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Home , Epinephrine (medication), Intramuscular injection

How to use an EpiPen® ( , USP) Auto-Injector

1 PREPARE

Remove the EpiPen® or EpiPen Jr® Auto-Injector from the clear carrier tube. Flip open the yellow cap of your EpiPen® or the green cap of your EpiPen Jr® carrier tube. Tip and slide the auto-injector out of the carrier tube.

Hold the auto-injector in your fist with the orange tip pointing downward. ® NEVER-SEE-NEEDLE helps with protection. Protects against needle Blue to the sky, orange to the ™. exposure before and after use. With your other hand, remove the blue NOTE: safety release by pulling straight up • The needle comes out of the orange tip. without bending or twisting it. • To avoid an accidental injection, never put your thumb, fingers or hand over the orange tip. If an accidental injection happens, get medical help right away.

2 ADMINISTER

If you are administering EpiPen® or EpiPen Jr® to a young child, hold the leg firmly in place while administering an injection.

Place the orange tip against the middle of the outer thigh (upper leg) at a right angle (perpendicular) to the thigh.

Swing and push the auto-injector firmlyuntil it “clicks.” The click signals that the injection has started.

Hold firmly in place for 3 seconds (count slowly 1, 2, 3).

Remove the auto-injector from the thigh. The orange tip will extend to cover the needle. If the needle is still visible, do not attempt to reuse it.

Massage the injection area for 10 seconds.

3 GET EMERGENCY MEDICAL HELP RIGHT AWAY

You may need further medical attention. If symptoms continue or recur, you may need to use a second EpiPen® or EpiPen Jr® Auto-Injector.

INDICATIONS

EpiPen® and EpiPen Jr® Auto-Injectors are for the emergency treatment of life-threatening allergic reactions () caused by allergens, exercise, or unknown triggers; and for people who are at increased risk for these reactions. EpiPen® and EpiPen Jr® are intended for immediate administration as emergency supportive therapy only. Seek immediate emergency medical help right away. IMPORTANT SAFETY INFORMATION

Use EpiPen® (epinephrine injection, USP) 0.3 mg or EpiPen Jr® (epinephrine injection, USP) 0.15 mg Auto-Injectors right away when you have an allergic emergency (anaphylaxis). Get emergency medical help right away. You may need further medical attention. Only a healthcare professional should give additional doses of epinephrine if you need more than two injections for a single anaphylactic episode. Not actual patient. Please see additional Important Safety Information and Indications on the back. Please see accompanying full Prescribing Information and Patient Information. ® Every EpiPen 2-Pak (epinephrine injection, USP) comes with an EpiPen® Trainer Practice with your Trainer repeatedly to become familiar with it.

The EpiPen®­ Auto-Injector The EpiPen® Trainer

Identify the EpiPen® Trainer by:

Label

The EpiPen® Trainer is clearly labeled TRAINER or TRAINING DEVICE.

or Color or The EpiPen® Trainer is shaded grey

EpiPen® is yellow & EpiPen Jr® is green

No Window or

Reset after each use

Always have access to two EpiPen® Auto-Injectors The grey EpiPen® Trainer contains no in all the places you may need them because some and no needle, and SHOULD NOT people require a second dose. More than two BE USED during an anaphylactic reaction. sequential doses of EpiPen® Auto-Injector should be administered only under direct medical supervision. Visit epipen.com to watch our How to Use video and more.

IMPORTANT SAFETY INFORMATION (Continued)

EpiPen® or EpiPen Jr® should only be injected into the middle of your outer thigh (upper leg), through clothing if necessary. Do not inject into your veins, buttocks, fingers, toes, hands or feet. Hold the leg of young children firmly in place before and during injection to prevent injuries. In case of accidental injection, please seek immediate medical treatment.

Rarely, patients who have used EpiPen® or EpiPen Jr® may develop an infection at the injection site within a few days. Some of these infections can be serious. Call your healthcare professional right away if you have any of the following at an injection site: redness that does not go away, swelling, tenderness, or the area feels warm to the touch.

Tell your healthcare professional about all of your medical conditions, especially if you have , a history of depression, thyroid problems, Parkinson’s disease, diabetes, high blood pressure or problems, have any other medical conditions, are pregnant or plan to become pregnant, or are or plan to breastfeed. Be sure to also tell your healthcare professional all the you take, especially medicines for asthma. If you have certain medical conditions, or take certain medicines, your condition may get worse or you may have longer lasting side effects when you use EpiPen® or EpiPen Jr®.

Common side effects include fast, irregular or “pounding” heartbeat, sweating, nausea or vomiting, breathing problems, paleness, dizziness, weakness, shakiness, headache, feelings of over excitement, nervousness or . These side effects usually go away quickly if you lie down and rest.Tell your healthcare professional if you have any side effect that bothers you or that does not go away.

Please see the full Prescribing Information and Patient Information. You are encouraged to report negative side effects of prescription to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088. For additional information, please contact us at 800-395-3376.

EpiPen®, EpiPen Jr®, EpiPen 2-Pak®, EpiPen Jr 2-Pak®, Blue to the Sky, Orange to the Thigh™ and Never-See-Needle® are trademarks owned by the Mylan companies. The Mylan logo is a registered trademark of Mylan Inc. All other trademarks and service marks are the property of their respective owners. © 2016 Mylan Specialty L.P. All rights reserved. 7/16 EPI-2016-0305 Mylan Specialty L.P., 1000 Mylan Blvd., Canonsburg, PA 15317 HIGHLIGHTS OF PRESCRIBING INFORMATION 3 DOSAGE FORMS AND STRENGTHS should be stored in the carrier tube provided to protect it These highlights do not include all the information 4 CONTRAINDICATIONS from light [see How Supplied/Storage and Handling (16.2)]. needed to use EPIPEN® and EPIPEN Jr® safely 5 WARNINGS AND PRECAUTIONS 3 DOSAGE FORMS AND STRENGTHS and effectively. See full prescribing information for • EpiPen ®: Injection, 0.3 mg/0.3 mL (0.3 mL, 1:1000) EPIPEN® and EPIPEN Jr®. 5.1 Emergency Treatment epinephrine injection, USP, pre-filled auto-injector EPIPEN® (epinephrine injection, USP), Auto-Injector 0.3 mg, 5.2 Injection-Related Complications • EpiPen Jr®: Injection, 0.15 mg/0.3 mL, (0.3 mL 1:2000) EPIPEN Jr® (epinephrine injection, USP) Auto-Injector 5.3 Serious Infections at the Injection Site epinephrine injection, USP, pre-filled auto-injector 0.15 mg, for intramuscular or subcutaneous use 5.4 Allergic Reactions Associated with Sulfite 4 CONTRAINDICATIONS Initial U.S. Approval: 1939 5.5 Disease Interactions None 5 WARNINGS AND PRECAUTIONS RECENT MAJOR CHANGES 6 ADVERSE REACTIONS • Dosage and Administration (2) 05/2016 5.1 Emergency Treatment 7 INTERACTIONS EpiPen® and EpiPen Jr® are intended for immediate • Warnings and Precautions (5.2, 5.3) 05/2016 8 USE IN SPECIFIC POPULATIONS administration as emergency supportive therapy and are 8.1 not intended as a substitute for immediate medical care. INDICATIONS AND USAGE In conjunction with the administration of epinephrine, ® ® 8.3 Nursing Mothers EpiPen and EpiPen Jr contain epinephrine, a non-selective the patient should seek immediate medical or hospital alpha and beta-adrenergic , indicated in the 8.4 Pediatric Use care. More than two sequential doses of epinephrine should emergency treatment of allergic reactions (Type I) including 8.5 Geriatric Use only be administered under direct medical supervision [see anaphylaxis. (1) 10 OVERDOSAGE Indications and Usage (1), Dosage and Administration (2) DOSAGE AND ADMINISTRATION and Patient Counseling Information (17)]. • Patients greater than or equal to 30 kg (66 lbs): 11 DESCRIPTION 5.2 Injection-Related Complications EpiPen® 0.3 mg (2) 12 CLINICAL PHARMACOLOGY EpiPen® and EpiPen Jr® should only be injected into • Patients 15 to 30 kg (33 lbs to 66 lbs): 12.1 Mechanism of Action the anterolateral aspect of the thigh [see Dosage and ® Administration (2) and Patient Counseling Information (17)]. EpiPen Jr 0.15 mg (2) 12.2 Inject EpiPen® and EpiPen Jr® intramuscularly or • Do not inject intravenously. Large doses or accidental 13 NONCLINICAL TOXICOLOGY subcutaneously into the anterolateral aspect of the thigh, intravenous injection of epinephrine may result in through clothing if necessary. Each device is a single-use 13.1 Carcinogenesis, Mutagenesis, Impairment cerebral hemorrhage due to sharp rise in blood pressure. injection. (2) of Fertility Rapidly acting vasodilators can counteract the marked pressor effects of epinephrine if there is such inadvertent 16 HOW SUPPLIED/STORAGE AND HANDLING DOSAGE FORMS AND STRENGTHS administration. ® • EpiPen : Injection, 0.3 mg: 0.3 mg/0.3 mL epinephrine, 16.1 How Supplied • Do not inject into buttock. Injection into the buttock may USP, pre-filled auto-injector (3) 16.2 Storage and Handling not provide effective treatment of anaphylaxis. Advise the ® • EpiPen Jr : Injection, 0.15 mg: 0.15 mg/0.3 mL 17 PATIENT COUNSELING INFORMATION patient to go immediately to the nearest emergency room epinephrine, USP, pre-filled auto-injector (3) for further treatment of anaphylaxis. Additionally, injection *Sections or subsections omitted from the full prescribing into the buttock has been associated with Clostridial CONTRAINDICATIONS information are not listed. None (4) infections (gas ). Cleansing with alcohol does not kill bacterial spores, and therefore, does not lower this risk. WARNINGS AND PRECAUTIONS FULL PRESCRIBING INFORMATION • Do not inject into digits, hands or feet. Since • In conjunction with use, seek immediate medical 1 INDICATIONS AND USAGE epinephrine is a strong vasoconstrictor, accidental or hospital care. (5.1) EpiPen® and EpiPen Jr® are indicated in the emergency injection into the digits, hands or feet may result in loss • Do not inject intravenously, into buttock, or into digits, treatment of allergic reactions (Type I) including anaphylaxis of blood flow to the affected area. Advise the patient to hands, or feet. (5.2) to stinging insects (e.g., order Hymenoptera, which go immediately to the nearest emergency room and to • To minimize the risk of injection related injury, instruct include bees, wasps, hornets, yellow jackets and fire ants) inform the healthcare provider in the emergency room of caregivers to hold the child’s leg firmly in place and limit and biting insects (e.g., triatoma, mosquitoes), allergen the location of the accidental injection. Treatment of such movement prior to and during injection when administering immunotherapy, , drugs, diagnostic testing substances inadvertent administration should consist of , to young children. (5.2) (e.g., radiocontrast media) and other allergens, as well as in addition to further appropriate treatment of anaphylaxis [see Adverse Reactions (6)]. • Rare cases of serious skin and soft tissue infections have idiopathic anaphylaxis or exercise-induced anaphylaxis. ® ® • Hold leg firmly during injection. Lacerations, bent been reported following epinephrine injection. Advise EpiPen and EpiPen Jr are intended for immediate needles, and embedded needles have been reported patients to seek medical care if they develop signs or administration in patients who are determined to be at when EpiPen® and EpiPen Jr® have been injected into the symptoms of infection. (5.3) increased risk for anaphylaxis, including individuals with a history of anaphylactic reactions. thigh of young children who are uncooperative and kick or • The presence of a sulfite in this product should Anaphylactic reactions may occur within minutes after move during an injection. To minimize the risk of injection not deter use. (5.4) exposure and consist of flushing, apprehension, syncope, related injury when administering EpiPen® to young • Administer with caution in patients with heart disease; , thready or unobtainable pulse associated with children, instruct caregivers to hold the child’s leg firmly in may aggravate angina pectoris or produce ventricular a fall in blood pressure, convulsions, vomiting, diarrhea place and limit movement prior to and during injection. . (5.5) and abdominal cramps, involuntary voiding, wheezing, 5.3 Serious Infections at the Injection Site ADVERSE REACTIONS dyspnea due to laryngeal spasm, pruritus, rashes, urticaria Rare cases of serious skin and soft tissue infections, Adverse reactions to epinephrine include anxiety, or angioedema. including necrotizing fasciitis and myonecrosis caused ® ® apprehensiveness, restlessness, , weakness, EpiPen and EpiPen Jr are intended for immediate by Clostridia (gas gangrene), have been reported at the dizziness, sweating, , pallor, nausea and vomiting, administration as emergency supportive therapy only and injection site following epinephrine injection for anaphylaxis. headache, and/or respiratory difficulties. (6) are not a substitute for immediate medical care. Clostridium spores can be present on the skin and To report SUSPECTED ADVERSE REACTIONS, 2 DOSAGE AND ADMINISTRATION introduced into the deep tissue with subcutaneous or contact Mylan Specialty, L.P. at 1-877-446-3679 Selection of the appropriate dosage strength (EpiPen® . While cleansing with alcohol may (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or 0.3 mg or EpiPen Jr® 0.15 mg) is determined according reduce presence of on the skin, alcohol cleansing www.fda.gov/medwatch. to patient body weight. does not kill Clostridium spores. To decrease the risk of • Patients greater than or equal to 30 kg (approximately Clostridium infection, do not inject EpiPen® into the buttock DRUG INTERACTIONS 66 pounds or more): EpiPen® 0.3 mg [see Warnings and Precautions (5.2)]. Advise patients to seek • Cardiac glycosides or diuretics: observe for • Patients 15 to 30 kg (33 pounds to 66 pounds): medical care if they develop signs or symptoms of infection, development of cardiac arrhythmias. (7) EpiPen Jr® 0.15 mg such as persistent redness, warmth, swelling, • Tricyclic antidepressants, inhibitors, Inject EpiPen® or EpiPen Jr® intramuscularly or or tenderness, at the epinephrine injection site. levothyroxine sodium, and certain antihistamines: subcutaneously into the anterolateral aspect of the thigh, 5.4 Allergic Reactions Associated With Sulfite potentiate effects of epinephrine. (7) through clothing if necessary. Instruct caregivers of young The presence of a sulfite in this product should not deter • Beta-adrenergic blocking drugs: antagonize children who are prescribed an EpiPen® or EpiPen Jr® and administration of the drug for treatment of serious allergic cardiostimulating and bronchodilating effects of who may be uncooperative and kick or move during an or other emergency situations even if the patient is epinephrine. (7) injection to hold the leg firmly in place and limit movement sulfite-sensitive. • Alpha-adrenergic blocking drugs: antagonize prior to and during an injection [see Warnings and Precautions Epinephrine is the preferred treatment for serious allergic vasoconstricting and hypertensive effects of (5.2)]. reactions or other emergency situations even though this ® ® epinephrine. (7) Each EpiPen or EpiPen Jr contains a single dose of product contains sodium metabisulfite, a sulfite that may, epinephrine for single-use injection. Since the doses of in other products, cause allergic-type reactions including • Ergot alkaloids: may reverse the pressor effects epinephrine delivered from EpiPen® or EpiPen Jr® are fixed, anaphylactic symptoms or life-threatening or less severe of epinephrine. (7) consider using other forms of injectable epinephrine if asthmatic episodes in certain susceptible persons. USE IN SPECIFIC POPULATIONS doses lower than 0.15 mg are deemed necessary. The alternatives to using epinephrine in a life-threatening • Elderly patients may be at greater risk of developing The prescriber should carefully assess each patient to situation may not be satisfactory. adverse reactions. (5.5, 8.5) determine the most appropriate dose of epinephrine, 5.5 Disease Interactions See 17 for PATIENT COUNSELING INFORMATION recognizing the life-threatening nature of the reactions Some patients may be at greater risk for developing adverse and FDA approved patient labeling for which this drug is indicated. With severe persistent reactions after epinephrine administration. Despite these ® Revised: May 2016 anaphylaxis, repeat injections with an additional EpiPen concerns, it should be recognized that the presence of or EpiPen Jr® may be necessary. More than two sequential these conditions is not a contraindication to epinephrine doses of epinephrine should only be administered under direct administration in an acute, life-threatening situation. FULL PRESCRIBING INFORMATION: CONTENTS* medical supervision [see Warnings and Precautions (5.1)]. Therefore, patients with these conditions, and/or any other ® ® 1 INDICATIONS AND USAGE The epinephrine in the clear window of the EpiPen person who might be in a position to administer EpiPen Auto-Injector should be inspected visually for particulate or EpiPen Jr® to a patient experiencing anaphylaxis should 2 DOSAGE AND ADMINISTRATION matter and discoloration. Epinephrine is light sensitive and be carefully instructed in regard to the circumstances under which epinephrine should be used. recommended daily subcutaneous or intramuscular dose EpiPen Jr® if the epinephrine solution appears discolored • Patients with Heart Disease (on a mg/m2 basis at a maternal subcutaneous dose of (pinkish or brown color), cloudy, or contains particles. Epinephrine should be administered with caution to patients 0.5 mg/kg/day for 4 days). Thoroughly review the patient instructions and operation of who have heart disease, including patients with cardiac These effects were not seen in mice at approximately EpiPen® or EpiPen Jr® with patients and caregivers prior to arrhythmias, coronary artery or organic heart disease, 3 times the maximum recommended daily subcutaneous use [see Patient Counseling Information (17)]. or . In such patients, or in patients who are or intramuscular dose (on a mg/m2 basis at a subcutaneous 12 CLINICAL PHARMACOLOGY on drugs that may sensitize the heart to arrhythmias, maternal dose of 0.5 mg/kg/day for 10 days). 12.1 Mechanism of Action epinephrine may precipitate or aggravate angina pectoris 8.3 Nursing Mothers Epinephrine acts on both alpha- and beta-adrenergic receptors. as well as produce ventricular arrhythmias [see Drug It is not known whether epinephrine is excreted in human 12.2 Pharmacodynamics Interactions (7) and Adverse Reactions (6)]. milk. Because many drugs are excreted in human milk, Through its action on alpha-adrenergic receptors, • Other Patients and Diseases caution should be exercised when EpiPen® is administered epinephrine lessens the vasodilation and increased vascular Epinephrine should be administered with caution to patients to a nursing woman. permeability that occurs during anaphylaxis, which can lead with hyperthyroidism, diabetes, elderly individuals, and 8.4 Pediatric Use to loss of intravascular fl uid volume and hypotension. pregnant women. Patients with Parkinson’s disease may EpiPen® or EpiPen Jr® may be administered to pediatric Through its action on beta-adrenergic receptors, epinephrine notice a temporary worsening of symptoms. patients at a dosage appropriate to body weight [see causes bronchial relaxation and helps 6 ADVERSE REACTIONS Dosage and Administration (2)]. Clinical experience with alleviate , wheezing and dyspnea that may Due to the lack of randomized, controlled clinical trials the use of epinephrine suggests that the adverse reactions occur during anaphylaxis. of epinephrine for the treatment of anaphylaxis, the true seen in children are similar in nature and extent to those Epinephrine also alleviates pruritus, urticaria, and incidence of adverse reactions associated with the systemic both expected and reported in adults. Since the doses of angioedema and may relieve gastrointestinal and use of epinephrine is diffi cult to determine. Adverse epinephrine delivered from EpiPen® and EpiPen Jr® are genitourinary symptoms associated with anaphylaxis reactions reported in observational trials, case reports, fi xed, consider using other forms of injectable epinephrine because of its relaxer effects on the smooth muscle of the and studies are listed below. if doses lower than 0.15 mg are deemed necessary. stomach, intestine, uterus and . Common adverse reactions to systemically administered 8.5 Geriatric Use When given subcutaneously or intramuscularly, epinephrine epinephrine include anxiety; apprehensiveness; Clinical studies for the treatment of anaphylaxis have not has a rapid onset and short duration of action. restlessness; tremor; weakness; dizziness; sweating; been performed in subjects aged 65 and over to determine 13 NONCLINICAL TOXICOLOGY palpitations; pallor; nausea and vomiting; headache; and/ whether they respond differently from younger subjects. 13.1 Carcinogenesis, Mutagenesis, Impairment or respiratory diffi culties. These symptoms occur in some However, other reported clinical experience with use of of Fertility persons receiving therapeutic doses of epinephrine, but epinephrine for the treatment of anaphylaxis has identifi ed Long-term studies to evaluate the carcinogenic potential are more likely to occur in patients with hypertension or that geriatric patients may be particularly sensitive to of epinephrine have not been conducted. ® hyperthyroidism [see Warnings and Precautions (5.5)]. the effects of epinephrine. Therefore, EpiPen should be Epinephrine and other catecholamines have been shown Arrhythmias, including fatal ventricular fi brillation, have been administered with caution in elderly individuals, who may to have mutagenic potential in vitro and to be an oxidative reported, particularly in patients with underlying cardiac be at greater risk for developing adverse reactions after mutagen in a WP2 bacterial reverse mutation assay. disease or those receiving certain drugs [see Warnings and epinephrine administration [see Warnings and Precautions Epinephrine was positive in the DNA Repair test with Precautions (5.5) and Drug Interactions (7)]. (5.5), Overdosage (10)]. B. subtilis (REC) assay, but was not mutagenic in the Rapid rises in blood pressure have produced cerebral 10 OVERDOSAGE Salmonella bacterial reverse mutation assay. hemorrhage, particularly in elderly patients with Overdosage of epinephrine may produce extremely elevated The potential for epinephrine to impair fertility has not been cardiovascular disease [see Warnings and Precautions (5.5)]. arterial pressure, which may result in cerebrovascular evaluated. Angina may occur in patients with coronary artery disease hemorrhage, particularly in elderly patients. Overdosage This should not prevent the use of epinephrine under the [see Warnings and Precautions (5.5)]. may also result in because of peripheral conditions noted under Indications and Usage (1). Accidental injection into the digits, hands or feet may result vascular constriction together with cardiac stimulation. 16 HOW SUPPLIED/STORAGE AND HANDLING in loss of blood fl ow to the affected area [see Warnings and Treatment consists of rapidly acting vasodilators or alpha- 16.1 How Supplied Precautions (5.2)]. adrenergic blocking drugs and/or respiratory support. EpiPen® Auto-Injectors (epinephrine injections, USP, 1:1000, Adverse events experienced as a result of accidental Epinephrine overdosage can also cause transient 0.3 mL) are available as EpiPen 2-Pak®, NDC 49502- injections may include increased heart rate, local reactions followed by tachycardia, and these may be 500-02, a pack that contains two EpiPen® Auto-Injectors including injection site pallor, coldness and hypoesthesia accompanied by potentially fatal cardiac arrhythmias. (epinephrine injections, USP, 1:1000, 0.3 mL) and one or injury at the injection site resulting in bruising, bleeding, Premature ventricular contractions may appear within one EpiPen® Auto-Injector trainer device. discoloration, erythema or skeletal injury. minute after injection and may be followed by multifocal EpiPen Jr® Auto-Injectors (epinephrine injections, USP, Lacerations, bent needles, and embedded needles have ventricular tachycardia (prefi brillation rhythm). Subsidence 1:2000, 0.3 mL) are available as EpiPen Jr 2-Pak®, NDC been reported when EpiPen® has been injected into the of the ventricular effects may be followed by atrial 49502-501-02, a pack that contains two EpiPen Jr® Auto- thigh of young children who are uncooperative and kick or tachycardia and occasionally by atrioventricular block. Injectors (epinephrine injections, USP, 1:2000, 0.3 mL) and move during the injection [see Warning and Precautions (5.2)]. Treatment of arrhythmias consists of administration of one EpiPen® Auto-Injector trainer device. Injection into the buttock has resulted in cases of gas a beta-adrenergic blocking drug such as propranolol. EpiPen 2-Pak® and EpiPen Jr 2-Pak® also include an gangrene [see Warnings and Precautions (5.2)]. Overdosage sometimes results in extreme pallor and S-clip to clip two carrier tubes together. Rx only Rare cases of serious skin and soft tissue infections, coldness of the skin, metabolic acidosis, and kidney 16.2 Storage and Handling including necrotizing fasciitis and myonecrosis caused by failure. Suitable corrective measures must be taken in Protect from light. Epinephrine is light sensitive and should Clostridia (gas gangrene), have been reported following such situations. be stored in the carrier tube provided to protect it from light. epinephrine injection, including EpiPen®, in the thigh [see 11 DESCRIPTION Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Warnings and Precautions (5.3)]. ® ® EpiPen (epinephrine injection, USP) 0.3 mg and EpiPen Jr Temperature]. Do not refrigerate. Before using, check to make 7 DRUG INTERACTIONS (epinephrine injection, USP) 0.15 mg are auto-injectors sure the solution in the auto-injector is clear and colorless. Patients who receive epinephrine while concomitantly and combination products containing drug and device Replace the auto-injector if the solution is discolored (pinkish taking cardiac glycosides, diuretics, or anti-arrhythmics components. or brown color), cloudy, or contains particles. should be observed carefully for the development of cardiac Each EpiPen® Auto-Injector, 0.3 mg delivers a single dose of arrhythmias [see Warnings and Precautions (5.5)]. 0.3 mg epinephrine from epinephrine injection, USP 1:1000 17 PATIENT COUNSELING INFORMATION The effects of epinephrine may be potentiated by (0.3 mL) in a sterile solution. [See FDA-Approved Patient Labeling (Patient Information tricyclic antidepressants, monoamine oxidase inhibitors, Each EpiPen Jr® Auto-Injector, 0.15 mg delivers a single and Instructions for Use).] A healthcare provider should review the patient instructions levothyroxine sodium, and certain antihistamines, notably dose of 0.15 mg epinephrine from epinephrine injection, and operation of EpiPen® and EpiPen Jr® in detail, with the chlorpheniramine, , and . USP 1:2000 (0.3 mL) in a sterile solution. patient or caregiver. The cardiostimulating and bronchodilating effects of The EpiPen® and EpiPen Jr® each contain 2 mL epinephrine Epinephrine is essential for the treatment of anaphylaxis. epinephrine are antagonized by beta-adrenergic blocking solution. Approximately 1.7 mL remains in the auto-injector Patients who are at risk of or with a history of severe allergic drugs, such as propranolol. after activation, but is not available for future use, and reactions (anaphylaxis) to insect stings or bites, foods, drugs, The vasoconstricting and hypertensive effects of epinephrine should be discarded. and other allergens, as well as idiopathic and exercise- are antagonized by alpha-adrenergic blocking drugs, such Each 0.3 mL in the EpiPen® Auto-Injector contains 0.3 induced anaphylaxis, should be carefully instructed about as phentolamine. mg epinephrine, 1.8 mg sodium chloride, 0.5 mg sodium the circumstances under which epinephrine should be used. Ergot alkaloids may also reverse the pressor effects of metabisulfi te, hydrochloric acid to adjust pH, and Water for Administration and Training epinephrine. Injection. The pH range is 2.2-5.0. Instruct patients and/or caregivers in the appropriate use Each 0.3 mL in the EpiPen Jr® Auto-Injector contains 0.15 8 USE IN SPECIFIC POPULATIONS of EpiPen® and EpiPen Jr®. EpiPen® should be injected into mg epinephrine, 1.8 mg sodium chloride, 0.5 mg sodium 8.1 Pregnancy the middle of the outer thigh (through clothing, if necessary). metabisulfi te, hydrochloric acid to adjust pH, and Water for Teratogenic Effects: Pregnancy Category C. Each device is a single-use injection. Advise patients to seek Injection. The pH range is 2.2-5.0. There are no adequate and well controlled studies of the immediate medical care in conjunction with administration Epinephrine is a sympathomimetic catecholamine. acute effect of epinephrine in pregnant women. of EpiPen®. Chemically, epinephrine is (-)-3,4-Dihydroxy- - Epinephrine was teratogenic in rabbits, mice and hamsters. α Instruct caregivers to hold the leg of young children fi rmly [(methylamino)methyl]benzyl alcohol with the following Epinephrine should be used during pregnancy only if the in place and limit movement prior to and during injection. structure: potential benefi t justifi es the potential risk to the fetus (fetal Lacerations, bent needles, and embedded needles anoxia, spontaneous abortion, or both). have been reported when EpiPen® and EpiPen Jr® have Epinephrine has been shown to have teratogenic been injected into the thigh of young children who are effects when administered subcutaneously in rabbits at uncooperative and kick or move during an injection [see approximately 30 times the maximum recommended Warnings and Precautions (5.2)]. daily subcutaneous or intramuscular dose (on a mg/m2 Complete patient information, including dosage, directions basis at a maternal dose of 1.2 mg/kg/day for two to three for proper administration and precautions can be found days), in mice at approximately 7 times the maximum daily inside each EpiPen® or EpiPen Jr® carton. A printed label subcutaneous or intramuscular dose (on a mg/m2 basis at a Epinephrine solution deteriorates rapidly on exposure to air on the surface of EpiPen® shows instructions for use and a maternal subcutaneous dose of 1 mg/kg/day for 10 days), or light, turning pink from oxidation to adrenochrome and diagram depicting the injection process. and in hamsters at approximately 5 times the maximum brown from the formation of melanin. Replace EpiPen® and Instruct patients and/or caregivers to use and practice with the Trainer device to familiarize themselves with the use of • hoarseness (changes in the way your voice sounds) How should I use EpiPen® and EpiPen Jr®? EpiPen® in an allergic emergency. The Trainer may be used • hives (raised reddened rash that may itch) • Each EpiPen® or EpiPen Jr® Auto-Injector contains only 1 multiple times. A Trainer device is provided in 2-Pak cartons. • severe itching dose of medicine. Adverse Reactions ® ® • swelling of your face, lips, mouth, or tongue • EpiPen or EpiPen Jr should be injected into the middle Epinephrine may produce symptoms and signs that include of your outer thigh (upper leg). It can be injected through • skin rash, redness, or swelling an increase in heart rate, the sensation of a more forceful your clothing if needed. heartbeat, palpitations, sweating, nausea and vomiting, • fast heartbeat • Read the Instructions for Use at the end of this Patient difficulty breathing, pallor, dizziness, weakness or shakiness, • weak pulse Information Leaflet about the right way to use EpiPen® headache, apprehension, nervousness, or anxiety. These • feeling very anxious and EpiPen Jr®. signs and symptoms usually subside rapidly, especially with rest, quiet and recumbency. Patients with hypertension or • confusion • Your healthcare provider will show you how to safely ® ® hyperthyroidism may develop more severe or persistent • stomach use the EpiPen or EpiPen Jr Auto-Injector. ® ® effects, and patients with coronary artery disease could • losing control of urine or bowel movements • Use your EpiPen or EpiPen Jr exactly as your healthcare experience angina. Patients with diabetes may develop (incontinence) provider tells you to use it. You may need to use a second increased blood glucose levels following epinephrine EpiPen® or EpiPen Jr® if symptoms continue or recur. • diarrhea or stomach cramps administration. Patients with Parkinson’s disease may notice Only a healthcare provider should give additional doses of a temporary worsening of symptoms [see Warnings and • dizziness, fainting, or “passing out” (unconsciousness) epinephrine if you need more than 2 injections for a single Precautions (5.5)]. 2. Always carry your EpiPen® or EpiPen Jr® with you anaphylaxis episode. Accidental Injection because you may not know when anaphylaxis • Caution: Never put your thumb, fingers, or hand over Advise patients to seek immediate medical care in the may happen. the orange tip. Never press or push the orange tip with case of accidental injection. Since epinephrine is a strong Talk to your healthcare provider if you need additional your thumb, fingers, or hand. The needle comes out of vasoconstrictor when injected into the digits, hands, or feet, units to keep at work, school, or other locations. the orange tip. Accidental injection into finger, hands or treatment should be directed at vasodilatation if there is Tell your family members, caregivers, and others where feet may cause a loss of blood flow to these areas.If this such an accidental injection to these areas [see Warnings you keep your EpiPen® or EpiPen Jr® and how to use it happens, go immediately to the nearest emergency and Precautions (5.2)]. before you need it. You may be unable to speak in an room. Tell the healthcare provider where on your body you received the accidental injection. Serious Infections at the Injection Site allergic emergency. • Your EpiPen® and EpiPen Jr® Auto-Injector may come Rare cases of serious skin and soft tissue infections, 3. When you have an allergic emergency (anaphylaxis) packaged with an EpiPen® Trainer and separate Trainer including necrotizing fasciitis and myonecrosis caused ® ® • Use EpiPen or EpiPen Jr right away. Instructions for Use. The EpiPen® Trainer has a grey by Clostridia (gas gangrene), have been reported at the • Get emergency medical help right away. You may color. The grey EpiPen® Trainer contains no medicine injection site following epinephrine injection for anaphylaxis. need further medical attention. You may need to use a and no needle. Periodically practice with your EpiPen® Advise patients to seek medical care if they develop signs or second EpiPen® or EpiPen Jr® if symptoms continue or Trainer before an allergic emergency happens to make symptoms of infection, such as persistent redness, warmth, recur. Only a healthcare provider should give additional sure you are able to safely use the real EpiPen® and swelling, or tenderness, at the epinephrine injection site [see doses of epinephrine if you need more than EpiPen Jr® Auto-Injector in an emergency. Always carry Warnings and Precautions (5.3)]. 2 injections for a single anaphylaxis episode. your real EpiPen® or EpiPen Jr® Auto-Injector with you Storage and Handling in case of an allergic emergency. Additional training ® ® Instruct patients to inspect the epinephrine solution visually What are EpiPen and EpiPen Jr ? resources are available at www.epipen.com. through the clear window of the auto-injector periodically. • EpiPen ® and EpiPen Jr® are disposable, prefilled automatic • Do not drop the carrier tube or auto-injector. If the carrier Replace EpiPen® and EpiPen Jr® if the epinephrine solution injection devices (auto-injectors) used to treat life- tube or auto-injector is dropped, check for damage and appears discolored (pinkish or brown color), cloudy, or threatening, allergic emergencies including anaphylaxis leakage. Dispose of the auto-injector and carrier tube, and contains particles. Epinephrine is light sensitive and should in people who are at risk for or have a history of serious replace if damage or leakage is noticed or suspected. be stored in the carrier tube provided to protect it from light. allergic emergencies. Each device contains a single dose The carrier tube is not waterproof. Instruct patients that of epinephrine. What are the possible side effects of the EpiPen® and ® ® EpiPen Jr®? EpiPen and EpiPen Jr must be used or properly disposed • EpiPen ® and EpiPen Jr® are for immediate self (or once the blue safety release is removed or after use [see caregiver) administration and do not take the place of EpiPen® and EpiPen Jr® may cause serious side effects. Storage and Handling (16.2)]. emergency medical care. You should get emergency help • The EpiPen® or EpiPen Jr® should only be injected into Complete patient information, including dosage, directions right away after using EpiPen® and EpiPen Jr®. the middle of your outer thigh (upper leg). Do for proper administration and precautions can be found • EpiPen ® and EpiPen Jr® are for people who have been not inject the EpiPen® or EpiPen Jr® into your: inside each EpiPen® Auto-Injector carton. prescribed this medicine by their healthcare provider. • veins Manufactured for Mylan Specialty L.P., Morgantown, WV • The EpiPen® Auto-Injector (0.3 mg) is for patients who • buttocks 26505, U.S.A. by Meridian Medical Technologies, Inc., weigh 66 pounds or more (30 kilograms or more). • fingers, toes, hands, or feet Columbia, MD 21046, U.S.A., a Pfizer company • The EpiPen Jr® Auto-Injector (0.15 mg) is for patients who If you accidentally inject EpiPen® or EpiPen Jr® into any EpiPen® and EpiPen Jr® are registered trademarks of Mylan weigh about 33 to 66 pounds (15 to 30 kilograms). other part of your body, go to the nearest emergency room Inc. licensed exclusively to its wholly-owned affiliate, Mylan • It is not known if EpiPen® and EpiPen Jr® are safe and right away. Tell the healthcare provider where on your body Specialty L.P. of Morgantown, WV 26505, U.S.A. effective in children who weigh less than 33 pounds you received the accidental injection. Copyright © 2016 Meridian Medical Technologies. All rights (15 kilograms). • Rarely, patients who have used EpiPen® or EpiPen Jr® may reserved. What should I tell my healthcare provider before using develop infections at the injection site within a few days of May 2016 MS:EPI:R2 0001928 the EpiPen® or EpiPen Jr®? an injection. Some of these infections can be serious. Call Before you use EpiPen® or EpiPen Jr®, tell your your healthcare provider right away if you have any of the PATIENT INFORMATION and INSTRUCTIONS FOR USE healthcare provider about all your medical conditions, following at an injection site: EPIPEN® but especially if you: • redness that does not go away (epinephrine injection, USP) Auto-Injector 0.3 mg • have heart problems or high blood pressure • swelling Epipen® = one dose of 0.30 mg epinephrine (USP, 1:1000, 0.3 • have diabetes • tenderness EPIPEN JR® • have thyroid problems • the area feels warm to the touch (epinephrine injection, USP) Auto-Injector 0.15 mg • have asthma • Cuts on the skin, bent needles, and needles that remain Epipen® = one dose of 0.15 mg epinephrine (USP, 1:2000, 0.3 mL) • have a history of depression in the skin after the injection, have happened in young children who do not cooperate and kick or move during an • have Parkinson’s disease For allergic emergencies (anaphylaxis) injection. If you inject a young child with EpiPen® or EpiPen Jr®, • have any other medical conditions hold their leg firmly in place before and during the injection Patient Information • are pregnant or plan to become pregnant. It is not known if to prevent injuries. Ask your healthcare provider to show Read this Patient Information Leaflet carefully before using epinephrine will harm your unborn baby. you how to properly hold the leg of a young child during the EpiPen® or EpiPen Jr® Auto-Injector and each time you injection. get a refill. There may be new information. You, your parent, • are breastfeeding or plan to breastfeed. It is not known if caregiver, or others who may be in a position to administer epinephrine passes into your breast milk. • If you have certain medical conditions, or take certain ® ® medicines, your condition may get worse or you may EpiPen or EpiPen Jr Auto-Injector, should know how to Tell your healthcare provider about all the medicines you have longer lasting side effects when you use your use it before you have an allergic emergency. take, including prescription and over-the-counter medicines, EpiPen® or EpiPen Jr®. Talk to your healthcare provider This information does not take the place of talking with your vitamins, and herbal supplements. Tell your healthcare about all your medical conditions. healthcare provider about your medical condition or your provider of all known . treatment. Common side effects of EpiPen® and EpiPen Jr® include: Especially tell your healthcare provider if you take certain asthma medicines. • fast, irregular or “pounding” heartbeat What is the most important information I should know ® ® • sweating about the EpiPen® and EpiPen Jr®? EpiPen or EpiPen Jr and other medicines may affect each other, causing side effects. EpiPen® or EpiPen Jr® may affect • headache 1. EpiPen ® and EpiPen Jr® contain epinephrine, a medicine the way other medicines work, and other medicines may used to treat allergic emergencies (anaphylaxis). • weakness affect how EpiPen® or EpiPen Jr® work. Anaphylaxis can be life threatening, can happen within • shakiness minutes, and can be caused by stinging and biting Know the medicines you take. Keep a list of them to show • paleness your healthcare provider and pharmacist when you get a insects, injections, foods, medicines, exercise, or • feelings of over excitement, nervousness or anxiety unknown causes. new medicine. ® ® • dizziness Symptoms of anaphylaxis may include: Use your EpiPen or EpiPen Jr for treatment of anaphylaxis as prescribed by your healthcare provider, regardless • nausea or vomiting • trouble breathing of your medical conditions or the medicines you take. • breathing problems • wheezing These side effects may go away with rest. Tell your Your EpiPen® and EpiPen Jr® Auto-Injector Remove the auto-injector from healthcare provider if you have any side effect that the thigh. The orange tip will bothers you or that does not go away. EpiPen® Auto-Injector (yellow label) extend to cover the needle. in Carrier Tube These are not all the possible side effects of the EpiPen® If the needle is still visible, or EpiPen Jr®. For more information, ask your healthcare do not attempt to reuse it. provider or pharmacist. Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. ® ® How should I store EpiPen and EpiPen Jr ? Massage the injection area • Store EpiPen® and EpiPen Jr® at room temperature EpiPen® Auto-Injector (yellow label) removed from Carrier Tube for 10 seconds. between 68° to 77° F (20° to 25° C). • Protect from light. EpiPen Jr® Auto-Injector (green label) • Do not expose to extreme cold or heat. For example, do in Carrier Tube not store in your vehicle’s glove box and do not store in the refrigerator or freezer. • Examine the contents in the clear window of your auto- injector periodically. The solution should be clear. If the solution is discolored (pinkish or brown color) or contains solid particles, replace the unit. Step 3. Get emergency medical help now. • Always keep your EpiPen® or EpiPen Jr® Auto-Injector in You may need further medical attention. You may need the carrier tube to protect it from damage; however, the EpiPen Jr® Auto-Injector (green label) to use a second EpiPen® or EpiPen Jr® Auto-Injector if carrier tube is not waterproof. removed from Carrier Tube symptoms continue or recur. • The blue safety release helps to prevent accidental A dose of EpiPen® or EpiPen Jr® requires 3 simple steps: • Take your used auto-injector with you when you go to injection. Keep the blue safety release on until you need to see a healthcare provider. ® ® Prepare, Administer and Get emergency medical help use EpiPen or EpiPen Jr . • Tell the healthcare provider that you have received an ® ® • Your EpiPen or EpiPen Jr has an expiration date. injection of epinephrine. Show the healthcare provider Step 1. Prepare EpiPen® or EpiPen Jr® for injection Replace it before the expiration date. where you received the injection. ® ® Keep EpiPen and EpiPen Jr and all medicines out of ® ® ® • Give your used EpiPen or EpiPen Jr Auto-Injector to the the reach of children. Remove the EpiPen or healthcare provider for inspection and proper disposal. EpiPen Jr® from the clear General information about the safe and effective use of • Ask for a refi ll, if needed. EpiPen® and EpiPen Jr® carrier tube. Note: Medicines are sometimes prescribed for purposes other Flip open the yellow cap of your than those listed in a Patient Information Leafl et. Do not EpiPen® or the green cap of • The used auto-injector with extended needle cover will use the EpiPen® or EpiPen Jr® for a condition for which it your EpiPen Jr® carrier tube. not fi t in the carrier tube. was not prescribed. Do not give your EpiPen® or EpiPen Jr® • EpiPen ® and EpiPen Jr® are single-use injectable devices to other people. that deliver a fi xed dose of epinephrine. The auto-injector This Patient Information Leafl et summarizes the most cannot be reused. Do not attempt to reuse EpiPen® after important information about EpiPen® and EpiPen Jr®. If you the device has been activated. It is normal for most of the would like more information, talk to your healthcare provider. medicine to remain in the auto-injector after the dose is You can ask your pharmacist or healthcare provider injected. The correct dose has been administered if the for information about EpiPen® and EpiPen Jr® orange needle tip is extended and the window is blocked. Tip and slide the auto-injector that is written for health professionals. • Your EpiPen® and EpiPen Jr® Auto-Injector may come out of the carrier tube. For more information and video instructions on the use packaged with an EpiPen® Trainer and separate Trainer of EpiPen® and EpiPen Jr®, go to www.epipen.com or Instructions for Use. The EpiPen® Trainer has a grey color. call 1-800-395-3376. The grey EpiPen® Trainer contains no medicine and no ® What are the ingredients in EpiPen® and EpiPen Jr®? needle. Practice with your EpiPen Trainer, but always carry your real EpiPen® or EpiPen Jr® Auto-Injector in case Active Ingredients: Epinephrine Grasp the auto-injector in your of an allergic emergency. Inactive Ingredients: sodium chloride, sodium metabisulfi te, fi st with the orange tip (needle • If you will be administering EpiPen® or EpiPen Jr® to a hydrochloric acid, and water. end) pointing downward. young child, ask your healthcare provider to show you how Important Information With your other hand, remove the to properly hold the leg in place while administering a dose. • The EpiPen® Auto-Injector has a yellow colored label. blue safety release by pulling • Do not try to take the EpiPen® or EpiPen Jr® Auto-Injector apart. straight up without bending or • The EpiPen Jr® Auto-Injector has a green colored label. twisting it. ® This Patient Information and Instructions for Use has been • The EpiPen Trainer has a grey color and contains no approved by the U.S. and Drug Administration. medicine and no needle. Manufactured for: • Your auto-injector is designed to work through clothing. Mylan Specialty L.P., Morgantown, WV 26505, U.S.A. by Meridian • The blue safety release on the EpiPen® and EpiPen Jr® Medical Technologies, Inc., Columbia, MD 21046, U.S.A., a Pfi zer company ® ® Auto-Injector helps to prevent accidental injection of Note: EpiPen and EpiPen Jr are registered trademarks of Mylan Inc. the device. Do not remove the blue safety release until licensed exclusively to its wholly-owned affi liate, Mylan Specialty L.P. • The needle comes out of the orange tip. you are ready to use it. of, Morgantown, WV 26505, U.S.A. • To avoid an accidental injection, never put your thumb, Copyright © 2016 Meridian Medical Technologies. All rights reserved. • Only inject into the middle of the outer thigh (upper fi ngers or hand over the orange tip. If an accidental Revised: May 2016 leg). Never inject into any other part of the body. injection happens, get medical help right away MS:PIL:EPI:R2 • Never put your thumb, fi ngers, or your hand over the EPI-2016-0247 Register your EpiPen® or EpiPen Jr® Auto-Injector at orange tip. The needle comes out of the orange tip. Step 2. Administer EpiPen® or EpiPen Jr® ® ® • If an accidental injection happens, get medical help If you are administering EpiPen or EpiPen Jr to PI EN® right away. a young child, hold the leg fi rmly in place while E P administering an injection. (epinephrine injection, USP) Auto-Injector 0.3 mg • Do not place patient information or any other foreign Epipen® = one dose of 0.30 mg epinephrine (USP, 1:1000, 0.3 objects in the carrier tube with the Auto-Injector, as ® this may prevent you from removing the Auto-Injector Place the orange tip against the EPIPEN JR for use. middle of the outer thigh (upper (epinephrine injection, USP) Auto-Injector 0.15 mg Epipen® = one dose of 0.15 mg epinephrine (USP, 1:2000, 0.3 mL) INSTRUCTIONS FOR USE leg) at a right angle

® (perpendicular) to the thigh. EPIPEN Swing and push the auto- (epinephrine injection, USP) Auto-Injector 0.3 mg injector fi rmly until it ‘clicks’. ® Epipen = one dose of 0.30 mg epinephrine (USP, 1:1000, 0.3 mL) The click signals that the injection EPIPEN JR® has started. MyEpiPen.com and fi nd out more about: (epinephrine injection, USP) Auto-Injector 0.15 mg • Free EpiPen® Auto-Injector Refi ll Reminder Program. Epipen® = one dose of 0.15 mg epinephrine (USP, 1:2000, 0.3 mL) It is important to keep your auto-injector up-to-date. Hold fi rmly in place for 3 Register up to 6 EpiPen® or EpiPen Jr® Auto-Injectors and For allergic emergencies (anaphylaxis) seconds (count slowly 1,2,3). receive automatic Refi ll Reminder Alerts. The injection is now complete. Read these Instructions for Use carefully before you • Receive periodic information related to allergies use EpiPen® or EpiPen Jr®. Before you need to use your and allergens. EpiPen® or EpiPen Jr®, make sure your healthcare provider • Instructional Video shows you the right way to use it. Parents, caregivers, For more information about EpiPen® or EpiPen Jr® ® and others who may be in a position to administer EpiPen Auto-Injectors and proper use of the product, call ® or EpiPen Jr Auto-Injector should also understand how Mylan at 1-877-446-3679 or visit www.epipen.com. to use it as well. If you have any questions, ask your healthcare provider.