Poltraxin

Package leaflet: information for the patient

Poltraxin, 25 mg, prolonged-release injection suspension in pre-filled syringe
Poltraxin, 50 mg, prolonged-release injection suspension in pre-filled syringe
Poltraxin, 75 mg, prolonged-release injection suspension in pre-filled syringe
Poltraxin, 100 mg, prolonged-release injection suspension in pre-filled syringe
Poltraxin, 150 mg, prolonged-release injection suspension in pre-filled syringe
Initiation pack
Poltraxin, 100 mg/150 mg, prolonged-release injection suspension in pre-filled syringe
Paliperidone
Please read this leaflet carefully before using this medicine, as 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, pharmacist or nurse.
• If you experience any side effects, including any not listed in this leaflet, tell your doctor, pharmacist or nurse. See section 4.

Leaflet contents

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

1. What Poltraxin is and what it is used for

Poltraxin contains the active substance paliperidone, which belongs to a group of medicines
called antipsychotics, and is used for the maintenance treatment of symptoms of schizophrenia
in stable adult patients previously treated with paliperidone or risperidone.
For patients who previously responded to oral paliperidone or risperidone and whose psychotic symptoms are mild to moderate, the doctor may initiate treatment with Poltraxin without prior stabilization with paliperidone or risperidone.
Schizophrenia is a disorder with "positive" and "negative" symptoms. Positive symptoms
refer to the presence of symptoms that normally do not occur. For example, a person with schizophrenia
may hear voices or see things that are not there (hallucinations), believe in things that are not true (delusions), or be excessively suspicious of others. Negative symptoms
refer to the absence of normal behaviors or emotions. For example, a person with schizophrenia may appear withdrawn, emotionally unresponsive, or have difficulty speaking clearly and logically. Individuals affected by this disorder may also experience depression, anxiety, feelings of guilt, or tension.
Poltraxin helps to reduce the symptoms of the illness and prevent their recurrence.

2. Important information before using Poltraxin

When not to use Poltraxin

• if the patient is allergic to paliperidone or any of the other ingredients of this medicine (listed in section 6).
• if the patient is allergic to another antipsychotic medicine, including the substance risperidone.

Warnings and precautions
Before starting treatment with Poltraxin, discuss this with your doctor, pharmacist, or nurse.
The use of this medicine has not been studied in elderly patients with dementia. However, in such patients treated with other similar types of medicines, there may be an increased risk of stroke or death (see section 4 "Possible side effects").
All medicines can cause side effects. Some of the side effects of this medicine may worsen symptoms of other conditions. For this reason, during treatment with this medicine, discuss each of the following conditions with your doctor:

• if the patient has Parkinson's disease
• if the patient has ever been diagnosed with a condition characterized by high fever and muscle stiffness (also known as neuroleptic malignant syndrome)
• if the patient has ever experienced abnormal movements of the tongue or facial muscles (tardive dyskinesia)
• if the patient has previously had a low white blood cell count (whether or not caused by other medicines)
• if the patient has diabetes or is predisposed to developing diabetes
• if the patient has breast cancer or a pituitary gland tumor
• if the patient has heart disease or is being treated for heart disease that predisposes to hypotension
• if the patient has low blood pressure upon sudden change to standing or sitting position
• if the patient has epilepsy
• if the patient has impaired kidney function
• if the patient has impaired liver function
• if the patient experiences prolonged and (or) painful erection
• if the patient has problems with body temperature regulation or overheating
• if the patient has abnormally increased levels of prolactin hormone in the blood or suspected prolactin-dependent tumor
• if the patient or their family members have a history of blood clots in blood vessels, as antipsychotic medicines are associated with their development.

If the patient meets any of the above criteria, they should consult their doctor, who may adjust the dose or monitor the patient periodically.
The treating doctor may order a white blood cell count test, as very rarely, dangerously low levels of certain types of white blood cells necessary to fight infections have been observed in patients taking this medicine.
Even if the patient previously tolerated oral paliperidone or risperidone, allergic reactions may rarely occur after Poltraxin injections. Seek immediate medical help if the patient develops rash, throat swelling, itching, or difficulty breathing, as these may be symptoms of a severe allergic reaction.
This medicine may cause weight gain. Significant weight gain may negatively affect the patient's health. The treating doctor will regularly monitor the patient's body weight.
The treating doctor will check for symptoms of elevated blood sugar levels, as new-onset diabetes or worsening of pre-existing diabetes has been observed in patients taking this medicine. Patients with pre-existing diabetes should have their blood glucose levels monitored regularly.
Because this medicine may suppress vomiting, it may mask the body's normal response to ingestion of toxic substances or other medical conditions.
During cataract removal surgery, the pupil may not dilate sufficiently.
Also, the iris of the eye may become floppy during the procedure, which could lead to eye damage.
If the patient has planned eye surgery, inform the ophthalmologist about taking this medicine.
Children and adolescents
This medicine must not be used in children and adolescents under 18 years of age.
Poltraxin with other medicines
Tell your doctor about all medicines the patient is currently taking or has recently taken, as well as any medicines the patient plans to take.
Taking this medicine together with carbamazepine (an antiepileptic and mood-stabilizing medicine) may require adjustment of the dose of this medicine.
Because this medicine acts primarily in the brain, combining it with other medicines that act on the brain—such as other psychotropic medicines, opioids, antihistamines, and sedatives—may increase side effects such as drowsiness or other effects on the brain.
This medicine may lower blood pressure; therefore, caution is advised when using it together with other medicines that lower blood pressure.
This medicine may reduce the effectiveness of medicines used in Parkinson's disease and restless legs syndrome (e.g., levodopa).
This medicine may cause abnormalities in the electrocardiogram (ECG), manifesting as prolongation of the electrical impulse through a specific part of the heart (known as "QT interval prolongation"). Other medicines known to cause such effects include those used to regulate heart rhythm or treat infections, as well as other antipsychotic medicines.
If the patient is prone to seizures, this medicine may increase the risk of their occurrence. Other medicines with such effects include certain antidepressants or antimicrobials, as well as other antipsychotic medicines.
Caution is advised when using Poltraxin together with medicines that increase central nervous system activity (psychostimulants such as methylphenidate).
Poltraxin and alcohol
Alcohol consumption should be avoided.
Pregnancy and breastfeeding
If the patient is pregnant or breastfeeding, suspects she may be pregnant, or is planning to have a baby, she should consult her doctor or pharmacist before using this medicine.
This medicine should not be used during pregnancy unless discussed with a doctor.
Newborns whose mothers used paliperidone during the third trimester (last 3 months of pregnancy) may experience the following symptoms: tremors, muscle stiffness and (or) weakness, drowsiness, agitation, breathing difficulties, and feeding problems. If such symptoms are observed in your child, contact your doctor.
This medicine may pass from the mother's body into the child through breast milk and may harm the child. Therefore, breastfeeding must not be performed while taking this medicine.
Driving and operating machinery
During treatment with this medicine, dizziness, extreme tiredness, and visual disturbances may occur (see section 4). These effects should be taken into account in situations requiring full alertness, such as driving vehicles or operating machinery.
Poltraxin contains sodium and polysorbate 20
This medicine contains less than 1 mmol of sodium (23 mg) per dose, meaning the medicine is considered "sodium-free".
This medicine contains 12 mg of polysorbate per ml, equivalent to 12 mg/ml. Polysorbates may cause allergic reactions. Inform the doctor if the patient has known allergic reactions.

3. How to use Poltraxin

The medicine will be administered by a doctor or other healthcare professional. The medicine will be injected into the muscle.
Your doctor will inform you when the next injection is due. It is important not to miss a scheduled dose. If you are unable to keep the scheduled appointment, you should contact your doctor immediately to arrange another appointment as soon as possible.
The first (150 mg) and second (100 mg) injections of this medicine will be given in the upper arm, approximately one week apart. After that, an injection (in a dose ranging from 25 mg to 150 mg) will be administered once a month into the upper arm or buttock.
If your doctor decides to switch from long-acting risperidone injections to this medicine, the first injection of this medicine (in a dose ranging from 25 mg to 150 mg) will be given into the upper arm or buttock on the day the next scheduled injection is due. After that, an injection (in a dose ranging from 25 mg to 150 mg) will be administered once a month into the upper arm or buttock.
Depending on the symptoms present in the patient, the doctor may increase or decrease the administered dose by one level at the time of the scheduled monthly injection.

Patients with kidney function disorders
The doctor will adjust the dose of the medicine according to kidney function. If the patient has mild kidney function impairment, the doctor may reduce the dose. This medicine should not be used in patients with moderate or severe kidney function impairment.

Elderly patients
The doctor may reduce the dose if the patient has impaired kidney function.

Use of a higher than recommended dose of Poltraxin
This medicine will be administered under medical supervision, so overdose is unlikely.
In patients who have received an excessive dose of paliperidone, the following symptoms may occur:
drowsiness and sedation, increased heart rate, low blood pressure, abnormal ECG (electrocardiogram) findings, or slowed or abnormal movements of the face, body, arms, or legs.

Stopping treatment with Poltraxin
If the patient stops receiving injections, the medicine will stop working. Do not discontinue treatment unless instructed by the doctor, as symptoms of the illness may return.
If you have any further questions about the use of this medicine, please consult your doctor or pharmacist.

4. Possible adverse reactions

Like all medicines, this medicine can cause adverse reactions, although not everyone will experience them.
You should immediately inform your doctor if:

• the patient develops blood clots in the veins, especially in the legs (symptoms include swelling, pain and redness in the leg), which may travel through the blood vessels to the lungs, causing chest pain and difficulty breathing. If such symptoms occur, seek immediate medical help
• the patient with dementia experiences a sudden change in mental state or sudden weakness or numbness of the face, arms or legs, particularly on one side, or speech disturbances, even if brief. These symptoms may indicate a stroke
• the patient develops fever, muscle stiffness, sweating or decreased level of consciousness (a condition called neuroleptic malignant syndrome). Immediate treatment may be necessary
• the man experiences prolonged or painful erection. This condition is known as "priapism". Immediate treatment may be necessary
• involuntary rhythmic movements of the tongue, lips or face occur. Discontinuation of paliperidone treatment may be necessary
• the patient develops a severe allergic reaction characterised by: fever, swelling of the lips, face, eyelids or tongue, shortness of breath, itching, skin rash, and sometimes low blood pressure (known as "anaphylactic reaction"). Even if the patient previously tolerated risperidone or paliperidone taken orally, allergic reactions may rarely occur after paliperidone injections
• the patient is scheduled for eye surgery, the ophthalmologist should be informed about taking this medicine. During cataract removal, floppy iris syndrome may occur, which may lead to eye damage
• the patient has dangerously low levels of certain white blood cells essential for fighting infections

The following adverse reactions may occur:
Very common adverse reactions (may affect more than 1 in 10 patients)

• difficulty falling asleep or waking up

Common adverse reactions (may affect less than 1 in 10 patients)

• cold-like symptoms, urinary tract infection, flu-like symptoms
• the medicine Poltraxin may increase the level of the hormone prolactin in the blood (which may, but does not necessarily, cause symptoms). If symptoms of increased prolactin occur, they may include in men: breast swelling, difficulty achieving or maintaining erection or other sexual disturbances. In women, they may include breast discomfort, milk discharge from the breasts, absence of menstrual bleeding or other menstrual cycle disturbances
• high blood sugar levels, weight gain, weight loss, decreased appetite
• irritability, depression, anxiety
• parkinsonism: this condition may include slow or abnormal movements, feeling of stiffness or muscle tension (causing uneven, jerky movements), and sometimes even a feeling of "freezing" of movements, followed by sudden release. Other symptoms of parkinsonism include: slow shuffling gait, resting tremor, increased salivation/drooling, and expressionless face
• psychomotor restlessness, feeling of drowsiness or reduced alertness
• dystonia: this condition includes slow or sustained involuntary muscle contractions. Although it may affect any part of the body (which may result in abnormal body posture), dystonia most commonly affects facial muscles, including abnormal eye, mouth, tongue or jaw movements
• dizziness
• dyskinesia: this condition includes involuntary muscle movements and may present as repetitive, spasmodic or twisting movements or jerks
• tremor
• headache
• rapid heartbeat
• high blood pressure
• cough, stuffy nose
• abdominal pain, vomiting, nausea, constipation, diarrhoea, indigestion, toothache
• increased liver enzyme activity in blood
• bone or muscle pain, back pain, joint pain
• absence of menstruation
• fever, weakness, fatigue
• injection site reaction, including itching, pain or swelling

Uncommon adverse reactions (may affect less than 1 in 100 patients)

• pneumonia, bronchitis, respiratory tract infections, sinus infection, bladder infection, ear infection, fungal nail infection, tonsillitis, skin infection
• decreased number of white blood cells, decreased number of certain white blood cells protecting against infections, anaemia
• allergic reaction
• onset of diabetes and worsening of pre-existing diabetes, increased blood insulin levels (hormone regulating blood sugar levels)
• increased appetite
• loss of appetite leading to malnutrition and low body weight
• high blood triglyceride (fat) levels, increased blood cholesterol levels
• sleep disturbances, elevated mood (mania), decreased libido, nervousness, nightmares
• tardive dyskinesia (twitching or jerking uncontrolled movements of the face, tongue or other body parts). Inform your doctor immediately if rhythmic involuntary movements of the tongue, lips or face occur. Discontinuation of this medicine may be necessary
• fainting, need to move body parts, dizziness upon changing to upright position, difficulty concentrating, speech difficulties, loss or altered sense of taste, reduced sensation to pain and touch on the skin, tingling, pricking or numbness of the skin
• blurred vision, eye infection or conjunctivitis, dry eyes
• feeling of dizziness, ringing in the ears, ear pain
• conduction block of impulses between heart chambers, abnormal electrical conduction in the heart, QT interval prolongation in the heart, rapid heartbeat upon standing, slow heart rate, abnormal electrocardiogram (ECG), palpitations
• low blood pressure, low blood pressure upon standing (as a result, some patients taking this medicine may faint, feel dizzy or lose consciousness when standing up suddenly or getting up)
• shortness of breath, sore throat, nosebleed
• abdominal discomfort, stomach or intestinal infection, difficulty swallowing, dry mouth
• excessive passing of gas
• increased GGTP enzyme activity (liver enzyme - gamma-glutamyl transferase) in blood, increased liver enzyme activity in blood
• hives, itching, rash, hair loss, skin eruption, dry skin, skin redness, acne, subcutaneous abscess
• increased CPK (creatine phosphokinase) enzyme activity in blood, an enzyme sometimes released from damaged muscles
• muscle cramps, joint stiffness, muscle weakness
• urinary incontinence, frequent urination, painful urination
• erectile dysfunction, ejaculation disorders, absence of menstruation and other menstrual cycle disturbances (women), breast enlargement in men, sexual disturbances, breast pain, galactorrhoea
• swelling of the face, lips, eyes or eyelids, body swelling, swelling of upper or lower limbs
• increased body temperature
• change in walking pattern
• chest pain, chest discomfort, malaise
• skin hardening
• fall

Rare adverse reactions (may affect less than 1 in 1,000 patients)

• eye infection
• skin inflammation caused by mites, scaly, itchy scalp or other body parts
• increased number of eosinophils (a type of white blood cells) in blood
• decreased number of platelets (blood cells responsible for stopping bleeding)
• tremulous movements of the head
• abnormal secretion of the hormone regulating urine volume
• glucose in urine
• life-threatening complications of untreated diabetes
• low blood sugar levels
• excessive water drinking
• lack of movement and response to stimuli in a patient who is not sleeping (catatonia)
• disorientation
• sleepwalking (somnambulism)
• lack of emotions
• inability to achieve orgasm
• neuroleptic malignant syndrome (disorientation, decreased or loss of consciousness, high fever and severe muscle rigidity), cerebrovascular disorders including sudden interruption of blood flow to the brain (stroke or "mini" stroke), lack of response to stimuli, loss of consciousness, low level of consciousness, seizures, balance disturbances
• abnormal motor coordination
• glaucoma (increased pressure in the eyeball)
• eye movement disorders, rotational eye movements, light sensitivity, increased tearing, eye redness
• atrial fibrillation (irregular heartbeat), irregular heart rhythm
• blood clot in the lungs causing chest pain and breathing difficulties. If such symptoms occur, seek immediate medical help
• blood clots in the veins, particularly in the lower limbs (symptoms include swelling, pain and redness of the lower limbs). If such symptoms occur, seek immediate medical help
• episodes of flushing
• breathing disorders during sleep (sleep apnoea)
• blood congestion in the lungs, respiratory tract congestion
• crackling sounds in the lungs, wheezing
• pancreatitis, tongue swelling, faecal incontinence, very hard stool
• intestinal obstruction
• chapped lips
• drug-related skin rash, skin thickening, psoriasis
• breakdown of muscle fibres and muscle pain (rhabdomyolysis)
• joint swelling
• inability to urinate
• breast discomfort, enlargement of breast glands, breast enlargement
• vaginal discharge
• priapism (prolonged erection, which may require surgical intervention)
• very low body temperature, chills, feeling of thirst
• withdrawal symptoms
• abscess due to infection at injection site, deep skin infection, cyst at injection site, bruising at injection site

Adverse reactions of unknown frequency (frequency cannot be estimated from available data)

• dangerously low number of certain white blood cells responsible for fighting infections;
• severe allergic reaction characterised by fever, swelling of lips, face, eyelids or tongue, shallow breathing, itching, skin rash, and sometimes low blood pressure;
• dangerously excessive water drinking - water intoxication;
• feeding disorders related to sleep;
• coma due to uncontrolled diabetes;
• reduced oxygenation of various body parts (due to reduced blood flow);
• rapid, shallow breathing, aspiration pneumonia, voice disorders;
• lack of intestinal peristalsis leading to obstruction;
• yellowing of the skin and eyes (jaundice);
• severe or life-threatening blistering rash with skin peeling, which may appear in the mouth, nose, eyes, genital organs and around these areas and may also spread to other body parts (Stevens-Johnson syndrome or toxic epidermal necrolysis);
• severe allergic reaction with swelling, which may involve the throat and lead to breathing difficulties;
• skin depigmentation;
• abnormal body posture;
• newborns whose mothers used paliperidone during pregnancy may experience adverse effects of the medicine and (or) withdrawal symptoms such as: irritability, slow or sustained muscle contractions, tremor, drowsiness, breathing difficulties and feeding problems;
• low body temperature;
• necrosis at injection site and ulceration at injection site.

Reporting of adverse reactions
If any adverse reactions occur, including any not listed in this leaflet, inform your doctor, pharmacist or nurse. Adverse reactions can be reported directly to the Department of Monitoring of Adverse Drug Reactions of the Office for Registration of Medicinal Products, Medical Devices and Biocidal Products
Al. Jerozolimskie 181C
02-222 Warsaw
Tel.: +48 22 49 21 301
Fax: +48 22 49 21 309
Website: https://smz.ezdrowie.gov.pl
Adverse reactions can also be reported to the marketing authorisation holder.
Reporting adverse reactions helps to provide more information on the safety of the medicine.

5. How to store Poltraxin

Keep this medicine out of sight and reach of children.
Do not use this medicine after the expiry date stated on the pre-filled syringe and carton. The expiry date refers to the last day of the stated month.
The marking following the abbreviation EXP indicates the expiry date, and the marking following the abbreviation Lot indicates the batch number.
Do not store above 30 °C. Do not freeze.
Medicines must not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. Such measures help protect the environment.

6. Contents of the pack and other information

What Poltraxin contains

• The active substance is paliperidone. Each 25 mg pre-filled syringe contains paliperidone palmitate equivalent to 25 mg of paliperidone. Each 50 mg pre-filled syringe contains paliperidone palmitate equivalent to 50 mg of paliperidone. Each 75 mg pre-filled syringe contains paliperidone palmitate equivalent to 75 mg of paliperidone. Each 100 mg pre-filled syringe contains paliperidone palmitate equivalent to 100 mg of paliperidone. Each 150 mg pre-filled syringe contains paliperidone palmitate equivalent to 150 mg of paliperidone.

Starting dose pack
Each 100 mg pre-filled syringe contains paliperidone palmitate equivalent to 100 mg of paliperidone.
Each 150 mg pre-filled syringe contains paliperidone palmitate equivalent to 150 mg of paliperidone.

• Other ingredients are: polysorbate 20, macrogol 4000, citric acid monohydrate, disodium phosphate, sodium dihydrogen phosphate monohydrate, sodium hydroxide (for pH adjustment), water for injections.

What Poltraxin looks like and contents of the pack
Poltraxin is a white or almost white suspension for injection in a pre-filled syringe (suspension for injection).
Each single pack contains:
1 pre-filled syringe (clear type I glass) with a plunger, lock, and a "tip-cap" closure, safety needle 22G 1½ inch and safety needle 23G 1 inch. All packed in a cardboard box.
Each starting dose pack contains:

• 1 pack of Poltraxin 150 mg, 1 pre-filled syringe and 2 needles (administered on day 1 of treatment).
• 1 pack of Poltraxin 100 mg, 1 pre-filled syringe and 2 needles (administered on day 8 of treatment).

Not all pack sizes may be marketed.
Marketing Authorisation Holder
Zakłady Farmaceutyczne POLPHARMA S.A.
ul. Pelplińska 19, 83-200 Starogard Gdański
tel. +48 22 364 61 01
Manufacturer/Importer
Universal Farma S.L.
Polígono Industrial Miralcampo
C/ El Tejido 2
19200 Azuqueca de Henares – Guadalajara
Spain
Pharmascience International Limited
1st Floor Jacovides Tower
81-83 Griva Digeni Avenue
1090 Nicosia
Cyprus
This medicinal product is authorised in the Member States of the European Economic Area under the following names:
Bulgaria: Полтраксин

Information intended exclusively for medical or healthcare professionals and must be read together with the complete product information (Summary of Product Characteristics).

The injection suspension is for single use only. Prior to administration, inspect the suspension visually for the presence of foreign particles. Do not use the medicinal product if foreign particles are observed in the pre-filled syringe.

The package contains a pre-filled syringe and two safety-protected needles (a 22G 1½ inch needle [38.1 mm x 0.72 mm] and a 23G 1 inch needle [25.4 mm x 0.64 mm]) for intramuscular administration. The treatment initiation pack contains two pre-filled syringes (150 mg + 100 mg) and a total of four needles.

1. Shake the pre-filled syringe vigorously for at least 10 seconds to ensure homogeneity of the suspension.

2. Select the appropriate needle.

The first initiating dose of Poltraxin (150 mg) must be administered on day 1 of treatment into the DELTOID MUSCLE using the needle intended for the DELTOID MUSCLE. The second initiating dose of Poltraxin (100 mg) must be administered one week later (day 8), also into the DELTOID MUSCLE, using the needle intended for the DELTOID MUSCLE.

If switching from long-acting risperidone injections to Poltraxin, the first Poltraxin injection (at a dose ranging from 25 mg to 150 mg) may be administered on the day of the next scheduled injection into either the DELTOID MUSCLE or the GLUTEAL MUSCLE, using the appropriate needle.

Subsequently, monthly maintenance doses may be administered into either the DELTOID MUSCLE or the GLUTEAL MUSCLE, using the appropriate needle.

For injections into the DELTOID MUSCLE in patients with body weight <90 kg, use the 1 inch, 23G needle (25.4 mm x 0.64 mm) (needle with blue hub). If the patient's body weight is ≥90 kg, use the 1½ inch, 22G needle (38.1 mm x 0.72 mm) (needle with gray hub).

For injections into the GLUTEAL MUSCLE, use the 1½ inch, 22G needle (38.1 mm x 0.72 mm) (needle with gray hub).

3. Hold the syringe with the tip pointing upward and remove the rubber cap from the tip with a gentle twisting motion.

4. Remove the safety-protected needle from its blister pack. Grasp the base of the needle, not the safety shield. Attach the safety-protected needle to the syringe tip by pressing and turning it gently clockwise with a slight twisting motion.

5. Pull the safety shield away from the needle toward the body of the syringe at the angle shown.

6. Remove the needle cap with a straight pull. Do not twist the cap, as this may loosen the needle from the pre-filled syringe.

7. Hold the pre-filled syringe with the attached needle in an upright vertical position to expel air. Expel air from the pre-filled syringe by gently pushing the plunger forward.

8. Administer the entire content of the pre-filled syringe slowly and deeply by intramuscular injection into the selected muscle—either the deltoid or gluteal muscle. Do not administer intravenously or subcutaneously.

9. After completing the injection, use one hand’s fingers (9a) or a flat surface (9b) to activate the needle safety system. The system is fully activated when you hear a "click." Dispose of the pre-filled syringe with the needle properly.

9a

9b

Any unused medicinal product or waste material should be disposed of in accordance with local regulations.