4.1. Therapeutic indications

Contraception

4.2. Posology and method of administration

Posology

How to take Slynd

One tablet is to be taken daily for 28 consecutive days, one white active tablet daily during the first 24 days and one green inactive tablet daily during the 4 following days. Tablets must be taken every day at about the same time of the day so that the interval between two tablets is always 24 hours. Tablets should be taken in the order shown on the blister. Stickers marked with the 7 days of the week are provided. The woman should choose the sticker that starts with the day she begins taking the tablets and stick it on the blister.

The first tablet of the treatment should be taken on the first day of menstrual bleeding. Thereafter tablet taking is continuous. A subsequent pack is started immediately after finishing the previous pack, without a break in daily tablet intake.

How to start Slynd

No preceding hormonal contraceptive use (in the past month)

Tablet-taking has to start on day 1 of the woman's natural cycle (first day of her menstrual bleeding). When doing so, no additional contraceptive measures are necessary.

Following first-trimester abortion

After first-trimester abortion it is recommended to start Slynd immediately after abortion took place. In that case there is no need to use an additional contraceptive method.

Following delivery or second-trimester abortion

Contraceptive treatment with Slynd is recommended to start between 21 and 28 days after delivery or second trimester abortion. If contraceptive treatment with Slynd is initiated later but before the menstruations have returned, pregnancy must be ruled out and an additional method of contraception should be used for the first week.

For breast-feeding women, see section 4.6.

Changing from a combined hormonal contraceptive (combined oral contraceptive (COC), vaginal ring or transdermal patch)

The woman should start Slynd 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.

The woman may also start Slynd at the latest on the day following the usual tablet-free, ring-free, patch-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 (progestogen-only pill (POP), injection, implant) or from a progestogen-releasing intrauterine system (IUS)

The woman may switch any day from another POP and should start Slynd the day after, within 24 hours of discontinuing the previous POP. A woman may switch from an implant or following IUS removal on the same day that the implant or IUS is removed. A woman may switch from using an injectable contraceptive and should start Slynd on the day the next injection was due to occur. In all of these cases, the use of an additional contraceptive is not necessary.

Management of missed tablets

Tablets should be taken every 24 hours. If the woman is less than 24 hours late in taking any single tablet, contraceptive protection is not reduced. The woman should take the tablet as soon as she remembers and should take further tablets at the usual time.

If the user is more than 24 hours late in taking any white, active tablet, contraceptive protection may be reduced and use of a barrier method such as a condom should be considered for the next 7 days. The missed tablet should be taken as soon as it is remembered, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time.

If tablets were missed in the first week after initiation of Slynd and intercourse took place in the week before the tablets were missed, the possibility of a pregnancy should be considered.

If tablets were missed in the third week of pill taking, the risk of reduced reliability is imminent because of the forthcoming 4-day hormone-free interval. However, by adjusting the tablet-intake schedule, reduced contraceptive protection can still be prevented. The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take the active tablets at her usual time. The user is advised not to take the placebo pills and continue straight on to the next active blister pack.

Missed (green) placebo tablets can be disregarded. However, they should be discarded to avoid unintentionally prolonging the interval between active tablet taking.

Advice in case of gastrointestinal disturbances

In case of severe gastrointestinal disturbances (e.g., vomiting or diarrhea), absorption may not be complete and additional contraceptive measures should be taken.

If vomiting or diarrhea occurs within 3-4 hours after tablet taking, a new (replacement) tablet should be taken as soon as possible. The new tablet should be taken within 24 hours of the usual time of tablet-taking if possible. If more than 24 hours elapse, the advice concerning missed tablets, as given in Section 4.2 “Management of missed tablets”, is applicable. If the woman does not want to change her normal tablet-taking schedule, she has to take the extra tablet(s) from another blister pack.

Paediatric population

Safety and efficacy of Slynd have been established in women of reproductive age. Safety and efficacy are expected to be the same for post pubertal adolescents under the age of 18 and users 18 years and older. Use of this product before menarche is not indicated.

Method of administration

Oral use.

4.3. Contraindications

Progestogen-only contraceptives (POCs) like Slynd should not be used in the presence of any of the conditions listed below. Should any of the conditions appear for the first time during Slynd use, the medicinal product should be discontinued immediately.

• Active venous thromboembolic disorder.

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

• Severe renal insufficiency or acute renal failure.

• Known or suspected sex-steroid sensitive malignancies.

• Undiagnosed vaginal bleeding.

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

4.4. Special warnings and precautions for use

If any of the conditions/risk factors mentioned below is present, the benefits of Slynd should be weighed against the possible risks for each individual woman and discussed with the woman before she decides to start using Slynd. 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 whether Slynd use should be discontinued.

Hyperkalemia

Drospirenone is an aldosterone antagonist with potassium sparing properties. In most cases, no increase of potassium levels is to be expected. However, it is recommended to check serum potassium levels during the first treatment cycle in women presenting with renal insufficiency and pre-treatment serum potassium in the upper reference range and during concomitant use of potassium sparing medicinal products (see section 4.5).

Circulatory disorders

From epidemiological studies there is little evidence for an association between progestogen-only preparations and an increased risk of myocardial infarction or cerebral thromboembolism. Rather, the risk of cardiovascular and cerebral events is related to increasing age, hypertension, and smoking. In women with hypertension the risk of stroke may be slightly enhanced by progestogen-only preparations.

Although not statistically significant, some studies indicate that there may be a slightly increased risk of venous thromboembolism (deep venous thrombosis, pulmonary embolism) associated with the use of progestogen-only preparations. Generally recognized risk factors for venous thromboembolism (VTE) include a positive personal or family history (VTE in a sibling or a parent at a relatively early age), age, obesity, prolonged immobilization, major surgery or major trauma.

Treatment should be stopped at once if there are symptoms of an arterial or venous thrombotic event or suspicion thereof and discontinuation of Slynd should be considered in case of prolonged immobilization due to surgery or illness.

Bone metabolism

Treatment with Slynd leads to decreased estradiol serum levels, to a level corresponding with the early follicular phase. It is currently unknown whether the decrease in estradiol serum levels may have a clinically relevant effect on bone mineral density. Loss of bone mineral density is of particular concern during adolescence and early adulthood, a critical period of bone accretion. It is unknown if bone mineral density decrease in this population will reduce peak bone mass and increase the risk for fracture in later life.

Breast Cancer

A meta-analysis from 54 epidemiological studies reported that there is a slightly increased relative risk (RR = 1.24) of having breast cancer diagnosed in women who are currently using oral contraceptives (OCs), mainly using estrogen-progestogen preparations. The excess risk gradually disappears during the course of the 10 years after cessation of combined OC (COC) use. Because breast cancer is rare in women under 40 years of age, the excess number of breast cancer diagnoses in current and recent COC users is small in relation to the overall risk of breast cancer. These studies do not provide evidence for causation. The observed pattern of increased risk may be due to an earlier diagnosis of breast cancer in OC users, the biological effects of OCs or a combination of both. The breast cancers diagnosed in users of OCs tend to be less advanced clinically than the cancers diagnosed in those who have never used OCs.

The risk of having breast cancer diagnosed in users of progestogen-only preparations is possibly of similar magnitude to that associated with COC. However, for progestogen-only preparations, the evidence is based on much smaller populations of users and so is less conclusive than that for COCs.

Other tumours

In rare cases, benign liver tumours, and even more rarely, malignant liver tumours have been reported in users of combined hormonal contraceptives. In isolated cases, these tumours have led to life-threatening intra-abdominal haemorrhages. A hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal haemorrhage occur

Ectopic pregnancy

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 Slynd consistently inhibits ovulation ectopic pregnancy should be taken into account in the differential diagnosis if the woman presents amenorrhoea or abdominal pain.

Liver function

Discontinue Slynd if jaundice develops. Steroid hormones may be poorly metabolized in patients with impaired liver function. Acute or chronic disturbances of liver function may require the discontinuation of Slynd use until markers of liver function return to normal and Slynd causation has been excluded.

Diabetes

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 POPs such as Slynd. However, diabetic patients should be carefully observed during the first months of use. Special attention should be paid to diabetic patients with vascular involvement.

Other conditions

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

Like with any other hormonal contraceptive, 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 Slynd.

Depressed mood and depression are well-known undesirable effects of hormonal contraceptive use (see section 4.8). Depression can be serious and is a well-known risk factor for suicidal behaviour and suicide. Women should be advised to contact their physician in case of mood changes and depressive symptoms, appearing shortly after initiation of the treatment.

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.

Each white active tablet contains 17.50 mg of lactose and each green placebo tablet contains 55.50 mg of lactose (as monohydrate). Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Medical examination/consultation

Prior to the initiation or reinstitution of Slynd a complete medical history (including family history) should be taken and pregnancy must be ruled out. Blood pressure should be measured, and a physical examination should be performed, guided by the contra-indications (see section 4.3) and warnings (see section 4.4). The woman should also be instructed to carefully read the user leaflet and to adhere to the advice given. The frequency and nature of examinations should be based on established practice guidelines and be adapted to the individual woman.

Women should be advised that oral contraceptives do not protect against HIV infections (AIDS) and other sexually transmitted diseases.

Changes in the menstrual bleeding pattern

Disruption of the menstrual bleeding pattern may occur during use of hormonal contraceptives that inhibit ovulation, including Slynd (see section 5.1).

If the 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.

Reduced efficacy

The efficacy of POPs may be reduced in the event of e.g. missed tablets (see section 4.2), gastro-intestinal disturbances (see section 4.2) or concomitant medication (see section 4.5).

Laboratory tests

The use of contraceptive steroids may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, serum levels of (carrier) proteins, e.g. corticosteroid binding globulin and lipid/lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis.

4.5. Interaction with other medicinal products and other forms of interaction

Influence of other medicinal products on Slynd

Interactions can occur between Slynd and other medicinal products that induce microsomal enzymes. This can result in increased clearance of sex hormones and may lead to breakthrough bleeding and/or contraceptive failure.

Management

Enzyme induction can already be observed after a few days of treatment. Maximum enzyme induction is generally seen within a few weeks. After drug therapy is discontinued, enzyme induction may be sustained for about 4 weeks.

Short-term treatment

Women on treatment with enzyme inducing drugs should temporarily use a barrier method or another method of contraception in addition to the POP. The barrier method must be used during the whole time of the concomitant drug therapy and for 28 days after its discontinuation.

If the drug therapy runs beyond the end of the active tablets in the POP pack, the placebo tablets must be discarded, and the next POP pack should be started right away.

Long-term treatment

In women on long-term treatment with enzyme-inducing active substances, another reliable, nonhormonal, method of contraception is recommended.

The following interactions have been reported in the literature (mainly with combined contraceptives but occasionally also with progestogen-only pills).

Substances increasing the clearance of contraceptive hormones (diminished contraceptive efficacy by enzyme induction) e.g.:

Barbiturates, bosentan, carbamazepine, phenytoin, primidone, rifampicin, and HIV medication ritonavir, nevirapine and efavirenz and possibly also felbamate, griseofulvin, oxcarbazepine, topiramate and products containing the herbal remedy St. John's Wort (hypericum perforatum).

Substances with variable effects on the clearance of contraceptive hormones:

When co-administered with sex hormones, many combinations of HIV protease inhibitors (e.g. ritonavir, nelfinavir) and non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine, efavirenz) and/or combinations with Hepatitis C virus (HCV) medicinal products (e.g. boceprevir, telaprevir), can increase or decrease plasma concentrations of progestins. The net effect of these changes may be clinically relevant in some cases.

Therefore, the prescribing information of concomitant HIV/HCV medications should be consulted to identify potential interactions and any related recommendations. In case of any doubt, an additional barrier contraceptive method should be used by women on protease inhibitor or non-nucleoside reverse transcriptase inhibitor therapy.

Substances decreasing the clearance of contraceptive hormones (enzyme inhibitors):

The clinical relevance of potential interactions with enzyme inhibitors remains unknown.

Concomitant administration of strong or moderate CYP3A4 inhibitors such as azole antifungals (e.g. fluconazole, itraconazole, ketoconazole, voriconazole), verapamil, macrolides (e.g. clarithromycin, erythromycin), diltiazem and grapefruit juice can increase plasma concentrations of the progestogen.

In a multiple dose study evaluating the daily (10 days) co-administration of the strong CYP3A4 inhibitor ketoconazole with two drospirenone-containing hormone preparations (drospirenone 3 mg + estradiol 1.5 mg and drospirenone 3 mg + ethinylestradiol 0.02 mg) the AUC (0-24h) of drospirenone was increased 2.3-fold and 2.7-fold, respectively.

Influence of Slynd on other medicinal products

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

Based on in vitro studies and in vivo interaction studies in female volunteers using omeprazole, simvastatin and midazolam as marker substrate, a clinically relevant interaction of drospirenone with the cytochrome P450 mediated metabolism of other active substances is unlikely.

Pharmacodynamic interactions

Published data did not show a significant effect on serum potassium following the concomitant use of drospirenone and ACE-inhibitors or NSAIDs in patients without renal insufficiency. The concomitant use of Slynd with aldosterone antagonists or potassium-sparing diuretics has not been studied. In this case, serum potassium should be tested during the first treatment cycle (see section 4.4).

4.6. Fertility, pregnancy and lactation

Pregnancy

Slynd should not be used during pregnancy.

If pregnancy occurs during treatment with Slynd, further intake should be stopped.

Epidemiological studies have revealed neither an increased risk of birth defects in children born to women who used drospirenone prior to pregnancy, nor a teratogenic effect when drospirenone was taken inadvertently during pregnancy.

Animal studies have shown reproductive toxicity (see section 5.3) Based on these animal data, undesirable effects due to hormonal action of the active compound cannot be excluded.

Breastfeeding

Negligible amounts of drospirenone are excreted in the breast milk. The daily dose of drospirenone in the baby is <1% of the maternal dose. Thus, at therapeutic doses of Slynd, no effects on the breastfed newborns/infants are anticipated. Based on the available data Slyndmay be used during lactation.

Fertility

Slynd is indicated for the prevention of pregnancy.

4.7. Effects on ability to drive and use machines

No studies on the influence on the ability to drive and use machines have been performed with Slynd.

No effects on ability to drive and use machines have been observed in users of oral hormonal contraceptives.

4.8. Undesirable effects

Changes in the bleeding pattern was an adverse reaction frequently reported in the clinical trials (see section 5.1).

The most commonly reported adverse reactions in long-term clinical trials of more than 9 cycles of treatment with <drospirenone> (2,700 women) were acne (3.8%), metrorrhagia (2.9%), headache (2.7%) and breast pain (2.2%).

Tabulated list of adverse reactions

Adverse reactions that have been reported in short- and long- term clinical trials with Slynd are listed in the table below.

All adverse reactions are listed by system organ class and frequency: 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).

System Organ Class (MedDRA version 17.1)

Common

Uncommon

Rare

Infections and infestations

Vaginal infection

Neoplasms benign. malignant and unspecified

Uterine leiomyoma

Blood and lymphatic system disorders

Anaemia

Immune system disorders

Hypersensitivity

Metabolism and nutrition disorders

Appetite disorder

Hyperkalaemia

Psychiatric disorders

Libido disorder

Mood disturbances

Anxiety symptoms

Depression

Depressed mood

Nervous system disorders

Headache

Dizziness

Eye disorders

Contact lens intolerance

Vascular disorders

Hot flush

Hypertension

Gastrointestinal disorders

Nausea

Abdominal pain

Vomiting

Diarrhoea

Constipation

Skin and subcutaneous tissue disorders

Acne

Alopecia

Hyperhidrosis

Rash

Seborrhoea

Pruritus

Dermatitis

Renal and urinary disorders

Polyuria

Reproductive system and breast disorders

Breast discomfort

Metrorrhagia

Vaginal haemorrhage

Dysmenorrhea

Menstruation irregular

Amenorrhoea

Menstrual disorders

Pelvic pain

Ovarian cyst

Vulvovaginal dryness

Vaginal discharge

Breast cyst

Cervical dysplasia

Galactorrohoea

Vulvovaginal pruritus

General disorders and administration site conditions

Fatigue

Oedema peripheral

Investigations

Weight increased

Transaminases increased

Blood bilirubin increased

Blood creatine phosphokinase increased

Gamma-Glutamyltransferase increased

Blood triglycerides increased

Weight decreased

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 national reporting system listed in Appendix V.

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 slight vaginal bleeding. There are no antidotes and further treatment should be symptomatic.

Drospirenone however is a spironolactone analogue which has antimineralocorticoid properties. Serum potassium and sodium, and evidence of metabolic acidosis, should be monitored in cases of overdose.