HIGHLIGHTS OF PRESCRIBING INFORMATION WARNING AND PRECAUTIONS These highlights do not include all the information needed • Vascular risks: Stop drospirenone and ethinyl estradiol to use DROSPIRENONE AND ETHINYL ESTRADIOL tablets if a thrombotic event occurs. Stop at least 4 weeks TABLETS safely and effectively. See full prescribing before and through 2 weeks after major surgery. Start no earlier than 4 weeks after delivery, in women who are not information for DROSPIRENONE AND ETHINYL breastfeeding (5.1). COCs containing DRSP may be ESTRADIOL TABLETS. associated with a higher risk of venous thromboembolism (VTE) than COCs containing levonorgestrel or some other DROSPIRENONE and ETHINYL ESTRADIOL tablets, for progestins. Before initiating drospirenone and ethinyl oral use. estradiol tablets in a new COC user or a woman who is Initial U.S. Approval: 2001 switching from a contraceptive that does not contain DRSP, consider the risks and benefits of a DRSP-containing COC in light of her risk of a VTE (5.1). WARNI NG: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS • Hyperkalemia: DRSP has anti-mineralocorticoid activity. See full prescribing information for complete boxed Do not use in patients predisposed to hyperkalemia. Check warning. serum potassium concentration during the first treatment • Women over 35 years old who smoke should cycle in women on long-term treatment with medications that may increase serum potassium concentration. (5.2, 7.1, not use drospirenone and ethinyl estradiol tablets (4). 7.2) • • Liver disease: Discontinue drospirenone and ethinyl estradiol Cigarette smoking increases the risk of serious cardiovascular events from tablets if jaundice occurs. (5.4) combination oral contraceptive (COC) use. • High blood pressure: Do not prescribe drospirenone and (4) ethinyl estradiol tablets for women with uncontrolled hypertension or hypertension with vascular disease. (5.5) • Carbohydrate and lipid metabolic effects: Monitor prediabetic and diabetic women taking drospirenone and RECENT MAJOR CHANGES ethinyl estradiol tablets. Consider an alternate contraceptive method for women with uncontrolled dyslipidemia. (5.7) Contraindications (4) 08/2017 • Headache: Evaluate significant change in headaches and Warnings and Precautions (5.5) 08/2017 discontinue drospirenone and ethinyl estradiol tablets if INDICATIONS AND USAGE indicated. (5.8) • Uterine bleeding: Evaluate irregular bleeding or amenorrhea. (5.9) Drospirenone and ethinyl estradiol tablets are an estrogen/progestin COC indicated for use by women to prevent pregnancy. (1) ADVERSE REACTIONS DOSAGE AND ADMINISTRATION The most frequent adverse reactions (≥ 2%) are premenstrual syndrome (13.2%), headache /migraine (10.7%), breast • Take one tablet daily by mouth at the same time every day. (2.1) pain/tenderness/discomfort (8.3%), nausea/vomiting (4.5%), • Tablets must be taken in the order directed on the blister pack. (2.1) abdominal pain/tenderness/discomfort (2.3%), mood changes (2.3%). (6.1) DOSAGE FORMS AND STRENGTHS To report SUSPECTED ADVERSE REACTIONS, Drospirenone and ethinyl estradiol tablets consists of 28 film-coated, contact Apotex Corp. at 1-800-706-5575 or FDA at 1- biconvex tablets in the following order (3): 800-FDA-1088 or www.fda.gov/medwatch • 21 yellow tablets, each containing 3 mg drospirenone (DRSP) and 0.03 mg ethinyl estradiol (EE) • 7 inert white tablets DRUG INTERACTIONS CONTRAINDICATIONS Drugs or herbal products that induce certain enzymes (for example, CYP3A4) may decrease the effectiveness of COCs or • Renal impairment (4) increase breakthrough bleeding. Counsel patients to use a back-up • Adrenal insufficiency (4) or alternative method of contraception when enzyme inducers are • A high risk of arterial or venous thrombotic diseases (4) used with COCs. (7.1) • Undiagnosed abnormal uterine bleeding (4) • Breast cancer or other estrogen-or progestin-sensitive cancer (4) • Liver tumors or liver disease (4) USE IN SPECIFIC POPULATIONS • Pregnancy (4) • Co-administration with Hepatitis C drug combinations containing Nursing mothers: Not recommended; can decrease milk ombitasvir, paritaprevir/ritonavir, with or without dasabuvir (4) production. (8.3) See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling. Page 1 of 31 Revised 08/2017 FULL PRESCRIBING INFORMATION: CONTENTS* WARNING: CIGARETTE SMOKING AND SERIOUS 7 DRUG INTERACTIONS CARDIOVASCULAR EVENTS 7.1 Effects of Other Drugs on Combined Oral Contraceptives 1 INDICATIONS AND USAGE 7.2 Effects of Combined Oral Contraceptives on Other Drugs 2 DOSAGE AND ADMINISTRATION 7.3 Concomitant Use of HCV Combination Therapy – Liver 2.1 How to Take Drospirenone and Ethinyl Estradiol Tablets Enzyme Elevation 2.2 How to Start Drospirenone and Ethinyl Estradiol Tablets 7.4 Interference with Laboratory Tests 2.3 Advice in Case of Gastrointestinal Disturbances 8 USE IN SPECIFIC POPULATIONS 3 DOSAGE FORMS AND STRENGTHS 8.1 Pregnancy 4 CONTRAINDICATIONS 8.3 Nursing Mothers 5 WARNINGS AND PRECAUTIONS 8.4 Pediatric Use 5.1 Thromboembolic Disorders and Other Vascular Problems 8.5 Geriatric Use 5.2 Hyperkalemia 8.6 Patients with Renal Impairment 5.3 Carcinoma of the Breasts and Reproductive Organs 8.7 Patients with Hepatic Impairment 5.4 Liver Disease 8.8 Race 5.5 Risk of Liver Enzyme Elevations with Concomitant 10 OVERDOSAGE Hepatitis C Treatment 11 DESCRIPTION 5.6 High Blood Pressure 12 CLINICAL PHARMACOLOGY 5.7 Gallbladder Disease 12.1 Mechanism of Action 5.8 Carbohydrate and Lipid Metabolic Effects 12.2 Pharmacodynamics 5.9 Headache 12.3 Pharmacokinetics 5.10 Bleeding Irregularities 13 NONCLINICAL TOXICOLOGY 5.11 COC Use Before or During Early Pregnancy 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility 5.12 Depression 14 CLINICAL STUDIES 5.13 Interference with Laboratory Tests 15 REFERENCES 5.14 Monitoring 16 HOW SUPPLIED/STORAGE AND HANDLING 5.15 Other Conditions 16.1 How Supplied 6 ADVERSE REACTIONS 16.2 Storage 6.1 Clinical Trials Experience 17 PATIENT COUNSELING INFORMATION 6.2 Postmarketing Experience *Sections or subsections omitted from the full prescribing information are not listed Page 2 of 31 FULL PRESCRIBING INFORMATION WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptives (COC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, COCs should not be used by women who are over 35 years of age and smoke [see Contraindications (4)]. 1 INDICATIONS AND USAGE Drospirenone and ethinyl estradiol tablets are indicated for use by women to prevent pregnancy. 2 DOSAGE AND ADMINISTRATION 2.1 How to Take Drospirenone and Ethinyl Estradiol Tablets Take one tablet by mouth at the same time every day. The failure rate may increase when pills are missed or taken incorrectly. To achieve maximum contraceptive effectiveness, drospirenone and ethinyl estradiol tablets must be taken as directed, in the order directed on the blister pack. Single missed pills should be taken as soon as remembered. 2.2 How to Start Drospirenone and Ethinyl Estradiol Tablets Instruct the patient to begin taking drospirenone and ethinyl estradiol tablets either on the first day of her menstrual period (Day 1 Start) or on the first Sunday after the onset of her menstrual period (Sunday Start). Day 1 Start During the first cycle of drospirenone and ethinyl estradiol tablets use, instruct the patient to take one yellow drospirenone and ethinyl estradiol tablet daily, beginning on Day 1 of her menstrual cycle. (The first day of menstruation is Day 1.) She should take one yellow drospirenone and ethinyl estradiol tablet daily for 21 consecutive days, followed by one white tablet daily on Days 22 through 28. Drospirenone and ethinyl estradiol tablets should be taken in the order directed on the package at the same time each day, preferably after the evening meal or at bedtime with some liquid, as needed. Drospirenone and ethinyl estradiol tablets can be taken without regard to meals. If drospirenone and ethinyl estradiol tablets are first taken later than the first day of the menstrual cycle, drospirenone and ethinyl estradiol tablets should not be considered effective as a contraceptive until after the first 7 consecutive days of product administration. Instruct the patient to use a non-hormonal contraceptive as back-up during the first 7 days. The possibility of ovulation and conception prior to initiation of medication should be considered. Sunday Start During the first cycle of drospirenone and ethinyl estradiol tablets use, instruct the patient to take one yellow drospirenone and ethinyl estradiol tablet daily, beginning on the first Sunday after the onset of her menstrual period. She should take one yellow drospirenone and ethinyl estradiol tablet daily for 21 consecutive days, followed by one white tablet daily on Days 22 through 28. Drospirenone and ethinyl estradiol tablets should be taken in the order directed on the package at the same time each day, preferably after the evening meal or at bedtime with some liquid, as needed. Drospirenone and ethinyl Page 3 of 31 estradiol tablets can be taken without regard to meals. Drospirenone and ethinyl estradiol tablets should not be considered effective as a contraceptive until after the first 7 consecutive days of product administration. Instruct the patient to use a non-hormonal contraceptive as back-up during the first 7 days. The possibility of ovulation