Metex pen

Package leaflet: Information for the user

Metex PEN, 7.5 mg, solution for injection in a pre-filled pen
Metex PEN, 10 mg, solution for injection in a pre-filled pen
Metex PEN, 12.5 mg, solution for injection in a pre-filled pen
Metex PEN, 15 mg, solution for injection in a pre-filled pen
Metex PEN, 17.5 mg, solution for injection in a pre-filled pen
Metex PEN, 20 mg, solution for injection in a pre-filled pen
Metex PEN, 22.5 mg, solution for injection in a pre-filled pen
Metex PEN, 25 mg, solution for injection in a pre-filled pen
Metex PEN, 27.5 mg, solution for injection in a pre-filled pen
Metex PEN, 30 mg, solution for injection in a pre-filled pen
Methotrexatum
Please read this leaflet carefully before using this medicine because it contains
important information for you.

• Keep this leaflet as 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 a specific person only. Do not pass it on to others. This medicine may harm other people, even if their symptoms are the same.
• If you experience any adverse reactions, including any not listed in this leaflet, tell your doctor or pharmacist. See section 4.

Leaflet contents

1. What Metex PEN is and what it is used for
2. Important information before using Metex PEN
3. How to use Metex PEN
4. Possible side effects
5. How to store Metex PEN
6. Contents of the pack and other information

1. What Metex PEN is and what it is used for

Indications for Metex PEN medicinal product

• Active rheumatoid arthritis in adult patients, polyarticular forms of severe, active juvenile idiopathic arthritis, when response to non-steroidal anti-inflammatory drugs (NSAIDs) is inadequate,
• Moderate to severe psoriasis in adult patients, and severe psoriatic arthritis in adults,
• Mild to moderate Crohn's disease in adult patients when treatment with other agents is not possible.

Rheumatoid arthritis (RA) is a chronic disease classified as a collagenosis,
characterized by inflammation of the synovial membranes lining the joints. The synovial membranes produce fluid
which acts as a lubricant for many joints. The inflammatory process causes thickening of the membranes and joint swelling.
Juvenile arthritis occurs in children and adolescents under the age of 16. Polyarticular forms are defined by
involvement of 5 or more joints within the first 6 months of the disease.
Psoriasis is a common chronic skin disease characterized by red patches covered with thick,
dry, silvery, tightly adherent scales.
Psoriatic arthritis refers to joint inflammation, particularly in fingers and toes,
associated with psoriatic skin and nail changes.
Metex PEN modifies and slows the progression of the disease.
Crohn's disease is a type of inflammatory bowel disease that may affect any segment
of the gastrointestinal tract, causing symptoms such as abdominal pain, diarrhea, vomiting, or
weight loss.

2. Important information before using Metex PEN

When not to use Metex PEN

• if the patient is allergic to methotrexate or to any of the other ingredients of this medicine (listed in section 6);
• if the patient has liver disease, severe kidney or blood disorders;
• if the patient regularly consumes large amounts of alcohol;
• if the patient has severe infections, such as tuberculosis, HIV infection, or other immunodeficiency syndromes;
• if the patient has oral mucosal ulcers, gastric or intestinal ulcers;
• if the patient is pregnant or breastfeeding (see section "Pregnancy, breastfeeding and fertility");
• if the patient is simultaneously receiving a vaccine containing live microorganisms.

Warnings and precautions
Before starting treatment with Metex PEN, discuss with your doctor or pharmacist:

• if the patient is elderly, debilitated, or in poor general condition;
• if the patient has impaired liver function;
• if the patient has dehydration (lack of water in the body);
• if the patient has diabetes and is using insulin.

Special precautions for the use of Metex PEN
Methotrexate temporarily impairs the production of sperm and egg cells; in most cases, this effect is reversible. Methotrexate may cause miscarriage and severe congenital malformations. Women should avoid becoming pregnant during treatment with methotrexate and for at least 6 months after treatment ends. Men should avoid impregnating their partner during treatment with methotrexate and for at least 3 months after treatment ends. See also the section "Pregnancy, breastfeeding and fertility".

Recommended monitoring tests and precautions
Severe adverse effects may occur even after low doses of methotrexate. To detect them early, your doctor must perform regular monitoring and laboratory tests.

Before starting treatment
A blood test will be performed before starting treatment to check whether the patient has an adequate number of blood cells. Blood tests will also be carried out to assess liver function and to check for hepatitis. Additionally, serum albumin (a blood protein) levels, kidney function, and signs of hepatitis (liver infection) will be evaluated. The doctor may also decide to perform other liver tests, which may include imaging tests of the liver or taking a small tissue sample from the liver for more detailed assessment. Furthermore, the doctor may check for tuberculosis and may perform a chest X-ray or lung function tests.

During treatment
The doctor may perform the following tests:

• examination of the mouth and throat for mucosal changes, such as inflammation or ulceration;
• blood tests / blood cell counts and assessment of methotrexate concentration in blood serum;
• blood tests to monitor liver function;
• imaging tests to monitor the condition of the liver;
• taking a small tissue sample from the liver for more detailed assessment;
• blood tests to monitor kidney function;
• respiratory system check-up and, if necessary, lung function tests.

It is very important that the patient attends these scheduled examinations.
If any of these test results show abnormalities, the doctor will adjust the treatment accordingly.

Elderly patients
Elderly patients receiving methotrexate should remain under close medical supervision to detect possible adverse effects as early as possible.
Age-related impairments in liver and kidney function, as well as low levels of folic acid in elderly individuals, require relatively low dosing of methotrexate.

Other precautions
Cases of acute pulmonary hemorrhage have been reported in patients with underlying rheumatological diseases during methotrexate treatment. If the patient develops hemoptysis (coughing up blood-tinged sputum), medical advice should be sought immediately.
Methotrexate may affect the immune system, vaccine efficacy, and results of immunological tests. It may lead to reactivation of latent chronic diseases (e.g., shingles, tuberculosis, hepatitis B or C virus). Do not use vaccines containing live microorganisms during treatment with Metex PEN.
Methotrexate may increase skin sensitivity to sunlight. Avoid intense sun exposure and do not use solariums or tanning lamps without consulting your doctor. To protect the skin from intense sunlight, wear appropriate clothing or use a high-protection sunscreen.
During methotrexate treatment, radiation-induced skin inflammation and sunburns ("recall reaction") may be triggered. UV radiation exposure during methotrexate treatment may worsen psoriatic skin lesions.
Lymph node enlargement (lymphadenopathy) may occur. In such cases, treatment should be discontinued.
Diarrhea may be a sign of toxicity from Metex PEN and requires discontinuation of treatment. If the patient develops diarrhea, inform the doctor immediately.
In cancer patients receiving methotrexate treatment, certain neurological disorders (encephalopathy/leukoencephalopathy) have been reported. Such adverse effects cannot be ruled out when methotrexate is used to treat other diseases.
If the patient, their partner, or caregiver notice new onset or worsening of neurological symptoms, including general muscle weakness, visual disturbances, changes in thinking, memory, and orientation leading to disorientation and personality changes, seek immediate medical advice, as these may be symptoms of a very rare but serious brain infection called progressive multifocal leukoencephalopathy (PML).

Metex PEN and other medicines
Tell your doctor or pharmacist about all medicines the patient is currently taking or has recently taken, as well as any medicines the patient plans to take in the future. This includes all medications, including those intended for future use.
Concurrent administration of certain medicines may affect the action of Metex PEN:

• antibiotics, e.g.: tetracyclines, chloramphenicol, non-absorbable broad-spectrum antibiotics, penicillins, glycopeptides, sulfonamides, ciprofloxacin, and cephalothin (medicines used to prevent and treat certain infections);
• non-steroidal anti-inflammatory drugs or salicylates (pain-relieving and/or anti-inflammatory medicines, e.g., acetylsalicylic acid, diclofenac, ibuprofen, or pyrazole);
• metamizole (synonyms: novaminsulfone and dipyrone) (a strong pain-relieving and/or antipyretic medicine);
• probenecid (used in the treatment of gout);
• weak organic acids such as loop diuretics (diuretic medicines);
• medicines that may adversely affect bone marrow function, e.g., trimethoprim-sulfamethoxazole (a bactericidal agent) or pyrimethamine;
• other medicines used in the treatment of rheumatoid arthritis, e.g., leflunomide, sulfasalazine, and azathioprine;
• cyclosporine (an immunosuppressive agent);
• mercaptopurine (a cytostatic medicine);
• retinoids (medicines for psoriasis and other skin diseases);
• theophylline (a medicine for bronchial asthma and other lung diseases);
• certain medicines used for stomach disorders, e.g., omeprazole and pantoprazole;
• hypoglycemic agents (medicines that reduce glucose ["sugar"] levels in blood).

Vitamin supplements containing folic acid should only be used if recommended by a doctor, as they may reduce the effectiveness of methotrexate.
Avoid vaccines containing live microorganisms.

Metex PEN with food, drink, and alcohol
During treatment with Metex PEN, avoid consuming alcohol as well as large amounts of coffee, caffeine-containing beverages, and black tea.

Pregnancy, breastfeeding, and fertility
Pregnancy
Do not use Metex PEN if the patient is pregnant or trying to become pregnant. Methotrexate may cause congenital malformations, harm the unborn child, or cause miscarriage. This is associated with developmental abnormalities of the skull, face, heart and blood vessels, brain, and limbs. Therefore, it is very important that women who are pregnant or planning pregnancy do not take methotrexate. If the patient is of childbearing age, pregnancy must be definitively ruled out before starting treatment by appropriate measures, such as performing a pregnancy test.
The patient should avoid becoming pregnant during methotrexate treatment and for at least 6 months after treatment ends, using reliable contraception methods throughout this period (see also section "Warnings and precautions").
If the patient becomes pregnant or suspects she may be pregnant during treatment, she should consult her doctor immediately. The patient should seek advice regarding the potential harmful effects of treatment on the child.
If the patient plans to become pregnant, she should consult her treating doctor, who may refer her to a specialist for advice before planned initiation of treatment.

Breastfeeding
Breastfeeding must be discontinued before starting and during treatment with Metex PEN.

Male fertility
Available evidence does not indicate an increased risk of developmental abnormalities or miscarriages following paternal exposure to methotrexate at doses below 30 mg/week. However, the risk cannot be completely excluded. Methotrexate may be genotoxic, meaning it may cause genetic mutations. Methotrexate may affect sperm and lead to congenital malformations. Therefore, the patient should avoid impregnating his partner and must not be a sperm donor during methotrexate treatment and for at least 3 months after its discontinuation.

Driving and operating machinery
During treatment with Metex PEN, adverse effects on the central nervous system, such as fatigue and dizziness, may occur. Therefore, the ability to drive motor vehicles and/or operate machinery may be impaired in some cases. Do not drive or operate machinery if feeling drowsy or fatigued.

Metex PEN contains sodium
This medicine contains less than 1 mmol (23 mg) of sodium per dose, meaning the medicine is considered "sodium-free".

3. How to use Metex PEN

Important warning regarding dosing of Metex PEN (methotrexate):
In the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis, psoriatic arthritis, and Crohn's disease, Metex PEN must be used only once a week. Taking more than the prescribed amount of Metex PEN (methotrexate) may result in death. Please read section 3 of this leaflet carefully. If you have any questions, consult your doctor or pharmacist before taking the medicine.
This medicine must always be used exactly as prescribed by your doctor. If in doubt, consult your doctor or pharmacist.
Your doctor decides on the dosage, which is individually adjusted to the patient.
Therapeutic effects are usually noticeable only after 4–8 weeks of treatment.
Metex PEN is administered by subcutaneous injection by or under the supervision of a doctor or qualified healthcare professional only once a week. The patient should agree with the doctor on a specific day of the week for the injection to be given.

Use in children and adolescents
The doctor determines the appropriate dose for children and adolescents with polyarticular juvenile idiopathic arthritis.
Metex PEN is not recommended for use in children under 3 years of age due to insufficient experience in patients in this age group.

Method and timing of administration
Metex PEN is injected once a week!
The duration of treatment is determined by the treating physician. Treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis, psoriatic arthritis, and Crohn's disease with Metex PEN is long-term therapy.
At the beginning of treatment, Metex PEN may be administered by healthcare personnel. However, the doctor may decide that the patient is capable of self-injecting Metex PEN. The patient will be properly trained accordingly. Never attempt self-injection of the medicine without prior training.
Instructions on how to correctly use Metex PEN are provided in the "Instructions for Use" section at the end of this leaflet.
Remember to use the entire contents of the pre-filled syringe.
Preparation of the medicine for use and disposal of the medicine and the pre-filled semi-automatic injector must comply with local requirements. Healthcare workers who are pregnant should not prepare or (and) administer the medicinal product Metex PEN.
Methotrexate must not come into contact with the skin or mucous membranes. In case of contact, the contaminated area should be immediately rinsed thoroughly with plenty of water.

Overdose of Metex PEN
If a patient has taken more than the recommended dose of Metex PEN, seek immediate medical advice from a doctor.

Missed dose of Metex PEN
Do not take a double dose to make up for a missed dose.

Stopping Metex PEN
If you stop taking Metex PEN, inform your doctor immediately.
If you feel that the effect of Metex PEN is too strong or too weak, consult your doctor or pharmacist.

4. Possible adverse reactions

Like all medicines, this medicine can cause adverse reactions, although not everyone will experience them.
The frequency and severity of adverse reactions depend on the dose size and frequency of administration.
Since severe adverse reactions may occur even after administration of small doses, regular medical examinations are necessary.
Therefore, the doctor should perform examinations to rule out abnormalities in blood parameters (e.g. low white blood cell count, low platelet count, lymphadenopathy) and changes in the liver and kidneys.
You should inform the doctor immediately if any of the following symptoms occur in the patient, as they may indicate severe, potentially life-threatening adverse reactions requiring urgent treatment:

• persistent dry cough without sputum, shortness of breath, and fever; these may be symptoms of pneumonia [common]
• haemoptysis, i.e. coughing up blood-stained sputum; this may be a sign of bleeding from the lungs [frequency not known]
• signs of liver damage, e.g. yellowing of the skin and whites of the eyes; methotrexate may cause chronic liver damage (liver cirrhosis), scarring of liver tissue (liver fibrosis), fatty degeneration of the liver (fatty liver), [all uncommon], inflammation of the liver (acute hepatitis) [rare], and liver failure [very rare]
• allergic symptoms such as skin rash, including itchy redness of the skin, swelling of the hands, feet, ankles, face, lips, mouth or throat (which may cause difficulty in swallowing or breathing), and the patient may feel as if they are about to faint; these may be symptoms of severe allergic reactions or anaphylactic shock [rare]
• signs of kidney damage such as swelling of the hands, ankles or feet, or changes in frequency of urination, reduced urine volume (oliguria), or absence of urine (anuria); these may be symptoms of kidney failure [rare]
• signs of infection such as fever, chills, pain, sore throat; methotrexate may increase susceptibility to infections. Severe infections may occur, such as a specific type of pneumonia (Pneumocystis jirovecii pneumonia) and blood poisoning (sepsis) [rare]
• symptoms such as weakness on one side of the body (stroke) or pain, swelling, redness and unusual warmth in one leg (deep vein thrombosis); this may occur when a dislodged blood clot blocks a blood vessel (thromboembolic event) [rare]
• fever and severe worsening of general health or sudden fever accompanied by sore throat or mouth pain or disturbances in urination; methotrexate may cause acute reduction in the number of certain white blood cells (agranulocytosis) and severe bone marrow suppression [very rare]
• unexpected bleeding, e.g. bleeding gums, blood in urine, in vomit, or appearance of petechiae (small red or purple spots on the skin); these may be symptoms of a significant decrease in platelet count due to severe bone marrow suppression [very rare]
• symptoms such as severe headache accompanied by fever, neck stiffness, nausea, vomiting, disorientation, and sensitivity to light; these may indicate meningitis (acute aseptic meningitis) [very rare]
• in cancer patients receiving methotrexate treatment, certain brain function disorders (encephalopathy/leukoencephalopathy) have been reported. The occurrence of such adverse reactions cannot be excluded when methotrexate is used to treat other diseases. Symptoms of such brain function disorders include altered mental status, movement disorders (ataxia), visual and memory disturbances [frequency not known]
• severe skin rash or blisters on the skin (which may also occur in the mouth, eyes, and genital organs); these may be symptoms of Stevens-Johnson syndrome or toxic epidermal necrolysis (Lyell's syndrome) [very rare]

Other adverse reactions that may occur are listed below:
Very common: may occur in more than 1 in 10 patients

• inflammation of the mucous membrane of the mouth, indigestion, nausea, decreased appetite, abdominal pain,
• abnormal liver function tests (AST, ALT, bilirubin, alkaline phosphatase).

Common: may occur in 1 in 10 patients

• ulceration of the mucous membrane of the mouth, diarrhoea,
• rash, skin redness, itching,
• headache, fatigue, drowsiness,
• reduced production of blood cells leading to decreased number of white and/or red blood cells and/or platelets.

Uncommon: may occur in 1 in 100 patients

• sore throat,
• enteritis, vomiting, pancreatitis, black or tarry stools, bleeding and ulcers from the gastrointestinal tract,
• reactions resembling sunburn due to increased skin sensitivity to sunlight, hair loss, increase in the number of rheumatoid nodules, skin ulceration, shingles, vasculitis, herpes-like rash, urticaria,
• onset of diabetes,
• dizziness, confusion, depression,
• decreased serum albumin concentration,
• decreased number of all blood cells and platelets,
• inflammation and ulceration of the bladder or vagina, impaired kidney function, disturbances in urination,
• joint pain, muscle pain, decreased bone mass.

Rare: may occur in 1 in 1,000 patients

• gingivitis,
• increased skin pigmentation, acne, blue spots on the skin due to bleeding from blood vessels (purpura, petechiae), allergic vasculitis,
• decreased concentration of antibodies in the blood,
• infection (including latent chronic infection), redness of the eyes (conjunctivitis),
• mood changes (mood swings),
• visual disturbances,
• inflammation of the sac surrounding the heart (pericarditis), fluid accumulation in the pericardium, impaired heart filling due to fluid in the pericardial sac,
• low blood pressure,
• development of scar tissue in the lungs (pulmonary fibrosis), shortness of breath and bronchial asthma, fluid accumulation in the pleural cavity,
• stress fractures,
• electrolyte disturbances,
• fever, impaired wound healing.

Very rare: may occur in 1 in 10,000 patients

• acute toxic megacolon (toxic dilation of the colon),
• increased pigmentation of the nails, inflammation of the skin around the nail (acute paronychia), deep infection of hair follicles (furunculosis), visible enlargement of small blood vessels,
• pain, loss of muscle strength, or numbness or tingling sensation, reduced response to stimuli, taste disturbances (metallic taste), seizures, paralysis, meningeal reaction,
• impaired vision, non-inflammatory eye disease (retinopathy),
• decreased libido, impotence, breast enlargement in men, disturbances in sperm production (oligospermia), menstrual disorders, vaginal discharge,
• enlarged lymph nodes (lymphadenopathy),
• lymphoproliferative disorders (overproduction of white blood cells).

Frequency not known: frequency cannot be determined from available data

• increased number of certain white blood cells,
• nosebleeds,
• proteinuria,
• feeling of fatigue,
• jaw bone damage (due to overproduction of white blood cells),
• tissue necrosis at the injection site,
• redness and peeling of the skin,
• swelling.

Subcutaneously administered doses of methotrexate are locally well tolerated. Only mild local skin reactions (such as burning sensation, erythema, swelling, discoloration, itching, intense pruritus, pain) have been observed, which decrease during treatment.
Reporting of adverse reactions
If any adverse reactions occur, including any adverse reactions not listed in this leaflet, inform your doctor, pharmacist, or nurse. Adverse reactions can be reported directly to the Department of Monitoring Adverse Drug Reactions at the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products:
Al. Jerozolimskie 181C, PL-02-222 Warsaw, tel.: +48 22 49-21-301, fax: +48 22 49-21-309,
website: ://smz.ezdrowie.gov.pl
Adverse reactions can also be reported to the marketing authorization holder.
Reporting adverse reactions helps to provide more information on the safety of the medicine.

5. How to store Metex PEN

Keep this medicine out of sight and reach of children.
Do not store above 25°C. Do not freeze.
Store pre-filled auto-injectors in their outer packaging to protect from light.
Do not use this medicine after the expiry date stated on the carton and auto-injector under "Expiry date". The expiry date refers to the last day of the stated month.
Medicines must not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. These measures help protect the environment.

6. Contents of the pack and other information

What Metex PEN contains

• The active substance is methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.15 ml solution contains 7.5 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.2 ml solution contains 10 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.25 ml solution contains 12.5 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.3 ml solution contains 15 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.35 ml solution contains 17.5 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.4 ml solution contains 20 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.45 ml solution contains 22.5 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.5 ml solution contains 25 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.55 ml solution contains 27.5 mg methotrexate.
  1 pre-filled semi-automatic syringe with a volume of 0.6 ml solution contains 30 mg methotrexate.

• Other ingredients are sodium chloride, hydrochloric acid and sodium hydroxide (for pH adjustment) and water for injections.

What Metex PEN looks like and contents of the pack
Metex PEN is a solution for injection in a pre-filled syringe.
The solution is clear and yellowish-brown in colour.

Metex PEN pre-filled semi-automatic syringe is a three-step automatic injector with a yellow cap and a yellow injection button.

Metex PEN pre-filled semi-automatic syringe is a two-step automatic injector with a transparent protective cap and a blue needle shield.

The following pack sizes are available:
Metex PEN is available in packs containing 1, 2, 4, 5, 6, 10, 11, 12, 14, 15 or 24 pre-filled semi-automatic syringes.
Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer
medac
Gesellschaft für klinische Spezialpräparate mbH
Theaterstr. 6
22880 Wedel
Germany
Telephone: +49 4103 8006-0
Fax: +49 4103 8006-100

This medicinal product is authorised in the European Economic Area and the United Kingdom (Northern Ireland) under the following names:
Austria, Czech Republic, Finland, Greece, Spain, Netherlands, Slovakia, Slovenia, Hungary, United Kingdom (Northern Ireland):
Metoject PEN
Iceland, Sweden:
Metojectpen
Germany:
metex PEN
Estonia, Lithuania, Latvia, Norway:
Metex
Poland, Portugal:
Metex PEN
Denmark:
Metex Pen
Belgium:
Metoject

Instructions for use
Recommendations

• Read the following instructions carefully before administering the medicine.
• Always follow the injection technique recommended by your doctor, pharmacist or nurse.

Additional information
Preparation of the medicine for use and disposal of the medicine and the pre-filled semi-automatic syringe must comply with local regulations. Healthcare professionals who are pregnant should not prepare or (and) administer the medicinal product Metex PEN.
Methotrexate must not come into contact with the skin or mucous membranes. In case of contact, the affected area should be immediately rinsed thoroughly with plenty of water.

Components of the Metex PEN injector:

Injection button
Area for holding the injector
Transparent inspection window
Cap

a) With cap before injection
b) After removing the cap before injection
c) After completing the injection

What to do before administering the injection

1. Wash your hands thoroughly.
2. Remove the device from its packaging.
3. Check the Metex PEN injector before use:

If the Metex PEN injector appears damaged,

do not use it. Use another injector and contact your doctor, pharmacist or nurse.
If a small air bubble is visible in the transparent inspection window, this does not affect the dose and does not pose a risk to the patient.
If the patient is unable to properly see or inspect the injector before injection, ask another person for help.

4. Place the Metex PEN injector on a clean, flat surface (e.g. a table).

Where to administer the injection
The most suitable injection sites

include:

• the upper part of the thigh,
• the abdomen, except the area around the navel.
  • If another person is administering the injection, it may also be given into the upper, back part of the arm, just below the shoulder.
  • Always select a different injection site each time. This will help reduce the risk of local reactions at the injection site.
  • Never inject the medicine into areas that are painful, bruised, red, hardened, scarred or have stretch marks. If the patient has psoriasis, do not inject the medicine directly into raised, thickened, red or flaky skin areas or skin lesions.

How to prepare for the injection

5. Select the injection site and clean

the chosen injection site and the surrounding skin area.

• Do not remove the cap before preparing for injection.

6. Hold the injector in one hand at the designated holding area, with the cap pointing upwards. With the other hand, gently remove the cap with a straight motion (do not bend or twist the cap). The cap contains a small needle shield, which should automatically slide off with the cap. If the needle shield does not slide off, use another injector and contact your doctor, pharmacist or nurse.

• If the patient has difficulty removing the cap, ask another person for help.

Warning: Immediately administer the injection after removing the cap.

7. Create a skin fold by gently pinching the skin at the

cleaned injection site.

• Hold the skin fold until the injector is withdrawn from the skin after completing the injection.

8. Place the exposed, transparent end

of the Metex PEN injector perpendicularly onto the skin fold.

9. Without pressing the button, firmly press the Metex PEN injector against the skin to unlock the injection button.

• If the patient cannot firmly press the Metex PEN injector in place, ask another person for help.

How to administer the injection:

10. While firmly holding the Metex PEN injector

pressed against the skin, press the button with your thumb.

11. A clicking sound indicates that the injection has started. Keep holding the injector pressed against the skin until the full dose of medicine has been injected. This may take up to 5 seconds.

Warning:
To avoid incomplete injection, do not remove the Metex PEN injector from the skin before the injection is complete.
If the injection does not start, release the button, ensure the Metex PEN injector is firmly pressed against the skin, and press the button firmly again.
If you cannot hear the click, count 5 seconds from the moment you pressed the button, then lift the injector away from the injection site.

12. Remove the Metex PEN injector from the injection

site by pulling it straight out (perpendicular to the skin).

13. The protective shield automatically returns into place over the needle. The protective shield then locks, covering the needle.
14. If there is minor bleeding, apply a plaster or dressing.

Before disposing of the Metex PEN injector, visually check whether any liquid remains at the bottom of the transparent inspection window. If liquid remains in the injector, this means that an incomplete dose has been administered and you should contact your doctor.

Warning
To avoid needlestick injuries, never insert your fingers into the opening of the protective needle shield.
Do not destroy the injector.

Who to contact if needed

• For any problems or questions, contact your doctor, pharmacist or nurse.
• In case of a needlestick injury to the patient or another person, seek immediate medical advice and dispose of the Metex PEN injector.

INSTRUCTIONS FOR USE

This Instructions for Use contains information on how to inject using the prefilled Metex PEN
auto-injector.

Before using the prefilled semi-automatic injector for subcutaneous injection,
read this entire Instructions for Use. Read this Instructions for Use
each time a new prescription is received and keep this Instructions for Use for reference
in case information is needed after use.

After receiving a new medicine or a new dosage of medicine, always check whether it is in accordance with the doctor's instructions.
Before using the injector, a healthcare professional should demonstrate to the patient or caregiver how to properly use the injector.
The user should not use the injector until trained by a healthcare professional on how to use the injector.
If there are any questions, contact a healthcare professional.

Important information to read before administering an injection using a prefilled semi-automatic injector for Metex PEN
The injection using a prefilled semi-automatic injector for Metex PEN should be administered once weekly, always on the same day of the week.
Pregnant women must not administer or prepare the medication.

• Keep the injector in a safe place, out of sight and out of reach of children.
• In case of contact with the medication, immediately wash the affected area thoroughly with plenty of water.

Do NOT remove the protective cap until immediately before administering the injection.
Do NOT share your injector with another person.
Do NOT use the injector if:

• it has fallen on a hard surface or appears damaged;
• the clear yellow solution has changed color, is cloudy, or contains solid particles;
• it has been frozen or stored at temperatures above 25°C;
• the expiration date has passed. If in doubt, contact a healthcare professional.

How to store the prefilled semi-automatic Metex PEN injector

• Store below 25°C.
• Transport and store the injector in its original outer packaging to protect it from light.
• Keep the injector in a safe place, out of sight and out of reach of children.

Do NOT freeze.
Do NOT store above 25°C.
Metex PEN prefilled semi-automatic injector (Fig. A)
The Metex PEN prefilled semi-automatic injector is a two-step, single-dose automatic injector for single use. It is available in 10 different doses ranging from 7.5 mg to 30 mg.
Before use After use

Protective cap Blue needle shield
(clear) (locks after injection, needle inside)
Viewing window

(yellow medication inside) Protective cap
(needle shield inside)
Plunger
(position depends on prescribed dose)
Blue plunger body

(indicates complete injection)
Medication label
7.5 mg 15 mg 30 mg
(for checking dose and expiration date) (example doses)
Color-coded area
(unique for each dose)
Fig. A
Supplies needed for injection (Fig. B)
On the day of your weekly injection, find a comfortable place, ensure it is well-lit, and have available a clean, flat surface, such as a table, where you can place the supplies needed for the injection.
Required item:

• Metex PEN prefilled semi-automatic injector.

Ensure that the following additional materials, which are not included in the package, are available for administration of the injection:
materials, since they are not included in the package:

• A calendar to track the weekly injection day;
• A skin cleansing agent, e.g., alcohol swab, or if unavailable, water and soap;
• A cotton swab or gauze pad to wipe the injection site;
• A sharps container compliant with local regulations.

Metex PEN calendar Automatic Skin cleansing Cotton swab Sharps
indicating weekly injection agent or gauze container
injection day device filled
Fig. B
Preparing for the injection

1. Wash hands and remove the injector
from the packaging (Fig. C)

• Wash hands with soap and water.
• Carefully remove the syringe from the packaging.

Do not remove the protective cap until
the patient is ready for injection.

Fig. C
2. Check the injector before use

(Fig. D)

Check carefully the name and dose on
the injector and make sure it is the
correct medicine. If the user cannot see
well enough, ask someone
for help.

• Check the expiry date on the injector label.
• Do not use the injector if the Fig. D expiry date has passed.
• Inspect the medicine through the viewing window by turning the injector upside down or gently shaking it. The medicine in the injector should be clear and yellow.
  • Do not inject if the solution is cloudy, has changed colour, or contains solid particles.
  • It is normal to see one or more small air bubbles. Do not attempt to remove them.
  • A scale may be visible in the viewing window; this can be ignored.
• Check that the injector is not damaged and that the cap is properly attached. Do not use the injector if it appears damaged or if the cap has been removed or is not securely attached.

If the expiry date of the injector has passed,
if it appears damaged, or does not look as
expected, do not use it and contact a healthcare
professional.
Before proceeding with the next steps,
carefully place the injector on a clean,
flat surface, such as a table.
3. Choose the injection site (Fig. E)

• The patient may self-inject in the:
  • upper thigh,
  • lower abdomen, except within 5 cm of the navel.
• If an caregiver is administering the injection, the back of the upper arm may also be used.
• Use a different injection site from the previous injection.

When selecting the injection site:
do not inject into other parts of the body;
do not inject into bruised, tender, peeling, red, or hardened skin;
do not inject into moles, scars, or stretch marks;
do not inject through clothing.

Injection site
Injection site
for
for
caregiver
caregiver
Fig. E
4. Clean the injection site (Fig. F)

• Clean the injection site with an alcohol-based disinfectant; if unavailable, use soap and water.
• Wait for the skin to dry completely. Do not fan or do not blow on the cleaned area. Do not touch the injection site again until the injection is complete. Fig. F

Administering the dose
5. Remove the cap (Fig. G)

The protective cap should only be removed when
the patient is ready to administer the
injection.
Do not attempt to reattach the cap to the
injector after removal.

• Hold the injector with the cap pointing upward and remove the cap with a firm motion. Fig. G Do not bend or do not twist the cap while removing it.
• Immediately discard the cap.
• Small droplets of medicine may appear. This is normal.
• Administer the injection immediately after removing the cap.

Do not touch the blue needle shield with fingers.
Touching the blue needle shield may
accidentally activate the injection
and cause injury.

6. Position the injector (Fig. H)

• Place the open blue needle shield flat against the skin at a 90-degree angle, with the viewing window facing toward you so it remains visible.
• It may be more comfortable to pinch a skin fold by gently squeezing the area around the injection site between thumb and fingers before injecting, but this is not required with this injector. Fig. H

7. Start the injection (Fig. I)

• To start the injection, press the injector firmly and completely against the skin. This will retract the blue needle shield into the injector and the injection will begin automatically.
• The first audible click indicates the start of the injection. The blue plunger rod will move downward.
• Continue to hold the injector firmly against the skin until the entire Fig. I dose is delivered. Once the injection has started, do not change the position of the injector.

8. Hold the injector in place to complete
the injection (Fig. J)

• Continue to hold the injector firmly against the skin for 5 seconds.
• The injection is complete when:
  • a second audible click is heard shortly after the first;
  • or: the blue plunger rod has stopped moving and fills the viewing window;
  • or: 5 seconds have passed. Fig. J

Do not remove the injector from the injection site
until at least 5 seconds have passed.
5 seconds.

9. Completing the injection (Fig. K)

• Remove the injector straight upwards from the injection site.
• The blue needle shield automatically returns into place around the needle and locks.
• Check the viewing window to ensure no residue of yellow medicine remains. If yellow medicine is still visible in the window, the full dose may not have been delivered. In this case, or if you have any other Fig. K doubts, contact a healthcare professional.

Do not touch the blue needle shield after
the injection, as this may cause injury.
After the injection

10. Care for the injection site (Fig. L)

• A small drop of blood may appear at the injection site. This is normal. If needed, press a swab or gauze lightly against the site.
• If necessary, cover the injection site with a small plaster.

Do not rub the injection site.
Fig. L

11. Disposal of the injector (Fig. M)
Each injector may be used only
once. Do not replace the cap back onto
the injector.
The used injector and protective cap must be stored
out of sight and out of reach of children.
Fig. M

• The cap and injector must be disposed of immediately after use. The method of disposal of the pre-filled automatic injector must
  comply with local regulations.

• Dispose of used materials in a household waste container. The cardboard box can be disposed of in the paper recycling bin.

Pre-filled automatic injectors
Metex PEN that have passed their expiry date,
are no longer needed, or are no longer suitable for use
must be safely disposed of.