surgery, particularly abdominal or orthopaedic surgery to the lower limbs, consideration should be given to temporarily stopping HRT 4 to 6 weeks earlier, if possible. Treatment should not be restarted until the woman is completely mobilised.

If VTE develops after initiating therapy, the drug should be discontinued. Patients should be told to contact their doctors immediately when they are aware of a potential thrombo-embolic symptom (eg, painful swelling of a leg, sudden pain in the chest, dyspnoea).

Coronary artery disease (CAD)

There is no evidence from randomised controlled trials of cardiovascular benefit with continuous combined conjugated estrogens and medroxyprogesterone acetate MPA. Two large clinical trials (WHI and HERS i.e. Heart and Oestrogen/progestin Replacement Study) showed a possible increased risk of cardiovascular morbidity in the first year of use and no overall benefit. For other HRT products there are only limited data from randomised controlled trials examining effects in cardiovascular morbidity or mortality. Therefore, it is uncertain whether these findings also extend to other HRT products.

Stroke

One large randomised clinical trial (WHI-trial) found, as a secondary outcome, an increased risk of ischaemic stroke in healthy women during treatment with continuous combined conjugated oestrogens and MPA. For women who do not use HRT, it is estimated that the number of cases of stroke that will occur over a 5 year period is about 3 per 1000 women aged 50-59 years and 11 per 1000 women aged 60-69 years. It is estimated that for women who use conjugated oestrogens and MPA for 5 years, the number of additional cases will be between 0 and 3 (best estimate = 1) per 1000 users aged 50-59 years and between 1 and 9 (best estimate = 4) per 1000 users aged 60-69 years. It is unknown whether the increased risk also extends to other HRT products.

Ovarian cancer

Long-term (at least 5-10 years) use of oestrogen-only HRT products in hysterectomised women has been associated with an increased risk of ovarian cancer in some epidemiological studies. It is uncertain whether long-term use of combined HRT confers a different risk than oestrogen-only products.

Other conditions

Oestrogens may cause fluid retention, and therefore patients with cardiac or renal dysfunction should be carefully observed. Patients with terminal renal insufficiency should be closely observed, since it is expected that the level of circulating active ingredients in Evorel Sequi is increased.

Women with pre-existing hypertriglyceridaemia should be followed closely during oestrogen replacement or hormone replacement therapy, since rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with oestrogen therapy in this condition.

Oestrogens increase thyroid binding globulin (TBG), leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T4 levels (by column or radio-immunoassay) or T3 levels (by radio-immunoassay). T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are unaltered. Other binding proteins may be elevated in serum, i.e. corticoid binding globulin (CBG), sex-hormone-binding globulin (SHBG) leading to increased circulating corticosteroids and sex steroids, respectively. Free or biological active hormone concentrations are unchanged. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-l-antitrypsin, ceruloplasmin).

Chloasma may occasionally occur, especially in women with a history of chloasma gravidarum. Women with a tendency to chloasma should minimise exposure to the sun or ultraviolet radiation whilst taking HRT.

There is no conclusive evidence for improvement of cognitive function. There is some evidence from the WHI trial of increased risk of probable dementia in women who start using continuous combined CEE and MPA after the age of 65. It is unknown whether the findings apply to younger post-menopausal women or other HRT products.

Evorel Sequi is not to be used for contraception. Women of child-bearing potential should be advised to use non-hormonal contraceptive methods to avoid pregnancy.

The metabolism of oestrogens and progestogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants (e.g. phenobarbital, phenytoin, carbamazepine) and anti-infectives (e.g. rifampicin, rifabutin, nevirapine, efavirenz) and also bosentan.

Ritonavir and nelfinavir, although known as strong inhibitors, by contrast exhibit inducing properties when used concomitantly with steroid hormones. Herbal preparations containing St. John's Wort (Hypericum perforatum) may raise the metabolism of oestrogens and progestogens.

With transdermal administration, the first-pass effect in the liver is avoided and thus, transdermally applied oestrogens and progestogens might be less affected by enzyme inducers than oral hormones.

Clinically, an increased metabolism of oestrogens and progestogens may lead to decreased effect and changes in the uterine bleeding profile.

Estrogen-containing oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine when co-administered due to induction of lamotrigine glucuronidation. This may reduce seizure control. Although the potential interaction between estrogen-containing hormone replacement therapy and lamotrigine has not been studied, it is expected that a similar interaction exists, which may lead to a reduction in seizure control among women taking both drugs together. Therefore, dose adjustment of lamotrigine may be necessary.

Pregnancy

Evorel Sequi is not indicated during pregnancy. If pregnancy occurs during use of Evorel Sequi, treatment should be withdrawn immediately.

Data on a limited number of exposed pregnancies indicate adverse effects of norethisterone on the foetus. At doses higher than normally used in oral contraceptives and HRT formulations masculinisation of female foetuses was observed.

The results of most epidemiological studies to date relevant to inadvertent foetal exposure to combinations of oestrogens and progestogens indicate no teratogenic or foetotoxic effect.

Lactation

Evorel Sequi is not indicated during lactation.

There are no known data on the effects of Evorel Sequi on the ability to drive or use machinery.

The safety of Evorel® Sequi was evaluated in 165 subjects who participated in 2 clinical trials. Based on safety data from these clinical trials, the most commonly reported (5% incidence) adverse drug reactions (ADRs) were (with % incidence): application site reaction (14.6%), headache (7.9%), breast pain (6.1%), and depression (5.5%).

Including the above-mentioned ADRs, the following table displays ADRs that have been reported with the use of Evorel® Sequi from either clinical trial or post-marketing experiences, and additional ADRs that have been reported with the use of Evorel® (estradiol alone) from clinical trial data. The displayed frequency categories use the following convention:

Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); very rare (<1/10,000); and not known (cannot be estimated from the available clinical trial data).

Adverse Drug Reactions

* Additional adverse drug reactions reported in clinical trials of Evorel®^® (estradiol only).

Breast Cancer

According to evidence from a large number of epidemiological studies and one randomised placebo-controlled trial, the Women's Health Initiative (WHI), the overall risk of breast cancer increases with increasing duration of HRT use in current or recent HRT users.

For oestrogen-only HRT, estimates of relative risk (RR) from a reanalysis of original data from 51 epidemiological studies (in which >80% of HRT use was oestrogen-only HRT) and from the epidemiological Million Women Study (MWS) are similar at 1.35 (95% CI 1.21-1.49) and 1.30 (95% CI 1.21-1.40), respectively.

For oestrogen plus progestogen combined HRT, several epidemiological studies have reported an overall higher risk for breast cancer than with oestrogens alone.

The MWS reported that, compared to never users, the use of various types of oestrogen-progestogen combined HRT was associated with a higher risk of breast cancer (RR = 2.00, 95%CI: 1.88-2.12) than use oestrogens alone (RR = 1.30, 95% CI: 1.21-1.40) or use of tibolone (RR =1.45; 95% CI 1.25-1.68).

The WHI trial reported a risk estimate of 1.24 (95% CI: 1.01-1.54) after 5.6 years of use of oestrogen-progestogen combined HRT (CEE +MPA) in all users compared with placebo.

The absolute risks calculated from the MWS and the WHI trial are presented below:

The MWS has estimated, from the known average incidence of breast cancer in developed countries, that:

For women not using HRT, about 32 in every 1000 are expected to have breast cancer diagnosed between the ages of 50 and 64 years.

For 1000 current or recent users of HRT, the number of additional cases during the corresponding period will be

The WHI trial estimated that after 5.6 years of follow-up of women between the ages of 50 and 79 years, an additional 8 cases of invasive breast cancer would be due to oestrogen-progestogen combined HRT (CEE + MPA) per 10 000 women years.

According to calculations from the trial data, it is estimated that:

The number of additional cases of breast cancer in women who use HRT is broadly similar for women who start HRT irrespective of age at start of use (between the ages of 45-65) (see section 4.4).

Endometrial Cancer

In women with an intact uterus, the risk of endometrial hyperplasia and endometrial cancer increases with increasing duration of use of unopposed oestrogens. According to data from epidemiological studies, the best estimate of the risk is that for women not using HRT, about 5 in every 1000 are expected to have endometrial cancer diagnosed between the ages of 50 and 65. Depending on the duration of treatment and oestrogen dose, the reported increase in endometrial cancer risk among unopposed oestrogen users varies from 2- to 12-fold greater compared with non-users. Adding a progestogen to oestrogen-only therapy greatly reduces this increased risk.

Other adverse events have been reported in association with oestrogen/progestogen treatment:

Venous thrombo-embolism, ie deep leg or pelvic venous thrombosis and pulmonary embolism, is more frequent among hormone HRT users than among non-users. For further information see Sections 4.3 Contraindications and 4.4 Special Warnings and Special Precautions for use.

Symptoms of overdose of oestrogen and progestogen therapy may include nausea, vomiting, break-through bleeding, breast tenderness, abdominal cramps and/or bloating. There is no specific antidote and treatment should be symptomatic. These symptoms can be reversed by removing the patch.

ATC code: G03F B05

Estradiol hemihydrate:

The active ingredient, synthetic estradiol, is chemically and biologically identical to endogenous human estradiol. It substitutes for the loss of oestrogen production in menopausal women, and alleviates menopausal symptoms. Oestrogens prevent bone loss following menopause or ovariectomy.

Norethisterone:

As oestrogens promote the growth of the endometrium, unopposed oestrogens increase the risk of endometrial hyperplasia and cancer. The addition of a progestogen reduces the oestrogen-induced risk of endometrial hyperplasia in non-hysterectomised women.

Clinical trial information:

Relief of oestrogen-deficiency symptoms and bleeding patterns:

Relief of menopausal symptoms was achieved during the first few weeks of treatment with Evorel Sequi.

Regular withdrawal bleeding occurs in over 95% of women using Evorel Sequi. Two thirds of treatment cycles have only one bleeding episode of a median duration of five days. Where secondary bleeding episodes occurred, they were shorter with a median duration of 1.5 days.

Prevention of osteoporosis

Oestrogen deficiency at menopause is associated with increasing bone turnover and decline in bone mass. The effect of oestrogens on the bone mineral density (BMD) is dose-dependent. Protection appears to be effective as long as treatment is continued. After discontinuation of HRT, bone mass is lost at a rate similar to that in untreated women.

Evidence from the WHI trial and meta-analysed trials shows that current use of HRT, alone or in combination with a progestogen – given to predominantly healthy women – reduces the risk of hip, vertebral, and other osteoporotic fractures. HRT may also prevent fractures in women with low bone density and/ or established osteoporosis, but the evidence for that is limited.

Evorel Sequi was not tested for effects on bone mineral density (BMD). However, information is available on the efficacy of the two constituents of Evorel Sequi (Evorel 50 and Evorel Conti).

After two years of treatment with Evorel 50, the increase in lumbar spine bone mineral density (BMD) was 4.46 ± 4.04 % (mean±SD). The percentage of women who maintained or gained BMD in the lumbar zone during treatment was 84%.

Evorel 50 also had an effect on hip BMD. The increase in BMD in the femoral neck was 1.26 ± 2.86 % and the percentage of women maintaining or gaining BMD in the femoral neck was 65%. In the total hip, the increase in BMD was 2.17 ± 2.33 % (mean±SD) with 93% women maintaining or gaining BMD.

After one year of treatment with Evorel Conti, the increase in lumbar spine bone mineral density (BMD) was 2.94 ± 2.62 % (mean±SD). The percentage of women who maintained or gained BMD in the lumbar zone during treatment was 90%.

Evorel Conti also had an effect on hip BMD. The increase in BMD in the femoral neck was 2.42 ± 3.04 % and the percentage of women maintaining or gaining BMD in the femoral neck was 82%. In the total hip, the increase in BMD was 1.73 ± 2.55 % (mean±SD) with 74% women maintaining or gaining in BMD.

The estradiol hemihydrate of the patch is taken up through the skin as estradiol. Estradiol is metabolised primarily in the liver to estrone, which has weak estrogenic activity. Estrone is either conjugated with glucuronic or sulphuric acid or reconverted to estradiol. Conjugates are excreted mainly by the kidneys. The estradiol / estrone ratio on use of Evorel 50 and Evorel Conti is close to one, similar to pre-menopausal women. Estradiol circulates in the blood bound to sex hormone binding globulin (35-45%) and albumin (60-65%).

Norethisterone acetate is cleaved immediately on resorption to yield norethisterone. Norethisterone distributes widely in the body and circulates bound to sex hormone binding globulin (about 36%) and albumin (about 61%). It is metabolised mainly in the liver. Metabolites are conjugated with glucuronic or sulfuric acid. Conjugates are excreted in faeces and urine.

The metabolism of both estradiol and norethisterone in the liver is mediated primarily by the P450 enzyme system. See Section 4.5, Interactions with other medicinal products and other forms of interaction.

Due to the transdermal administration, there is no noticeable first-pass effect.

Estradiol pharmacokinetics

Upon use of an estradiol-only patch (Evorel 50), serum estradiol levels rise within 11 hours (T_max, multiple application) from pre-treatment levels by an average of 316 pmol/L (86 pg/mL) (C_max, multiple application). The 95% confidence interval ranges from 150 to 484 pmol/L (42-132 pg/mL). Levels decrease over 3.5 days to an average of 77 pmol/L (21 pg/mL). When patch use is discontinued, serum estradiol levels decrease with a half-life of 6.6 hours. 24 hours after patch removal, pre-treatment levels are again observed.

On use of an estradiol+norethisterone patch (Evorel Conti), serum estradiol levels rise from pre-treatment levels within 21 hours from patch change (T_max, multiple application) by an average of 121 pmol/L (33 pg/mL) (C_max, multiple applications). The 95% confidence interval for C_max ranges from 77 to 165 pmol/L (21 to 45 pg/mL). 24 hours after patch removal, baseline levels are again observed.

Norethisterone pharmacokinetics

On first use of Evorel Conti by post-menopausal women, serum norethisterone levels rise over 37 hours (T_max, single application) to 706 pmol/L (240 pg/mL)(C_max, single application) and then decrease to 420 pmol/L (143 pg/mL) at day 3.5. On patch change, levels rise again over 22 hours (T_max, multiple applications) to 756 pmol/L (257 pg/mL)(C_max, multiple applications). When patch use is discontinued, norethisterone levels decrease with a half-life of ~15 hours.

Preclinical effects were observed at exposures considered sufficiently in excess of the maximum human exposure, or were related to an exaggerated pharmacological effect, or were related to differences between species regarding hormonal regulation/metabolism and indicate little relevance to clinical use.

Norethisterone, like other progestogens, caused virilisation of female foetuses in rats and monkeys. After high doses of norethisterone embryolethal effects were observed.

Local tolerance studies with Evorel Conti were conducted in rabbits. In this model, Evorel Conti showed a mild irritation potential. It is recognised that the rabbit model is over-predictive of irritation of human skin.

Sensitisation studies with Evorel Conti in guinea pigs showed a weak sensitisation potential. Clinical trial experience with Evorel Conti use for up to two years gave no evidence of a clinically relevant sensitisation potential in humans.

EVOREL^® 50

Adhesive: acrylate-vinylacetate copolymer (Duro-Tak 387-2287)

Guar gum

Backing film: polyethylene terephthalate foil (Hostaphan MN19)

Release liner: siliconised polyethylene terephthalate foil, is removed before application

EVOREL^® CONTI

Adhesive: acrylate-vinylacetate copolymer (Duro-Tak 387-2287)

Guar gum

Backing film: polyethylene terephthalate foil (Hostaphan MN19)

Release liner: siliconised polyethylene terephthalate foil, is removed before application

No creams, lotions or powders should be applied to the skin area where the TDS is to be applied to prevent interference with the adhesive properties of EVOREL^® 50 TDS and EVOREL^® CONTI TDS.

EVOREL^® SEQUI has a shelf-life of 24 months, when stored at or below 25°C. The product can be used until the expiration date mentioned on the container.

Do not store above 25°C. Store within the original sachet and box.

Keep out of reach and sight of children. This also applies to used and disposed TDSs.

Each carton box has 8 TDSs in individual foil-lined sachets. The sachet comprises a 4 layer laminate including:

- surlyn-ionomer film on the inside,

- then aluminium foil,

- then polyethylene film,

- with a layer of bleached reinforced paper on the outside.

One EVOREL^® SEQUI box contains 4 EVOREL^® 50 TDS and 4 EVOREL^® CONTI TDSs.

The EVOREL^® SEQUI TDS should be placed on a clean, dry area of skin on the trunk of the body below the waist. Creams, lotions or powders may interfere with the adhesive properties of the EVOREL^® SEQUI TDS. The TDS should not be applied on or near to the breasts. The area of application should be changed, with an interval of at least one week allowed between applications to a particular site. The skin area selected should not be damaged or irritated. The waistline should not be used because excessive rubbing of the TDS may occur.

The TDS should be used immediately after opening the sachet. Remove one part of the protecting foil. Apply the exposed part of adhesive to the application site from the edge to the middle; avoid wrinkling of the TDS. The second part of the protective foil should now be removed and the freshly exposed adhesive applied. Wrinkling should again be avoided and the palm of the hand used to press the TDS onto the skin and to bring the TDS to skin temperature at which the adhesive effect is optimised. Do not touch the adhesive part of the TDS.

When using EVOREL^® SEQUI for the first two weeks, one of the EVOREL^® 50 TDSs should be applied and changed twice weekly. During the following two weeks of EVOREL^® SEQUI, one of the EVOREL^® CONTI TDSs should be applied, also to be changed twice weekly. The patient then starts again with a new box of EVOREL^® SEQUI.

To remove the EVOREL^® TDS, peel away an edge of the patch and pull smoothly away from the skin.

Any gum that remains on the skin after removal of EVOREL^® TDS may be removed by rubbing it off with the fingers, washing with soap and water or by using baby oil.

The EVOREL^® TDS should be disposed of in household waste (do not flush down the toilet).

Janssen-Cilag Ltd

50 -100 Holmers Farm Way

High Wycombe

Buckinghamshire

HP12 4EG

UK

PL 00242/0320

25/09/2006

03 January 2012