Package Leaflet: Information For The User

Methotrexate 100 mg/ml Concentrate for Solution for Infusion

Methotrexate

Read all of this leaflet carefully before you

start using this medicine because it contains

important information for you.

-    Keep this leaflet. You may need to read it again.

-    If you have any further questions, ask your doctor or pharmacist or nurse.

-    This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their sign of illness are the same as yours.

-    If you get any side effects, talk to your doctor, or pharmacist or nurse. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet:

1.    What Methotrexate is and what it is used for

2.    What you need to know before you use Methotrexate

3.    How to use Methotrexate

4.    Possible side effects

5.    How to store Methotrexate

6.    Contents of the pack and other information

1. What Methotrexate is and what it is used for

Methotrexate contains the active substance methotrexate. Methotrexate is a cytostatic that inhibits cell growth. Methotrexate has its greatest effect on cells which increase frequently like cancer cells, bone marrow cells and skin cells.

Methotrexate is used in the treatment of the following types of cancer:

-    acute lymphocytic leukaemia,

-    non-Hodgkin's lymphomas,

-    osteogenic sarcoma,

-    adjuvant and in advance disease of breast cancer,

-    metastatic or recurrent head and neck cancer,

-    choriocarcinoma and similar trophoblastic diseases,

-    advanced cancer of urinary bladder.

2. What you need to know before you take Methotrexate

Do not use Methotrexate

-    If you are allergic (hypersensitive) to methotrexate or any of the other ingredients of this medicine (listed in section 6).

-    If you have severe liver or kidney disease .

-    If you have increased alcohol consumption.

-    If you have disorders of the blood-forming system.

-    If you have severe or existing infection such as tuberculosis and HIV.

-    If you have ulcers in the mouth and throat or ulcers in the stomach and gut.

-    If you are pregnant or breastfeeding (see section Pregnancy, breast-feeding and fertility).

You should not be given live vaccines during

treatment with Methotrexat Accord.

Warnings and precautions

-    Methotrexate can cause serious and sometimes life-threatening undesirable effects. Your doctor will talk to you about the advantage and risks of the treatment and what the early signs and symptoms of undesirable effects are.

-    Methotrexate has been reported to cause foetal death and/or congenital malformations. Pregnancy should be avoided if you or your partner is being treated with Methotrexate (see Pregnancy and breast-feeding and fertility).

-    Your skin or eyes can be extremely sensitive to sunlight or other forms of light during the treatment with Methotrexate. Therefore sunlight and solarium should be avoided.

-    Methotrexate can cause decrease in cells responsible for providing immunity, carrying oxygen, and those responsible for normal blood clotting, thereby increasing chances of you getting the infections (e.g pneumonia) or increased bleedings.

Talk to your doctor, pharmacist or nurse before

taking Methotrexate

-    If you are to undergo radiotherapy at the same time as the Methotrexate treatment. The risk of tissue and bone damage can increase with simultaneous treatment.

-    If you are having treatment in your spine (intrathecally) or in a vein (intravenously) this can cause a potentially life-threatening inflammation in the brain.

Methotrexate 100 mg/ml must not be administered in your spine (intrathecally).

-    If you have a medical condition that means that fluid is retained in your body, for example in the lungs or in the stomach.

-    If you have impaired kidney function.

-    If you have impaired liver function.

-    If you have an infection.

-    If you need to be vaccinated. Methotrexate can reduce the effect of the vaccines.

-    If you have insulin dependent diabetes, Methotrexate treatment should be carefully monitored.

Recommended follow-up examinations and

precautions:

Even when methotrexate is used at low doses,

serious side effects can occur. In order to

recognise these in good time, your doctor must carry out check-ups and laboratory tests.

Before the start of treatment:

Before treatment is started your doctor may carry out blood tests, and also to check how well your kidneys and liver are working. You may also have a chest X-ray. Further tests may also be done during and after treatment. Do not miss appointments for blood tests.

Other medicines and Methotrexate

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines, Methotrexate affects or is affected by certain other medicinal products against:

-    Pain and inflammation (so called NSAIDs and salicylates)

-    Cancer (cisplatin, cytarabine, mercaptopurine)

-    Infections (ciprofloxacin and antibiotics such as penicillins, tetracycline and chloramphenicol)

-    Asthma (theophylline)

-    Vitamin preparations containing folic acid or substances like folic acid

-    Rheumatism (leflunomide)

-    High blood pressure (furosemide)

-    Gout (probenicide)

-    Radiotherapy

-    Stomach ulcers, heartburn, reflux (such as omeprazole, pantoprazole, lansoprazole)

-    Epilepsy (phenytoin)

-    Psoriasis or severe acne (retinoids, such as acitretin ot isotretinoin)

-    Rheumatoid arthritis or bowel disease (sulfasalazine)

-    Rejection after an organ transplant (azathioprine)

-    If you need to be vaccinated with a live vaccination

Methotrexate with food, drink and alcohol

During treatment with Methotrexate, you should not drink any alcohol and you should avoid excessive consumption of coffee, soft drinks containing caffeine and black tea. Also make sure you drink plenty of liquids during treatment with Methotrexate because dehydartion (reduction in body water) can increase the toxicity of Methotrexate.

Pregnancy, breast-feeding and fertility

If you are pregnant or breast-feeding or think you may be pregnant or are planning to have a baby, tell your doctor for advice before taking this medicine.

Methotrexate has been reported to cause foetal death and/or congenital malformations. Therefore do not use Methotrexate during pregnancy except with an explicit prescription from a doctor. Tell your doctor immediately if you think you are pregnant.

Pregnancy should be avoided if you or your partner is being treated with Methotrexate, as treatment with Methotrexate of both male and female can affect the foetus. How long you and your partner should wait before you/your partner try to get pregnant after completing treatment is not known. The recommendations vary from three months to one year.

Methotrexate is excreted breast milk in such quantities that there are risks of affecting the baby. Breast-feeding should therefore be suspended during treatment with Methotrexate.

Methotrexate can cause genetic changes. It can affect the sperm and egg production, which leads to deformities. Treatment with methotrexate can leads to infertility. Male patients are exploring the possibility to preserve sperm before starting treatment.

Driving and using machines

Undesirable effects such as tiredness and dizziness may occur. If you feel tired or dizzy do not drive and do not use machines.

Methotrexate contains sodium

Methotrexate contains 194 mg of sodium per meximum daily dose.To be taken into consideration by patients on a controlled sodium diet.

3. How to take Methotrexate

Methotrexate is given to you by healthcare professionals.

The dose you receive and how often you receive the dose, depend on the disease you are being treated for your state of health and your age, weight and body surface. Methotrexate can be given in a muscle (intramuscularly), in a vein (intravenously), or in an artery (intra-arterially).

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them. Methotrexate can have undesirable effects which may be dangerous or life-threatening. During the treatment you should be alert to signs of undesirable effects and report them to your doctor.

Contact a doctor immediately if you notice any of the following undesirable effects. You may need immediate medical care.

The following information is intended for medical or healthcare professional only

Instruction on how to prepare, handle and dispose of Methotrexate 100 mg/ml concentrate for solution for infusion

The solution should be visually inspected prior to use. Only clear solution practically free from particles should be used.

Methotrexate injection may be further diluted with an appropriate preservative-free medium such as glucose solution (5%) or sodium chloride solution (0.9%). Chemical and physical stability of the diluted solution have been demonstrated in glucose solution (5%) and sodium chloride solution (0.9%) at concentrations of 5mg/ml and 20mg/ml for 36 hours at 20-25°C and 35 days at 2-8°C. Diluted product is stable in both diluents at both concentrations for 36 hours at 20-25°C and 35 days at 2-8°C. For microbial point of view, the product should be used immediately. If not used immediately, in-use storage times and condition prior to use are the responsibility of the user and would not longer than 24 hours at 2 to 8°C, unless dilution has taken place in controlled validated aseptic condition.

With respect to the handling the following general recommendations should be considered: The

•    Unexplained breathlessness, dry cough or wheezing (symptoms of lung problems).

•    Sudden itching, skin rash (urticaria), swollen hands, feet, ankles, face, lips, mouth or throat (which can make it hard to breathe and swallow). It can also feel as if you are going to faint (symptoms of a severe allergic reaction).

•    Vomiting, diarrhoea or stomatitis and peptic ulcers (Symptoms of effect on gastrointestinal track).

•    Yellowing of the skin or eyes, dark coloured urine (symptoms of effect on the liver)

•    Fever, shivering, aching body and sore throat (symptoms of infection).

•    Unexpected bleeding (for example bleeding gums, dark urine, blood in the urine or vomit) or unexpected bruising, black, tar-like faeces - this can be due to a reduced coagulation capacity or bleeding from the stomach or gut).

•    Skin rashes with flaking or blistering and effects on mucous membranes e.g. in the nose (symptoms of Stevens-Johnsons syndrome, toxic epidermal necrolysis and erythema multiforme).

•    Abnormal behaviour, transient blindness and generalised seizures (Symptoms of effect on central nervous system).

•    Paralysis (paresis).

A list of undesirable effects that have been

reported in treatment with Methotrexate is set out

below according to how common they are.

Very common (may affect more than 1 in 10

people):

•    Loss of appetite, nausea, vomiting, abdominal pain, impaired digestion, dyspepsia

•    Inflammation and ulceration in mouth and throat

•    Increase in level of liver enzyme

Common (may affect up to 1 in 10 people):

•    Herpes zoster

•    Effects on the blood e.g. anaemia, leukopenia, thrombocytopenia

•    Diarrhoea

•    Dry cough, shortness of breath, chest pain, fever

•    Rashes, redness and itching

•    Headache, Tiredness, drowsiness

Uncommon (may affect up to 1 in 100 people)

•    Pancytopenia, agranulocytosis

•    Inflammation of blood vessels

•    Anaphylactoid reactions and allergic vasculitis

•    Vertigo, confusion, depression

•    Convulsions, encephalopathy

•    Lymphoma (tumour in lymph tissue)

•    Pulmonary fibrosis

•    Bleeds and ulcers in the stomach and intestinal tract

•    Inflammation of pancreas

•    Diabetic complications

•    Reduced level of albumin

•    Enhanced pigmentation of the skin

•    Loss of hair, painful lesions of scaly patches caused by psoriasis

•    Increase of rheumatic nodules (lumps of tissues)

•    Effects on skin and mucous membrane, sometimes serious (Stevens-Johnsons syndrome, toxic epidermal necrolysis)

•    Skin becoming hypersensitive to sunlight, urticaria

•    Brittle bones (osteoporosis), arthralgia, myalgia

•    Liver fibrosis and cirrhosis, fatty liver

•    Inflammation and ulceration of urinary bladder, haematuria, dysuria

•    Inflammation and ulceration of vagina

Rare (may affect up to 1 in 1,000 people)

•    Pericarditis, pericarditis effusion and tamponade

•    Megaloblastic anaemia

•    Mood swings

•    Paresis

•    Effects on speech including dysarthria and aphasia

•    Myelopathy

•    Visual disturbance, blurred vision

•    Thrombosis (cerebral, deep vein and retinal vein)

•    Low blood pressure

•    Diabetes

•    Pharyngitis apnoea , bronchial asthma, gingivitis

•    Inflammation in the small intestine

•    Blood in the faeces

•    Malabsorption

•    Acne, sores on the skin, pigment changes of the nails, bruises

•    Fractures

•    Renal failure, oliguria, azotaemia and anuria

•    Hyperuricemia

•    Elevated serum creatinine and urea level

•    Liver damage.

•    Abnormal development of mammary glands

Very rare (may affect up to1 in 10,000 people)

•    Infections, sepsis opportunistic infections

•    Severe failure of the bone marrow, anaemia due to the fact that the bone marrow cannot produce blood cells (aplastic anaemia) Lymphadenopathy, lymphoproliferative disorder, eosinophilia, neutropenia and hypogammaglobulinaemia

•    Immunosuppression

•    Insomnia

•    Impaired intellectual functions such as thinking, remembering and reasoning

•    Joint and/or muscle pain, lack of strength

•    Myasthenia (muscle weakness)

•    Meningism (paralysis, vomiting), acute aseptic meningitis

•    Abnormal sensations, changes in sense of taste (metallic taste)

•    Conjunctivitis, retinopathy, loss of vision, puffy eye

•    Inflammation eye follicles epiphora and photophobia

•    Tumour lysis syndrome

•    Allergic vasculitis, hidradentis

•    Problem with lung function, shortness of breath pneumonia

•    Infections of lungs

•    Pleural effusion

•    Dilation of colon (Toxic megacolon), blood in vomit

•    Reactivation of chronic hepatitis, acute liver degeneration, herpes simplex hepatitis, liver insufficiency

•    Painful swelling of skin around nail

•    Expansion of small blood vessels in the skin (paronychia)

•    Proteinuria

•    Loss of libido impotence

•    Menstrual disorder

•    Discharge from the vagina

•    Infertility

•    Fever, impaired wound healing

Not known (frequency cannot be estimated from the available data):

•    Bleeding, blood outside of vessels

•    Psychosis

•    Accumulation of fluid in brain and lungs

•    Metabolic disorder

•    Skin necrosis, exfoliative dermatitis

Methotrexate must not be given in the spine as it may cause very serious side effects.

Reporting of side effects If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any side effects not listed in this leaflet. You can also report side effects directly (see details below). By reporting side effects you can help provide more information on the safety of this medicine.

United Kingdom

Yellow Card Scheme

Website:www.mhra.gov.uk/vellowcard

Ireland

HPRA Pharmacovigilance Earlsfort Terrace IRL - Dublin 2 Tel: +353 1 6764971 Fax: +353 1 6762517 Website: www.hpra.ie e-mail: medsafety@hpra.ie

Malta

ADR Reporting The Medicines Authority Post-Licensing Directorate 203 Level 3, Rue D'Argens GZR-1368 Gzira

Website: www.medicinesauthority.gov.mt e-mail: postlicensing.medicinesauthority@.gov.mt

5. How to store Methotrexate

Keep this medicines out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the label/carton after EXP The expiry date refers to the last day of the month.

Do not store above 30°C.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines no longer required. These measures will help to protect the environment.

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6. Contents of the pack and other information

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What Methotrexatecontains

-    The active substance is methotrexate.

-    1 ml solution contains 100 mg methotrexate The other ingredients are sodium hydroxide and water for injection.

What Methotrexatelooks like and contents of the pack

The medicinal product is a clear yellow solution. Package size:

1 vial in carton for 5 ml, 10 ml and 50 ml pack size 5 vials in a carton for 5 ml, 10 ml & 50 ml pack size

Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer

Marketing Authorisation Holder:

Accord Healthcare Limited

Sage House, 319 Pinner Road, North Harrow,

Middlesex, HA1 4HF, United Kingdom

Manufacturer:

Accord Healthcare Limited

Sage House, 319 Pinner Road, North Harrow,

Middlesex, HA1 4HF, United Kingdom

Wessling Hungary Kft

Foti ut 56., Budapest, 1047, Hungary

This leaflet was last revised in 07/2014

product should be used and administered only by trained personnel; the mixing of the solution should take place in designated areas, designed to protect personnel and the environment (e.g safety cabins); protective clothing should be worn (including gloves, eye protection, and masks if necessary).

Pregnant healthcare personnel should not handle and/or administer Methotrexate.

Methotrexate should not come into contact with the skin or mucosa. In the event of contamination, the affected area must be irrigated immediately with copious quantities of water at least ten minutes.

For single use only. Any unused solution should be discarded. Waste should be disposed of carefully in suitable separate containers, clearly labelled as to their contents (as the patient's body fluids and excreta may also contain appreciable amounts of antineoplastic agents and it has been suggested that they, and material such as bed linen contaminated with them, should also be treated as hazardous waste). Any unused product or waste should be disposed of in accordance with local requirements by incineration

Adequate procedures should be in place for accidental contamination due to spillage; staff exposure to antineoplastic agents should be recorded and monitored.