SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Nacrez 75 microgram Film-coated Tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains 75 micrograms desogestrel. Excipient with known effect

Each film-coated tablet contains 54.35 mg lactose monohydrate. For the full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Film-coated tablet.

White to off white, circular, biconvex tablets of 5.4-5.8 mm diameter without embossing.

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

Oral contraception.

4.2 Posology and method of administration

Posology

How to start Nacrez

No preceding hormonal contraceptive use (in the past month)

Tablet-taking has to start on day 1 of the woman’s natural cycle (day 1 is the first day of her menstrual bleeding). Starting on days 2-5 is allowed, but during the first cycle a barrier method is recommended for the first 7 days of tablet-taking.

Following first-trimester abortion

After first-trimester abortion it is recommended to start immediately. In that case there is no need to use an additional method of contraception.

Following delivery, preterm delivery or second-trimester abortion

Contraceptive treatment with Nacrez after delivery can be initiated before the menstruations have returned. If more than 21 days have elapsed after delivery, pregnancy ought to be ruled out and an additional method of contraception should be used for the first week (see section 4.6).

How to start Nacrez when changing from other contraceptive methods

Changing from a combined hormonal contraceptive (combined oral contraceptive

(COC), vaginal ring, or transdermalpatch).

The woman should start Nacrez preferably on the day after the last active tablet (the last tablet containing the active substances) of her previous COC or on the day of removal of her vaginal ring or transdermal patch. In these cases, the use of an additional contraceptive is not necessary. Not all contraceptive methods may be available in all EU countries.

The woman may also start at the latest on the day following the usual tablet-free, patch-free, ring-free, or placebo tablet interval of her previous combined hormonal contraceptive, but during the first 7 days of tablet-taking an additional barrier method is recommended.

Changing from a progestogen-only-method (minipill, injection, implant or from a progestogen-releasing intrauterine system [IUS])

The woman may switch any day from the minipill (from an implant or the IUS on the day of its removal, from an injectable when the next injection would be due).

Management of missed tablets

Contraceptive protection may be reduced if more than 36 hours have elapsed between two tablets. If the user is less than 12 hours late in taking any tablet, the missed tablet should be taken as soon as it is remembered and the next tablet should be taken at the usual time.

If she is more than 12 hours late, she should use an additional method of contraception for the next 7 days. If tablets were missed in the first week and intercourse took place in the week before the tablets were missed, the possibility of a pregnancy should be considered.

Advice in case of gastrointestinal disturbances

In case of severe gastro-intestinal disturbance, absorption may not be complete and additional contraceptive measures should be taken.

If vomiting occurs within 3-4 hours after tablet-taking, absorption may not be complete. In such an event, the advice concerning missed tablets, as given in this section is applicable.

Treatment surveillance

Before prescription, a thorough case history should be taken and a thorough gynaecological examination is recommended to exclude pregnancy. Bleeding disturbances, such as oligomenorrhoea and amenorrhoea should be investigated before prescription.

The interval between check-ups depends on the circumstances in each individual case. If the prescribed product may conceivably influence latent or manifest disease (see section 4.4), the control examinations should be timed accordingly.

Despite the fact that Nacrez is taken regularly, bleeding disturbances may occur. If bleeding is very frequent and irregular, another contraceptive method should be considered. If the symptoms persist, an organic cause should be ruled out.

Management of amenorrhoea during treatment depends on whether or not the tablets have been taken in accordance with the instructions and may include a pregnancy test.

The treatment should be stopped if a pregnancy occurs.

Women should be advised that Nacrez does not protect against HIV (AIDS) and other sexually transmitted diseases.

Paediatric population

The safety and efficacy of desogestrel in adolescents below 18 years has not yet been established. No data are available.

Method of administration

Tablets must be taken every day at about the same time with a small amount of liquid so that the interval between two tablets always is 24 hours. The first tablet should be taken on the first day of menstrual bleeding. Thereafter one tablet each day is to be taken continuously, without taking any notice on possible bleeding. A new blister is started directly the day after the previous one.

4.3 Contraindications

-    Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

-    Active venous thromboembolic disorder.

-    Presence or history of severe hepatic disease as long as liver function values have not returned to normal.

-    Known or suspected sex-steroid sensitive malignancies.

-    Undiagnosed vaginal bleeding.

4.4 Special warnings and precautions for use

If any of the conditions/risk factors mentioned below is present, the benefits of progestogen use should be weighed against the possible risks for each individual woman and discussed with the woman before she decides to start with Nacrez. In the event of aggravation, exacerbation, or first appearance of any of these conditions, the woman should contact her physician. The physician should then decide on whether the use of Nacrez should be discontinued.

The risk for breast cancer increases in general with increasing age. During use of combined oral contraceptives (COCs) the risk of having breast cancer diagnosed is slightly increased. This increased risk disappears gradually within 10 years after discontinuation of COC use and is not related to the duration of use, but to the age of the woman when using the COC. The expected number of cases diagnosed per 10,000 women who use COCs (up to 10 years after stopping) relative to never users over the same period has been calculated for the respective age groups and is presented in the table below.

Age Group	Expected Cases COC-users	Expected cases COC-non-users
16-19 years	4.5	4
20-24 years	17.5	16
25-29 years	48.7	44
30-34 years	110	100
35-39 yeas	180	160
40-44 years	260	230

The risk in users of progestogen-only contraceptives (POC), such as Nacrez, is possibly of similar magnitude as that associated with COCs. However, for POCs the evidence is less conclusive. Compared to the risk of getting breast cancer ever in life, the increased risk associated with COCs is low. The cases of breast cancer diagnosed in COC users tend to be less advanced than in those who have not used COCs. The increased risk in COC users may be due to an earlier diagnosis, biological effects of the pill or a combination of both.

Since a biological effect of progestogens on liver cancer cannot be excluded an individual benefit/risk assessment should be made in women with liver cancer.

When acute or chronic disturbances of liver function occur the woman should be referred to a specialist for examination and advice.

Epidemiological investigations have associated the use of COCs with an increased incidence of venous thromboembolism (VTE, deep venous thrombosis and pulmonary embolism). Although the clinical relevance of this finding for desogestrel used as a contraceptive in the absence of an oestrogenic component is unknown, Nacrez should be discontinued in the event of a thrombosis. Discontinuation of Nacrez should also be considered in case of long-term immobilisation due to surgery or illness. Women with a history of thrombo-embolic disorders should be made aware of the possibility of a recurrence.

Although progestogens may have an effect on peripheral insulin resistance and glucose tolerance, there is no evidence for a need to alter the therapeutic regimen in diabetics using progestogen-only pills. However, diabetic patients should be carefully observed during the first months of use.

If a sustained hypertension develops during the use of Nacrez, or if a significant increase in blood pressure does not adequately respond to antihypertensive therapy, the discontinuation of Nacrez should be considered.

Treatment with Nacrez leads to decreased oestradiol serum levels, to a level corresponding with the early follicular phase. It is as yet unknown whether the decrease has any clinically relevant effect on bone mineral density.

The protection with traditional progestogen-only pills against ectopic pregnancies is not as good as with combined oral contraceptives, which has been associated with the frequent occurrence of ovulations during the use of progestogen-only pills. Despite the fact that Nacrez consistently inhibits ovulation, ectopic pregnancy should be taken into account in the differential diagnosis if the woman gets amenorrhoea or abdominal pain.

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

The following conditions have been reported both during pregnancy and during sex steroid use, but an association with the use of progestogens has not been established:

-    jaundice and/or pruritus related to cholestasis;

-    gallstone formation; porphyria;

-    systemic lupus erythematosus;

-    haemolytic uraemic syndrome;

-    Sydenham’s chorea;

-    herpes gestationis;

-    otosclerosis-related hearing loss;

-    (hereditary) angioedema.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5 Interaction with other medicinal products and other forms of interaction

Interactions between hormonal contraceptives and other medicinal products may lead to breakthrough bleeding and/or contraceptive failure. The following interactions have been reported in the literature (mainly with combined contraceptives but occasionally also with progestogen-only contraceptives).

Hepatic metabolism:

Interactions can occur with medicinal products that induce microsomal enzymes, which can result in increased clearance of sex hormones (such as, hydantoins (e.g. phenytoin), barbiturates (e.g. phenobarbital), primidone, carbamazepine, rifampicin, and possibly also for oxcarbazepine, topiramate, rifabutin, felbamate, ritonavir, nelfinavir, griseofulvin and products containing St. John’s wort (Hypericum perforatum)).

Maximal enzyme induction is not seen for 2-3 weeks, but may then be sustained for at least 4 weeks after the cessation of medicinal product therapy. Women on treatment with any of these medicinal products should temporarily use a barrier method in addition to Nacrez. With microsomal enzyme-inducing medicinal products, the barrier method should be used during the time of concomitant medicinal product administration and for 28 days after their discontinuation. For women on long-term therapy with hepatic enzyme inducers a non-hormonal method contraception should be considered.

During treatment with medical charcoal, the absorption of the steroid in the tablet may be reduced and thereby the contraceptive efficacy. Under these circumstances, the advice as given for

missed tablets in section 4.2 is applicable.

Hormonal contraceptives may interfere with the metabolism of other active substances. Accordingly, plasma and tissue concentrations may either increase (e.g. cyclosporine) or decrease.

Note: The prescribing information of concomitant medicinal products should be consulted to identify potential interactions.

Laboratory tests

Data obtained with COCs have shown that contraceptive steroids may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, serum levels of (carrier) proteins, e.g. corticosteroid binding globulin and lipid/lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. The changes generally remain within the normal range. To what extent this also applies to progestogen-only contraceptives is not known.

4.6 Fertility, pregnancy and lactation

Pregnancy

Nacrez is contraindicated (see section 4.3) in pregnancy. If pregnancy occurs during

treatment with Nacrez,

further intake should be stopped.

Animal studies have shown that very high doses of progestogenic substances may cause masculinisation of female foetuses.

Extensive epidemiological studies have revealed neither an increased risk of birth defects in children born to women who used COCs prior to pregnancy, nor a teratogenic effect when COCs were taken inadvertently during early pregnancy. Pharmacovigilance data collected with various desogestrel-containing COCs also do not indicate an increased risk.

Breast-feeding

Nacrez does not influence the production or the quality (protein, lactose, or fat concentration) of breast milk. However, small amounts of etonogestrel are excreted in the breast milk. As a result, 0.01 - 0.05 microgram etonogestrel per kg body weight per day may be ingested by the child (based on an estimated milk ingestion of 150 millilitre per kg body weight per day.

Limited long-term follow-up data are available on children, whose mothers started using desogstrel during the 4^th to 8 ^th week post-partum. They were breast-fed for 7 months and followed up to 1.5 years (n=32) or to 2.5 years (n=14) of age. Evaluation of growth and physical and psychomotor development did not indicate any differences in comparison to breast-fed infants, whose mother used a copper-IUD. Based on the available data Nacrez may be used during lactation. The development and growth of a breast-fed infant, whose mother uses Nacrez, should however be carefully observed.

4.7 Effects on ability to drive and use machines

Nacrez has no or negligible influence on the ability to drive and use machines.

4.8 Undesirable effects

The most commonly reported undesirable effect in the clinical trials is bleeding irregularity. Some kind of bleeding irregularity has been reported in up to 50% of women using desogestrel. Since desogestrel causes ovulation inhibition close to 100%, in contrast to other progestogen-only-pills, irregular bleeding is more common than with other progestogen-only pills. In 20-30% of the women, bleeding may become more frequent, whereas in another 20% bleeding may become less frequent or totally absent. Vaginal bleeding may also be of longer duration. After a couple of months of treatment, bleedings tend to become less frequent. Information, counselling and a bleeding diary can improve the woman’s acceptance of the bleeding pattern.

The most commonly reported other undesirable effects in the clinical trials with desogestrel (> 2.5%) were acne, mood changes, breast pain, nausea and weight increase. The undesirable effects mentioned in the table below.

All ADRs are listed by system organ class and frequency; common (>1/100 to <1/10), uncommon (>1/1,000

to <1/100) and rare (>1/10,000 to <1/1,000) and not known (cannot be estimated from the available data).

System Organ Classes	Frequency of adverse reactions
	Common	Uncommon	Rare
Infections and infestations		Vaginal infection
Psychiatric disorders	Mood altered, Libido decreased Depressed mood
Nervous system disorders	Headache
Eye disorders		Contact lens intolerance
Gastrointestinal disorders	Nausea	Vomiting
Skin and	Acne	Alopecia	Rash, Urticaria,

subcutaneous tissue disorders			Erythema nodosum
Reproductive system and breast disorders	Breast pain, Menstruation irregular, Amenorrhoea	Dysmenorrhoea, Ovarian cyst
General disorders and administration site conditions		Fatigue
Investigations	Weight increased

Breast discharge may occur during use of desogestrel. On rare occasions, ectopic pregnancies have been reported (see section 4.4). In addition, (aggravation of) angioedema and/or aggravation of hereditary angioedema may occur (see section 4.4).

In women using (combined) oral contraceptives a number of (serious) undesirable effects have been reported. These include venous thromboembolic disorders, arterial thromboembolic disorders, hormone-dependent tumours (e.g. liver tumours, breast cancer) and chloasma, some of which are discussed in more detail in section 4.4.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows

continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are

asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

4.9 Overdose

There have been no reports of serious deleterious effects from overdose. Symptoms that may occur in this case are nausea, vomiting and, in young girls, slight vaginal bleeding. There are no antidotes and further treatment should be symptomatic.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: hormonal contraceptives for systemic use,

ATC code: G03AC09

Nacrez is a progestogen-only pill, which contains the progestogen desogestrel. Like other progestogen-only pills, Nacrez is best suited for use during breast-feeding and for women who may not or do not want to use oestrogens. In contrast to traditional progestogen-only pills, the contraceptive effect of Nacrez is achieved primarily by inhibition of ovulation. Other effects include increased viscosity of the cervical mucus.

When studied for 2 cycles, using a definition of ovulation as a progesterone level greater than 16 nmol/L for 5 consecutive days, the ovulation incidence was found to be 1% (1/103) with a 95% confidence interval of 0.02%- 5.29% in the ITT group (user and method failures). Ovulation inhibition was achieved from the first cycle of use. In this study, when desogestrel was discontinued after 2 cycles (56 continuous days) ovulation occurred on average after 17 days (range 7-30 days).

In a comparative efficacy trial (which allowed a maximum time of 3 hours for missed pills), the overall ITT Pearl-Index found for desogestrel was 0.4 (95% confidence interval 0.09 - 1.20), compared to 1.6 (95% confidence interval 0.42 - 3.96) for 30 pg levonorgestrel.

The Pearl-Index for Nacrez is comparable to the one historically found for COCs in the general COC-using population.

Treatment with Nacrez leads to decreased estradiol levels, to a level corresponding to the early follicular phase. No clinically relevant effects on carbohydrate metabolism, lipid metabolism and haemostasis have been observed.

Paediatric population

No clinical data on efficacy and safety are available in adolescents below 18 years.

5.2 Pharmacokinetic properties

Absorption

After oral dosing of desogestrel (DSG) is rapidly absorbed and converted into etonogestrel (ENG). Under steady-state conditions, peak serum levels are reached 1.8 hours after tablet-intake and the absolute bioavailability of ENG is approximately

70%.

Distribution

ENG is 95.5-99% bound to serum proteins, predominantly to albumin and to a lesser extent to SHBG.

Biotransformation

DSG is metabolised via hydroxylation and dehydrogenation to the active metabolite ENG. ENG is metabolised via sulphate and glucuronide conjugation.

Elimination

ENG is eliminated with a mean half-life of approximately 30 hours, with no difference between single and multiple dosing. Steady-state levels in plasma are reached after 4-5 days. The serum clearance after i.v. administration of ENG is approximately 10 l per hour. Excretion of ENG and its metabolites either as free steroid or as conjugates, is with urine and faeces (ratio 1.5:1).

In lactating women, ENG is excreted in breast milk with a milk/serum ratio of 0.370.55. Based on these data and an estimated milk intake of 150 ml/kg/day, 0.01 - 0.05 microgram etonogestrel may be ingested by the infant.

5.3 Preclinical safety data

Toxicological studies did not reveal any effects other than those, which can be explained from the hormonal properties of desogestrel.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Tablet core:

Lactose monohydrate Maize starch Povidone K30 Stearic acid

All-rac-alpha-tocopherol Silica, colloidal anydrous

Film coating:

Hypromellose Macrogol 400 Talc

Titanium Dioxide

6.2    Incompatibilities

Not applicable.

6.3    Shelf life

36 months: Blister pack packed in pouch.

30 months: Blister pack without pouch.

6.4    Special precautions for storage

This medicinal product does not require any special storage conditions.

Nature and contents of container

PVC/Al blister packs containing 28 film-coated tablets per blister. Each carton contains 1x28, 3x28 or 6x28 film-coated tablets.

Blisters have calendar pack design and may or may not be packed individually in laminated pouches

6.6 Special precautions for disposal

No special requirements

7 MARKETING AUTHORISATION HOLDER

Teva UK Limited,

Brampton Road,

Hampden Park,

Eastbourne,

East Sussex,

BN22 9AG UNITED KINGDOM

8    MARKETING AUTHORISATION NUMBER(S)

PL 00289/1706

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

01/08/2012

10    DATE OF REVISION OF THE TEXT

03/02/2016