Metoject
Package Leaflet: Information for the user
Metoject 10 mg/ml solution for injection, pre-filled syringe
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, please ask your doctor or pharmacist.
This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.
What is in this leaflet
What Metoject is and what it is used for
What you need to know before you use Metoject
How to use Metoject
Possible side effects
How to store Metoject
Contents of the pack and other information
1. What Metoject is and what it is used for
Metoject contains methotrexate as active substance.
Methotrexate is a substance with the following properties:
• it interferes with the growth of certain cells in the body that reproduce quickly
• it reduces the activity of the immune system (the body’s own defence mechanism)
• it has anti-inflammatory effects
Metoject is indicated for the treatment of:
Severe, active rheumatoid arthritis in adult patients,
Polyarthritic forms of severe, active juvenile idiopathic arthritis when treatment with non-steroidal anti-inflammatory medicines (NSAIDs) has been inadequate
Severe and generalised psoriasis vulgaris, especially the plaque-type, and psoriatic arthritis in adult patients
Mild to moderate Crohn’s Disease in adult patients when adequate treatment with other medicines is not possible.
Rheumatoid arthritis (RA)is a chronic collagen disease, characterised by inflammation of the synovial membranes (joint membranes). These membranes produce a fluid which acts as a lubricant for many joints. The inflammation causes thickening of the membrane and swelling of the joint.
Juvenile arthritis concerns children and adolescents less than 16 years. Polyarthritic forms are indicated if 5 or more joints are affected within the first 6 months of the disease.
Psoriatic arthritis is a kind of arthritis with psoriatric lesions of the skin and nails, especially at the joints of fingers and toes.
Psoriasis vulgaris is a common chronic skin disease, characterised by red patches covered by thick, dry, silvery, adherent scales.
Metoject modifies and slows down the progression of the disease.
Crohn’s Disease is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract causing symptoms such as abdominal pain, diarrhea, vomiting or weight loss.
2. What you need to know before you use Metoject
Do not use Metoject
if you are allergic to methotrexate or any of the other ingredients of this medicine (listed in section 6),
if you suffer from severe liver or kidney diseases or blood diseases,
if you regularly drink large amountsof alcohol,
if you suffer from a severe infection, e.g. tuberculosis, HIVor other immunodeficiency syndromes,
if you suffer from ulcers in the mouth, stomach ulcer or intestinal ulcer,
if you are pregnant or breast-feeding,
if you receive vaccinations with live vaccines at the same time.
Warnings and precautions
Talk to your doctor or pharmacist before taking Metoject if:
you are elderly or if you feelgenerallyunwell and weak
your liver function is impaired,
you suffer from dehydration(water loss).
Recommended follow-up examinations and safety measures:
Even when Metoject is administered in low doses, severe side effects can occur. In order to detect them in time, check-ups and laboratory tests have to be carried out by your doctor.
Before therapy:
Before starting the treatment, blood samples will be taken in order to check that you have enough blood cells, to check your liver function, serum albumin (a protein in the blood) and kidney function. Your doctor will also check if you suffer from tuberculosis (infectious disease in combination with little nodules in the affected tissue) and a chest X-ray will be taken.
During therapy:
You will have the following tests at least once a month during the first six months and at least every three months thereafter:
Examination of the mouth and throat for mucosal changes
Blood tests
Check of liver function
Check of kidney function
Check of respiratory system and if necessary lung function test
Methotrexate may affect your immune system and vaccination results. It may also affect the result of immunological tests. Inactive, chronic infections (e.g. herpes zoster [shingles], tuberculosis, hepatitis B or C) may flare up. During therapy with Metoject you must not be vaccinated with live vaccines.
Radiation induced dermatitis and sun-burn can reappear under methotrexate therapy (recall-reaction). Psoriatic lesions can exacerbate during UV-irradiation and simultaneous administration of methotrexate.
Enlarged lymph nodes (lymphoma) may occur and therapy does then have to be discontinued.
Diarrhoea can be a toxic effect of Metoject and requires an interruption of therapy. If you suffer from diarrhoea please speak to your doctor.
Encephalopathy (a brain disorder)/leukoencephalopathy (a special disorder of the white brain substance) have been reported in cancer patients receiving methotrexate therapy and cannot be excluded for methotrexate therapy in other diseases.
Other medicines and Metoject
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines
The effect of the treatment may be affected if Metoject is administered at the same time as certain other medicines:
Medicines harming the liver or the blood count, e.g. leflunomide
Antibiotics (medicines to prevent/fight certain infections) such as: tetracyclines, chloramphenicol, and non-absorbable broad-spectrum antibiotics, penicillines, glycopeptides, sulphonamides(sulphur containing medicines that prevent/fight certain infections),ciprofloxacin and cefalotin
Some medicines against pain and/or inflammation known as non-steroidal anti-inflammatory drugs (e.g. diclofenac and ibuprofen, salicylates like acetylsalicylic acid and pyrazoles like metamizole)
Probenecid (medicine against gout)
Weak organic acids such as loop diuretics ("water tablets")
Medicinal products, which may have adverse effects on the bone marrow, e.g. trimethoprim-sulphamethoxazole (an antibiotic) and pyrimethamine
Sulphasalazine (antirheumatic medicine)
Azathioprine (an immunosuppressive agent sometimes used in severe forms of rheumatoid arthritis)
Mercaptopurine (a cytostatic agent)
Retinoids (medicine against psoriasis and other dermatological diseases)
Theophylline (medicine against bronchial asthma and other lung diseases)
Proton-pump inhibitors (medicines against stomach trouble)
Hypoglycaemics (medicines that are used to lower the blood sugar)
Vitamins containing folic acid may impair the effect of your treatment and should only be taken when advised by your doctor.
Vaccination with live vaccine should be avoided.
Metoject with food, drink and alcohol
Consumption of alcohol as well as excessive consumption of coffee, caffeine-containing soft-drinks and black tea should be avoided during treatment with Metoject.
Pregnancy, breast-feeding and fertility
If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.
You must not take Metoject during pregnancy. There is a risk of harm to the foetus and miscarriage. Men and women should use effective contraception during treatment and during a further six months after treatment with Metoject has been discontinued.
In women of child-bearing age, pregnancy must be excluded with certainty by taking appropriate measures, e.g. pregnancy test, prior to therapy.
Breast-feeding should be discontinued prior and during treatment with Metoject.
As methotrexate can be genotoxic, all women who wish to become pregnant are advised to consult a genetic counselling centre, if possible, already prior to therapy, and men should seek advice about the possibility of sperm preservation before starting therapy.
Driving and using machines
Adverse reactions affecting the central nervous system, e.g. tiredness and dizziness, may occur during treatment with Metoject. Thus the ability to drive a vehicle and/or to operate machines may, in certain cases, be impaired. If you feel tired or drowsy you should not drive or use machines.
Metoject contains sodium
This medicinal product contains less than 1 mmol sodium (23 mg) per dose, i.e. essentially “sodium-free”.
3. How to use Metoject
Your doctor decides on the dosage, which is adjusted individually. Usually it takes 4 – 8 weeks before there is any effect of the treatment.
Metoject is administered as an injection once a week only. Together with your doctor you decide on a suitable weekday each week on which you receive your injection. Metoject may be injected intramuscularly (in a muscle), intravenously (in a vein) or subcutaneously (under the skin).
Children and adolescents
The use in children is limited to intramuscular injection due to the limited data of subcutaneous and intravenous use. The doctor decides on the appropriate dose in children and adolescents with polyarthritic forms of juvenile idiopathic arthritis.
Use in children less than 3 years of age is not recommended due to the insufficient experience in this age group.
The manner of handling and disposal must be consistent with that of other cytostatic preparations in accordance with local requirements. Pregnant health care personnel should not handle and/or administer Metoject.
Methotrexate should not come into contact with the surface of the skin or mucosa. In the event of contamination, the affected area must be rinsed immediately with ample amount of water.
The duration of the treatment is decided by your doctor.
If you experience the effect of Metoject as too strong or too weak, you should talk to your doctor or pharmacist.
If you use more Metoject than you should
Follow your doctor’s dosage recommendations. Do not change the dosage by yourself.
If you suspect that you have taken too much Metoject, contact your doctor immediately. He will decide on the adequate treatment depending on the severity of the intoxication.
If you forget to take Metoject
Do not take a double dose to make up for a forgotten individual dose. Ask your doctor for advice. Take the dose prescribed by your doctor as soon as possible and each week thereafter.
4. Possible side effects
Like all medicines, this medicine can cause side effects, although not everybody gets them.
The frequency as well as the degree of severity of the side effects depends on the dosage level and the frequency of administration. As severe side effects may occur even at low dosage, it is important that you are monitored regularly by your doctor.
Your doctor will do tests to check for abnormalitiesdeveloping in the blood (such as low white blood cells, low platelets, lymphoma) and changes in the kidneys and the liver.
Tell your doctor immediatelyif you experience any of the following symptoms, as these may indicate a serious, potentially life-threatening side effect, which require urgent specific treatment:
• persistent dry, non-productive cough, shortness of breath and fever; these may be signs of an inflammation of the lungs (pneumonia) [common - may affect up to 1 in 10 people]
• symptoms of liver damage such as yellowing of the skin and whites of the eyes; methotrexate can cause chronic liver damage (liver cirrhosis), formation of scar tissue of the liver (liver fibrosis), fatty degeneration of the liver [all uncommon - may affect up to 1 in 100 people], inflammation of the liver (acute hepatitis) [rare - may affect up to 1 in 1,000 people] and liver failure [very rare - may affect up to 1 in 10,000 people]
• allergy symptoms such as skin rash including red itchy skin, swelling of the hands, feet, ankles, face, lips, mouth or throat (which may cause difficulty in swallowing or breathing) and feeling you are going to faint;these may be signs of severe allergic reactions or an anaphylactic shock [rare - may affect up to 1 in 1,000 people]
• symptoms of kidney damage such as swelling of the hands, ankles or feet or changes in frequency of urination or decrease or absence of urine; these may be signs of kidney failure [rare - may affect up to 1 in 1,000 people]
• symptoms of infections, e.g. fever, chills, achiness, sore throat; methotrexate can make you more susceptible to infections. Rarely [may affect up to 1 in 1,000 people] severe infections like a certain type of pneumonia (Pneumocystis carinii pneumonia) or blood poisoning (sepsis) may occur
• severe diarrhoea, vomiting blood and black or tarry stools; these symptoms may indicate a rare [may affect up to 1 in 1,000 people] severe complication of the gastrointestinal system caused by methotrexate e.g. gastrointestinal ulcers
• fever and serious deterioration of your general condition, or sudden fever accompanied by a sore throat or mouth, or urinary problems; methotrexate can very rarely [may affect up to 1 in 10,000 people] cause a sharp fall in white blood cells (agranulocytosis) and severe bone marrow suppression
• unexpected bleeding, e.g. bleeding gums, blood in the urine, vomiting blood or bruising, these can be signs of a severely reduced number of blood platelets caused by severe courses of bone marrow depression [very rare - may affect up to 1 in 10,000 people]
• severe skin rash or blistering of the skin (this can also affect your mouth, eyes and genitals); these may be signs of the very rare [may affect up to 1 in 10,000 people] conditions called Stevens Johnson syndrome or burned skin syndrome (toxic epidermal necrolysis)
In the following, please find the other side effects that may occur:
Very common: may affect more than 1 in 10 people
• Mouth inflammation, indigestion, nausea (feeling sick), loss of appetite
• Increase in liver enzymes
Common: may affect up to 1 in 10 people
• Mouth ulcers, diarrhoea
• Rash, reddening of the skin, itching
• Headache, tiredness, drowsiness
• Reduced blood cell formation with decrease in white and/or red blood cells and/or platelets (leukopenia, anaemia, thrombocytopenia)
Uncommon: may affect up to 1 in 100 people
• Throat inflammation, inflammation of the bowels, vomiting
• Increased sensitivity to light, loss of hair, increased number of rheumatic nodules, shingles, inflammation of blood vessels, herpes-like skin rash, hives
• Onset of diabetes mellitus
• Dizziness, confusion, depression
• Decrease in serum albumin
• Decrease in the number of blood cells and platelets
• Inflammation and ulcer of the urinary bladder or vagina, reduced kidney function, disturbed urination
• Joint pain, muscle pain, osteoporosis (reduction of bone mass)
Rare: may affect up to 1 in 1,000 people
• Increased skin pigmentation, acne, blue spots due to vessel bleeding
• Allergic inflammation of blood vessels, fever, red eyes, infection, wound-healing impairment, decreased number of anti-bodies in the blood
• Visual disturbances
• Inflammation of the sac around the heart, accumulation of fluid in the sac around the heart
• Low blood pressure, occlusion of a blood vessel by dislodged blood clot (thromboembolic events)
• Lung fibrosis, shortness of breath and bronchial asthma, accumulation of fluid in the sac around the lung
• Electrolyte disturbances
Very rare: may affect up to 1 in 10,000 people
• Profuse bleeding, toxic megacolon (acute toxic dilatation of the gut)
• Increased pigmentation of the nails, inflammation of the cuticles, furunculosis (deep infection of hair follicles), visible enlargement of small blood vessels
• Local damage (formation of sterile abscess, changes in the fatty tissue) of injection site following administration into a muscle or under the skin
• Impaired vision, pain, loss of strength or sensation of numbness or tingling in arms and legs, changes in taste (metallic taste), convulsions, paralysis, severe headache with fever
• Retinopathy (noninflammatory eye disorder)
• Loss of sexual drive, impotence, male breast enlargement (gynaecomastia), defective sperm formation, menstrual disorder, vaginal discharge
• Enlargement of lymphatic nodes (lymphoma)
Not known:frequency cannot be estimated from the available data:
• Leukoencephalopathy (disease of the white brain substance)
When methotrexate is given by the intramuscular route, local undesirable effects (burning sensation) or damage (formation of sterile abscess, destruction of fatty tissue) at the site of injection can occur. Subcutaneous application of methotrexate is locally well tolerated. Only mild local skin reactions were observed, decreasing during therapy.
Reporting of side effects
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via (see details below). By reporting side effects you can help provide more information on the safety of this medicine.
[To be completed nationally]
5. how to store Metoject
Keep this medicine out of the sight and reach of children.
Store below 25 °C.
Keep the pre-filled syringes in the outer carton in order to protect from light.
Do not use this medicine after the expiry date stated on the packaging. The expiry date refers to the last day of that month.
6. Contents of the pack and other information
What Metoject contains
The active substance is methotrexate. 1 ml of solution contains methotrexate disodium corresponding to 10 mg methotrexate.
The other ingredients are sodium chloride, sodium hydroxide, water for injections.
What Metoject looks like and contents of the pack
Metoject pre-filled syringes contain a clear, yellow solution.
The following pack sizes are available: 0.75 ml, 1 ml, 1.5 ml, 2 ml and 2.5 ml solution for injection in packs of 1, 5, 10, 12 and 30 pre-filled syringes with graduation, with or without injection needle or with injection needle and alcohol pads. Not all pack sizes may be marketed.
Marketing Authorisation Holder and Manufacturer
medac Gesellschaft für klinische Spezialpräparate mbH
Theaterstraße 6
D-22880 Wedel
Germany
Phone: +49 4103 8006 0
Fax: +49 4103 8006 100
This leaflet was last revised on 7 May 2014