Tullex

Package leaflet: Information for the user

Tullex, 5 mg, solution for injection in prefilled syringe
Tullex, 7.5 mg, solution for injection in prefilled syringe
Tullex, 10 mg, solution for injection in prefilled syringe
Tullex, 12.5 mg, solution for injection in prefilled syringe
Tullex, 15 mg, solution for injection in prefilled syringe
Tullex, 17.5 mg, solution for injection in prefilled syringe
Tullex, 20 mg, solution for injection in prefilled syringe
Tullex, 22.5 mg, solution for injection in prefilled syringe
Tullex, 25 mg, solution for injection in prefilled syringe
Tullex, 27.5 mg, solution for injection in prefilled syringe
Tullex, 30 mg, solution for injection in prefilled syringe
Methotrexatum

Please read all of this leaflet carefully before using this medicine, as 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 symptoms are the same as yours.
• If you experience any side effects, including any not listed in this leaflet, tell your doctor or pharmacist. See section 4.

Contents of the leaflet

1. What Tullex injection solution is and what it is used for
2. What you need to know before using Tullex injection solution
3. How to use Tullex injection solution
4. Possible side effects
5. How to store Tullex injection solution
6. Contents of the pack and other information

1. What Tullex injection solution is and what it is used for

Methotrexate is a substance with the following properties:

• Slows down the growth of certain rapidly dividing cells in the body;
• Reduces the activity of the immune system (the body's defence mechanism);
• Has anti-inflammatory effects.

Indications for Tullex injection solution:

• Active rheumatoid arthritis in adult patients;
• Polyarticular juvenile idiopathic arthritis in children and adolescents, when response to non-steroidal anti-inflammatory drugs is inadequate;
• Severe, treatment-resistant, disabling psoriasis that has not responded satisfactorily to phototherapy, PUVA therapy, and retinoids, and severe psoriatic arthritis in adult patients;
• Crohn's disease of mild to moderate severity in adult patients when appropriate treatment with other medications is not possible.

Rheumatoid arthritis (RA) is a chronic disease classified among the collagenoses, characterized by inflammation of the synovial membranes lining the joints. These membranes produce fluid that acts as a lubricant for many joints. Inflammation causes thickening of the membranes and joint swelling.
Juvenile arthritis occurs in children and adolescents under the age of 16. The polyarticular form is defined by involvement of five or more joints within the first six months of the disease.
Psoriatic arthritis is a type of arthritis associated with psoriatic skin and nail changes, particularly affecting the joints of the fingers and toes.
Psoriasis is a common chronic skin disease characterized by red patches covered with thick, dry, silvery, tightly adherent scales.
Tullex injection solution modifies and slows the progression of the disease.
Crohn's disease is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract and causes symptoms such as abdominal pain, diarrhoea, vomiting, or weight loss.

2. Important information before using Tullex, solution for injection

If the patient, partner or caregiver notices new onset or worsening of neurological symptoms, including general muscle weakness, vision disturbances, changes in thinking, memory and orientation leading to confusion and personality changes, contact the physician immediately, as these may be symptoms of a very rare, serious brain infection called progressive multifocal leukoencephalopathy (PML).

When not to use Tullex, solution for injection

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

Warnings and precautions

Before starting treatment with Tullex, solution for injection, discuss with your doctor or pharmacist:

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

Cases of acute pulmonary haemorrhage have been reported in patients with underlying rheumatological disease during methotrexate treatment. If the patient develops haemoptysis (coughing up blood-tinged sputum), seek immediate medical advice.

Recommended tests and safety measures

Severe adverse reactions may occur even after administration of low doses of Tullex, solution for injection. To detect them in time, the doctor must perform regular check-ups and laboratory tests.

Before starting therapy

Prior to initiating treatment, the patient's blood will be tested to check whether the patient has an adequate number of blood cells. Blood will also be tested to assess liver function and to detect possible hepatitis (liver infection). Serum albumin (a blood protein), presence/occurrence of hepatitis (liver infection) and kidney function will also be monitored. The doctor may also decide to perform additional liver tests, some of which may include imaging studies of the liver, while others may require a small tissue sample taken from the liver for more detailed examination. The doctor may also 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 ulcers
• blood tests including complete blood count with blood cell counts and measurement of serum methotrexate concentration
• blood tests to monitor liver function
• imaging studies to monitor liver status
• liver biopsy (taking a small tissue sample from the liver for detailed examination)
• blood tests to monitor kidney function
• monitoring of the respiratory tract and, if necessary, lung function tests

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

Elderly patients

Elderly patients receiving methotrexate should be closely monitored by the doctor to allow early detection of possible adverse reactions. Age-related impairments in liver and kidney function, as well as low body reserves of a vitamin called folic acid, require relatively low doses of methotrexate.

Methotrexate may affect the immune system, vaccination outcomes and immunological test results. It may lead to reactivation of latent chronic diseases (e.g. shingles, tuberculosis, hepatitis B or C virus). During treatment with Tullex, solution for injection, vaccines containing live microorganisms should not be used.

Methotrexate may increase skin sensitivity to sunlight. Avoid intense sun exposure and do not use sunbeds or tanning lamps without consulting your doctor. To protect the skin from strong sunlight, wear appropriate clothing or use a high-protection sunscreen.

During methotrexate treatment, radiation-induced skin inflammation and sunburns ("recall reaction") may be triggered. Exposure to UV radiation during methotrexate treatment may worsen psoriatic skin lesions.

Lymph node enlargement (lymphadenopathy) may occur. In such a case, treatment should be discontinued.

Diarrhoea may be a sign of toxic effect of Tullex, solution for injection and requires interruption of treatment. If the patient develops diarrhoea, inform the doctor.

Encephalopathy (brain disease) and leukoencephalopathy (a specific brain disease affecting white matter) have been reported in cancer patients receiving methotrexate treatment. Such adverse effects cannot be ruled out when methotrexate is used to treat other diseases.

Special precautions for the use of Tullex, solution for injection

Methotrexate temporarily impairs sperm and egg cell production; in most cases, this effect is reversible. Methotrexate may cause miscarriage and severe congenital malformations. The patient should avoid becoming pregnant during methotrexate treatment and for at least 6 months after treatment ends. 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 completion. See also section "Pregnancy, breastfeeding and fertility".

Children

Tullex, solution for injection should not be used in children under 3 years of age due to insufficient experience with methotrexate in this age group.

Tullex, solution for injection 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.

Concomitant administration of certain medicines may affect the action of Tullex, solution for injection:

• hepatotoxic drugs or drugs reducing blood cell counts, e.g. leflunomide;
• antibiotics (medicines used to prevent and treat certain infections), e.g.: tetracyclines, chloramphenicol and non-absorbable broad-spectrum antibiotics, penicillins, glycopeptides, sulfonamides (medicines used to prevent and treat certain infections containing sulfur), ciprofloxacin and cephalothin;
• non-steroidal anti-inflammatory drugs or salicylates (pain-relieving and/or anti-inflammatory medicines);
• probenecid (used in the treatment of gout);
• weak organic acids such as loop diuretics (diuretics) or certain pain-relieving and anti-inflammatory medicines (e.g. acetylsalicylic acid, diclofenac and ibuprofen) and pyrazoles (used to treat pain);
• metamizole (synonyms: novaminsulfone and dipyrone) (a strong pain-relieving and/or antipyretic medicine);
• medicinal products that may adversely affect bone marrow function, e.g. trimethoprim-sulfamethoxazole (antibiotic) or pyrimethamine;
• other medicines used in the treatment of rheumatoid arthritis, e.g. penicillamine, hydroxychloroquine, sulfasalazine, azathioprine and cyclosporine;
• mercaptopurine (a cytostatic medicine);
• retinoids (medicines for psoriasis and other skin diseases);
• theophylline (a medicine for bronchial asthma and other lung diseases);
• proton pump inhibitors (medicines used in stomach disorders);
• hypoglycaemic agents (medicines reducing blood glucose concentration).

Vitamin products containing folic acid or folinic acid should be used only if prescribed by a doctor, as they may reduce the effectiveness of methotrexate.

During treatment with Tullex, solution for injection, vaccines containing live microorganisms should not be administered.

Tullex, solution for injection with food, drink and alcohol

During treatment with Tullex, solution for injection, avoid alcohol consumption as well as large amounts of coffee, caffeine-containing beverages and black tea.

Pregnancy, breastfeeding and fertility

If the patient is pregnant or breastfeeding, suspects she may be pregnant, or plans to have a child, she should consult her doctor or pharmacist before using this medicine.

Pregnancy

Do not use Tullex, solution for injection 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 defects of the skull, face, heart and blood vessels, brain and limbs. Therefore, it is extremely 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, e.g. performing a pregnancy test. The patient should avoid becoming pregnant during methotrexate treatment and for at least 6 months after its completion, using reliable contraception methods throughout this period (see also section "Warnings and precautions").

If the patient becomes pregnant during treatment or suspects she may be pregnant, she should consult her doctor immediately. The patient should seek advice regarding the possible 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 Tullex, solution for injection.

Male fertility

Available evidence does not indicate an increased risk of developmental defects or miscarriages following paternal exposure to methotrexate at doses below 30 mg per week. However, the risk cannot be completely ruled out. Methotrexate may be genotoxic. This means that the medicine may cause genetic mutations. Methotrexate may affect sperm and cause 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 completion.

Driving and operating machinery

During treatment with Tullex, solution for injection, adverse reactions affecting the central nervous system may occur, such as fatigue and dizziness. Therefore, the ability to drive motor vehicles and/or operate machinery may be impaired in some cases. If feeling drowsy or fatigued, do not drive or operate machinery.

Tullex, solution for injection contains sodium

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

3. How to use Tullex, injection solution

Important warning regarding dosing of Tullex (methotrexate)
In the treatment of rheumatoid arthritis, juvenile idiopathic arthritis,
psoriasis, psoriatic arthritis, and Crohn's disease, Tullex must be used only once a week.
Taking more Tullex (methotrexate) than prescribed may result in death.
Please read section 3 of this leaflet carefully. If you have any questions, consult your doctor or pharmacist before taking this medicine.
This medicine should always be used as directed by your doctor or pharmacist. Carefully follow the instructions provided at the end of this leaflet.
If in doubt, consult your doctor or pharmacist.
Tullex, injection solution should be administered by a doctor or healthcare professional, or under their supervision, only once a week.
The day for administration of the injection should be agreed upon by the patient and the doctor.
Tullex, injection solution may be administered subcutaneously (under the skin).

The appropriate dose for children and adolescents with polyarticular forms of juvenile idiopathic arthritis will be determined by the doctor.

Use in children
Tullex, injection solution should not be used in children under 3 years of age due to insufficient experience with use in this age group.

Method and timing of administration
Tullex, injection solution is administered once a week!
The duration of treatment will be determined by the treating physician. Treatment with Tullex, injection solution for rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis, psoriatic arthritis, and Crohn's disease is long-term.

At the beginning of treatment, Tullex, injection solution may be administered by medical personnel. However, the doctor may decide that the patient is capable of self-injecting Tullex, injection solution. The patient will be properly trained accordingly. Never attempt self-injection without prior training.

Handling and disposal of the medicine must comply with the guidelines for cytotoxic drugs and applicable local regulations. Pregnant healthcare personnel should not have contact with or administer Tullex, injection solution.

Avoid contact of methotrexate with skin surfaces or mucous membranes. In case of contamination, immediately flush the affected area thoroughly with water.

If you feel that the effect of Tullex, injection solution is too strong or too weak, consult your doctor or pharmacist.

Overdose of Tullex, injection solution
Always use the dose prescribed by your doctor. Do not change the dose on your own.
If you suspect that an overdose of Tullex, injection solution has been administered, contact your doctor immediately. The doctor will decide on appropriate treatment depending on the severity of poisoning.

Missed dose of Tullex, injection solution
Do not use a double dose to make up for a missed dose.
Take the dose prescribed by your doctor as soon as possible and continue treatment in the following weeks as scheduled.

Stopping treatment with Tullex, injection solution
Do not stop or discontinue treatment with Tullex, injection solution without consulting your doctor. If you suspect serious adverse effects, seek immediate medical advice.

If you have any further doubts regarding the use of this medicine, 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 frequencies of occurrence of symptoms are listed below. These frequencies are defined as follows:
very common: may occur in more than 1 in 10 patients
common: may occur in up to 1 in 10 patients
uncommon: may occur in up to 1 in 100 patients
rare: may occur in up to 1 in 1,000 patients
very rare: may occur in up to 1 in 10,000 patients
frequency not known: cannot be estimated from available data
The frequency and severity of adverse reactions depend on the dose and frequency of administration
of the medicine. Since severe adverse reactions may occur even after administration of small doses, regular medical examinations are necessary. The treating physician should order tests to rule out abnormalities in blood parameters (e.g. low white blood cell count, low platelet count and lymphoma) and changes in the liver and kidneys.
You should immediately inform the doctor 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;
• symptoms 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 red, itchy skin, swelling of the hands, feet, ankles, face, lips, mouth or throat (which may cause difficulty swallowing or breathing), and a feeling of fainting; these may be symptoms of severe allergic reactions or anaphylactic shock [rare]
• symptoms of kidney damage such as swelling of the hands, ankles or feet or changes in the frequency of urination or reduced volume (oliguria) or absence of urine (anuria); these may be symptoms of kidney failure [rare]
• symptoms of infection, e.g. fever, chills, soreness, sore throat; methotrexate may increase susceptibility to infections. Severe infections such as a specific type of pneumonia (Pneumocystis carinii pneumonia) and blood poisoning (septicaemia) may occur [rare]
• severe diarrhoea, bloody vomiting, black or tarry stools; these symptoms may indicate rare, severe gastrointestinal complications caused by methotrexate treatment, e.g. stomach and intestinal ulcers
• symptoms such as weakness on one side of the body (stroke) or pain, swelling, redness and an unusual feeling of 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 a sudden drop 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, blood in vomit, or appearance of blood spots; these may be symptoms of a significant decrease in the number of platelets due to severe bone marrow suppression [very rare]
• 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 (toxic epidermal necrolysis).

Other adverse reactions that may occur:
Very common:

• inflammation of the mucous membrane of the mouth, indigestion, nausea, loss of appetite
• increased liver enzyme activity.

Common:

• mouth ulcers, diarrhoea
• rash, redness of the skin, itching
• headache, feeling of fatigue, drowsiness
• reduced production of blood cells with decreased number of white and/or red blood cells or platelets (leukopenia, anaemia, thrombocytopenia).

Uncommon:

• sore throat, enteritis, vomiting
• reactions resembling sunburn due to increased sensitivity of the skin to sunlight
• hair loss, increased number of rheumatoid nodules, 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, osteoporosis (decreased bone mass).

Rare:

• intense skin pigmentation, acne, blue spots on the skin due to bleeding from blood vessels, allergic vasculitis, fever, redness of the eyes, infection, slow wound healing, decreased concentration of antibodies in the blood
• visual disturbances
• inflammation of the sac surrounding the heart, fluid in the sac surrounding the heart
• low blood pressure
• pulmonary fibrosis, shortness of breath and bronchial asthma, accumulation of fluid in the sac around the lung
• electrolyte disturbances.

Very rare:

• profuse bleeding, toxic dilation of the large intestine (toxic megacolon)
• increased pigmentation of the nails, dermatitis, severe infection of hair follicles (furunculosis), visible enlargement of small blood vessels
• local tissue damage (formation of sterile abscesses, changes in fatty tissue) at the site of intramuscular or subcutaneous injection
• blurred vision, pain, loss of muscle strength or numbness or tingling sensation, reduced response to stimuli, taste disturbances (metallic taste), seizures, paralysis, severe headache with fever
• retinopathy (non-inflammatory eye disease)
• decreased libido, impotence, breast enlargement in men (gynaecomastia), disturbances in sperm production, menstrual disorders, vaginal discharge
• enlarged lymph nodes (lymphoma)
• lymphoproliferative disorders (overproduction of white blood cells).

Frequency not known:

• leukoencephalopathy (disease of the white matter of the brain)
• pulmonary haemorrhage
• redness and peeling of the skin
• oedema
• jaw bone damage (due to overproduction of white blood cells).

Subcutaneous administration of methotrexate is well tolerated locally. Only mild skin reactions have been observed, which decrease during the course of treatment.
Reporting of adverse reactions
If any adverse reactions occur, including any not listed in this leaflet, inform your doctor or pharmacist. Adverse reactions can be reported directly to the Department of Monitoring 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.
By reporting adverse reactions, more information on the safety of the medicine can be collected.

5. How to store Tullex, solution for injection

Keep the medicine out of sight and reach of children.
Store below 25°C. Do not store in the refrigerator and do not freeze.
Keep the pre-filled syringe in the outer packaging to protect from light.
Do not use this medicine after the expiry date stated on the label and carton after "EXP".
The expiry date refers to the last day of the stated month.
Tullex, solution for injection is intended for single use only. Any unused
pre-filled syringe must be discarded.
Medicines must not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of medicines no longer required. Such measures will help protect the environment.

6. Contents of the pack and other information

What Tullex, solution for injection contains

• The active substance is methotrexate.
• The other components are sodium chloride, sodium hydroxide, hydrochloric acid, and water for injections.

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

What Tullex, solution for injection looks like and contents of the pack
Tullex, solution for injection is a syringe containing a clear, yellowish solution, free from visible solid particles.
Tullex, solution for injection is a prefilled syringe with an injection needle and a safety mechanism, available in packaging containing 1 prefilled syringe or 4, 12 prefilled syringes. The pack contains alcohol-impregnated swabs.

Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer
Marketing Authorisation Holder
Egis Pharmaceuticals PLC
Keresztúri út 30-38
1106 Budapest
Hungary

Manufacturer
Basic Pharma Manufacturing B.V.
Burgemeester Lemmensstraat 352
6163 JT Geleen
The Netherlands

This medicinal product is authorised in the European Economic Area countries under the following names:
Netherlands (RMS) Methotrexaat Basic Pharma 5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 7.5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 10 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 12.5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 15 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 17.5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 20 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 22.5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 25 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 27.5 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Methotrexaat Basic Pharma 30 mg, oplossing voor injectie in een voorgevulde spuit 37.5 mg/ml
Poland Tullex

Instructions for use
Before starting the injection, read the instructions carefully. Always administer the injection as recommended by your doctor or pharmacist.
Tullex, solution for injection is for single use only. Any unused solution remaining in the prefilled syringe must be discarded.
The solution should be clear and free from any solid particles.
If you have any problems or questions, consult your doctor or pharmacist.

Preparation
Prepare a clean, well-lit, flat working surface.
Before you begin, gather all necessary items:

• one prefilled syringe of Tullex, solution for injection
• one alcohol-impregnated swab (included in the pack)

Wash your hands thoroughly.
Inspect the prefilled syringe: check whether the syringe or the safety mechanism is damaged or any parts are detached. Ensure that the safety device is in the safe position before use. Do not use the prefilled syringe if it does not match the illustration below:

Figure 1.: Safety device
If you determine that the prefilled syringe is unsuitable for use, dispose of it in a container for biohazardous (sharp) waste.

Injection site

The best injection sites are:

• the upper thigh,
• the abdomen, avoiding the area around the navel.

If another person is assisting you with the injection, they may also administer it into the back of the upper arm, just below the shoulder.
Always change the injection site with each injection to reduce the risk of irritation at the injection site.
Never inject into areas of skin that are painful, have petechiae (small bleeding spots), are red, hard, or contain scars or stretch marks. If you have psoriasis, try to avoid injecting directly into raised, thickened, red, or scaly psoriatic lesions.

Injecting the solution

1. Unpack the prefilled syringe and carefully read the leaflet included in the package. Remove the prefilled syringe from its packaging at room temperature.
2. Disinfection

Choose the injection site and disinfect it using the provided alcohol-impregnated swab. Allow the disinfected injection site to dry for at least 60 seconds for the disinfectant to evaporate.

3. Remove the needle cap. Carefully pull the needle cap straight off along the needle's axis. Warning: Do NOT touch the needle of the prefilled syringe! After removing the needle cap, dispose of it in a container for biohazardous (sharp) waste.

4. Inserting the needle With one hand, gently pinch the skin at the injection site using two fingers. With the other hand, insert the needle at an angle of 45 to 90 degrees into the injection site, without pressing the plunger.

5. Injection and needle retraction Press the plunger fully down until it is completely depressed. Once the plunger is fully depressed, the needle will be safely retracted.

6. Dispose of the device Immediately after use, dispose of the prefilled syringe in a container for biohazardous waste (sharps). Do NOT dispose of the used prefilled syringe in a household waste bin.

Avoid contact of methotrexate with skin surfaces or mucous membranes. In case of contamination, immediately rinse the affected area thoroughly with large amounts of water.
If the patient or anyone else is accidentally injured by the needle, seek immediate medical advice and do not use that particular prefilled syringe.

Disposal and preparation of the medicinal product for use
Handling and disposal of the product must comply with the guidelines for cytotoxic medicinal products and applicable regulations. Pregnant healthcare personnel should not handle or (and/or) administer methotrexate.