METEX PEN

Package leaflet: Information for the user

Metex PEN, 7.5 mg, solution for injection in pre-filled syringe
Metex PEN, 10 mg, solution for injection in pre-filled syringe
Metex PEN, 12.5 mg, solution for injection in pre-filled syringe
Metex PEN, 15 mg, solution for injection in pre-filled syringe
Metex PEN, 17.5 mg, solution for injection in pre-filled syringe
Metex PEN, 20 mg, solution for injection in pre-filled syringe
Metex PEN, 22.5 mg, solution for injection in pre-filled syringe
Metex PEN, 25 mg, solution for injection in pre-filled syringe
Metex PEN, 27.5 mg, solution for injection in pre-filled syringe
Metex PEN, 30 mg, solution for injection in pre-filled syringe
Methotrexatum
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 or pharmacist.
• This medicine has been prescribed for a specific person only. Do not pass it on to others. It may harm other people, even if their symptoms are the same.
• 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 Metex PEN is and what it is used for
2. What you need to know 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 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 16 years of age. The polyarticular form is defined by involvement of five or more joints within the first six 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. Information before using Metex PEN

When not to use Metex PEN

• if the patient is allergic to methotrexate or any of the other ingredients of this medicine (listed in section 6);
• if the patient has liver disease, severe kidney disease 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 mucosal ulcers in the mouth, 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 health;
• 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 section "Pregnancy, breastfeeding and fertility".

Recommended monitoring tests and precautions
Severe adverse reactions may occur even after administration of low doses of methotrexate. To detect them in time, the doctor must perform regular check-ups and laboratory tests.

Before starting treatment
Before starting treatment, a blood test will be performed 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. Serum albumin (a blood protein) levels, kidney function, and signs of hepatitis (liver infection) will also be evaluated. The doctor may also decide to perform additional liver tests, which may include imaging studies 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 serum concentration;
• blood tests to monitor liver function;
• imaging studies to monitor liver status;
• 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 treated with methotrexate should remain under close medical supervision to detect possible adverse effects as early as possible. Age-related impairments in liver and kidney function and low levels of folic acid in older individuals require relatively low dosing of methotrexate.

Other precautions
Cases of acute pulmonary hemorrhage have been reported in patients with underlying rheumatologic disease 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 immunological test results. It may lead to reactivation of latent chronic diseases (e.g. shingles, tuberculosis, hepatitis B or C virus infection). During treatment with Metex PEN, do not use vaccines containing live microorganisms.

Methotrexate may increase skin sensitivity to sunlight. Exposure to intense sunlight should be avoided, and use of sunbeds or tanning lamps without prior consultation with a doctor is not recommended. To protect the skin from intense sunlight, appropriate clothing should be worn or a high-protection sunscreen filter applied.

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

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

Diarrhea may be a sign of toxic effects of Metex PEN and requires discontinuation of treatment. If the patient develops diarrhea, this should be reported to the doctor.

In cancer patients receiving methotrexate treatment, certain brain function disorders (encephalopathy/leukoencephalopathy) have been reported. Such adverse effects cannot be excluded 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, medical advice should be sought immediately, as these may be symptoms of a very rare but serious brain infection called progressive multifocal leukoencephalopathy (PML).

Metex PEN and other medicines
Inform your doctor or pharmacist about all medicines the patient is currently taking, has recently taken or plans to take in the future.

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 (analgesic and/or anti-inflammatory medicines, e.g. acetylsalicylic acid, diclofenac and ibuprofen or pyrazolones);
• metamizole (synonyms: novaminsulfone and dipyrone) (a potent analgesic 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 reducing glucose ["sugar"] concentration in blood).

Vitamin products containing folic acid should be used only if prescribed 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, alcohol consumption as well as large amounts of coffee, caffeine-containing beverages and black tea should be avoided.

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 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 or suspects she may be pregnant during treatment, she should consult her doctor as soon as possible. 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 physician, 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 defects or miscarriages after paternal exposure to methotrexate at doses below 30 mg/week. However, the risk cannot be completely excluded. Methotrexate may be genotoxic, meaning that it 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 using machines
During treatment with Metex PEN, 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, driving vehicles or operating machinery is not permitted.

Metex PEN contains sodium
This medicine contains less than 1 mmol (23 mg) of sodium per dose, meaning that 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 Metex PEN (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 the medicine.
This medicine should 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.
Metex PEN is administered as a 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.

Use in children and adolescents
The doctor determines the appropriate dose for children and adolescents with polyarticular course
juvenile idiopathic arthritis.
Metex PEN is not recommended for use in children under 3 years of age due to
insufficient experience 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 medical personnel. However,
the doctor may decide that the patient is capable of self-injecting Metex PEN. The patient will be
appropriately trained for this. Never attempt self-injection without prior training.
Instructions on how to properly use Metex PEN are provided in the "Instructions for Use"
included at the end of this leaflet.
Remember to use the entire contents.
Preparation of the medicine for use and disposal of the medicine and the prefilled automatic injector
must comply with local requirements. Healthcare personnel 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 treatment
If treatment with Metex PEN is discontinued, 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 serious 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,
platelets, lymphoma) as well as 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 serious, potentially life-threatening adverse reactions requiring urgent treatment:

• persistent dry cough without sputum, shortness of breath, and fever; these may be symptoms of pneumonitis [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], hepatitis (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 swallowing or breathing), and the patient may feel 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, e.g. fever, chills, pain, sore throat; methotrexate may increase susceptibility to infections. Severe infections such as a specific type of pneumonia (Pneumocystis jirovecii pneumonia) and blood poisoning (sepsis) may occur [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 if a dislodged blood clot blocks a blood vessel (thromboembolic event) [rare]
• symptoms such as 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 or vomit, or appearance of petechiae (small red or purple spots on the skin due to bleeding); these may be signs of significant reduction 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 light sensitivity; 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 ruled out when methotrexate is used to treat other diseases. Symptoms of such brain 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]

The following are other adverse reactions that may occur:
Very common: may occur in more than 1 in 10 patients

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

Common: may occur in 1 in 10 patients

• mouth ulcers, diarrhoea,
• skin rash, redness of the skin, itching,
• headache, fatigue, drowsiness,
• reduced production of blood cells leading to decreased numbers 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, gastrointestinal bleeding and ulcers,
• sunburn-like reactions due to increased skin sensitivity to sunlight, hair loss, increase in rheumatoid nodules, skin ulceration, herpes zoster, 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, 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 dilation of the large intestine (toxic megacolon),
• increased nail pigmentation, inflammation of the nail fold (acute paronychia), deep infection of hair follicles (furunculosis), visible enlargement of small blood vessels,
• pain, loss of muscle strength, or numbness or tingling sensations, reduced sensitivity to stimuli, taste disturbances (metallic taste), seizures, meningeal reaction,
• impaired vision, non-inflammatory eye disease (retinopathy),
• decreased libido, impotence, breast enlargement in men, disturbances in semen production (oligospermia), menstrual disorders, vaginal discharge,
• enlarged lymph nodes (lymphoma),
• lymphoproliferative disorders (overproduction of white blood cells).

Frequency not known: frequency cannot be estimated 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 generally well tolerated locally. Only
mild local skin reactions (such as burning sensation, erythema, swelling, discoloration, itching,
intense pruritus, pain) have been observed, which tend to diminish during treatment.
Reporting of adverse reactions
If any adverse symptoms occur, including any adverse reactions not listed
in this leaflet, you should inform your doctor, pharmacist, or nurse. 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, 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 provide more information on the safety of the medicine.

5. How to store Metex PEN

Keep this medicine out of the sight and reach of children.
Do not store above 25°C. Do not freeze.
Store the pre-filled automatic injection pens in their outer packaging to protect from light.
Do not use this medicine after the expiry date stated on the carton and the 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 will help protect the environment.

6. Contents of the pack and other information

What Metex PEN contains

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

One pre-filled semi-automatic syringe with a solution volume of 0.55 ml contains 27.5 mg
of methotrexate.
One pre-filled semi-automatic syringe with a solution volume of 0.6 ml contains 30 mg
of 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 injection device with a yellow cap and a yellow injection button.

Metex PEN pre-filled semi-automatic syringe is a two-step automatic injection device 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

• Before administering the medicine, carefully read the instructions below.
• 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 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 syringe:

Injection button
Area for holding the syringe
Transparent control zone
Cap

a) With cap before injection
b) After removing the cap before injection
c) After injection has been administered

What to do before administering the injection

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

If the Metex PEN syringe appears damaged,

do not use it. Use another syringe and contact your doctor, pharmacist or nurse.
If a small air bubble is visible in the transparent control zone, this does not affect the dose and does not pose a risk to the patient.
If the patient cannot properly see or check the syringe before injection, ask another person for assistance.

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

Where to administer the injection
The most suitable injection sites

include:

• the upper thigh,
• the abdomen, except the area around the navel.
  • If another person administers the injection to the patient, it may also be given in 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 the injection

5. Select the injection site and clean

the selected injection site and the surrounding skin area.

• Do not remove the cap before preparing for injection.

6. Hold the syringe 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). Inside the cap is a small needle shield, which should automatically slide off together with the cap. If the needle shield does not slide off, use another syringe and contact your doctor, pharmacist or nurse.

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

Warning: After removing the cap, administer the injection immediately.

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

injection site.

• Hold the skin fold until the syringe is removed from the skin after the injection.

8. Place the exposed, transparent end

of the Metex PEN syringe perpendicularly onto the skin fold.

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

• If the patient cannot firmly and steadily press the Metex PEN syringe in place, ask another person for assistance.

How to administer the injection:

10. While firmly holding the Metex PEN syringe

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

11. A clicking sound indicates that the injection has started. Keep holding the syringe 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 syringe from the skin before the injection is complete.
If the injection does not start, release the button, ensure the Metex PEN syringe is firmly pressed against the skin, and press the button firmly again.
If you cannot hear the click, count to 5 seconds from the moment the button was pressed, then lift the syringe away from the injection site.

12. Remove the Metex PEN syringe from the injection

site by pulling it straight out, perpendicularly to the skin.

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

Before disposing of the Metex PEN syringe, visually check whether any liquid remains at the bottom of the transparent control zone. If liquid is still present in the syringe, this means that an incomplete dose has been administered, and you should contact your doctor.

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

Whom 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 syringe.

INSTRUCTIONS FOR USE

Before using the prefilled automatic injector for subcutaneous injection,
read this Instructions for Use in its entirety. Read this Instructions for Use
each time a new prescription is received, and keep this Instructions for use
to obtain information that may be needed after use.

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

• Store the injector in a safe place, out of sight and reach of children.
• If contact with the medicine occurs, 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 particles;
• it has been frozen or stored at temperatures above 25°C;
• the expiration date has passed. If in doubt, consult a healthcare professional.

How to store the prefilled semi-automatic injector for Metex PEN

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

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

(indicates complete injection)
Medicine label
7.5 mg 15 mg 30 mg
(for checking dose (example doses)
and expiration date)
Color-coded area
(unique for each dose)
Fig. A
Materials needed for administering the injection (Fig. B)
On the day of your weekly injection, find a comfortable location, ensure it is well-lit, and have a clean, flat surface available—such as a table—on which to place the materials needed for the injection.
Required item:

• Metex PEN prefilled semi-automatic injector.

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

Metex PEN calendar Alcohol swab or gauze Sharps
indicating the weekly injector for cleaning container
injection day automatic or skin
Fig. B
Preparing to administer the injection

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

Fig. C
2. Check the injector before use

(Fig. D)

• Check the expiration date on the injector label.
• Do not use the injector if the Fig. D expiration date has passed.
• Inspect the medicine through the viewing window by turning the injector upside down or gently shaking it. The solution in the injector should be clear and yellow.
  • Do not inject if the solution is cloudy, has changed color, or contains 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 does not require attention.
• Check that the injector is undamaged 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 expiration date of the injector has passed,
the injector 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 the injection is administered by a caregiver, the back of the upper arm may also be used.
• Use a different injection site than the one used for the last 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.

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

• Clean the injection site with an alcohol-based disinfectant; if unavailable, use water and soap.
• Wait until the skin is dry. Do not fan or do not blow on the cleaned area. Do not touch the injection site again until the injection is completed. 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 medication 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 the thumb and other fingers before injecting, but this is not required for this injector. Fig. H

7. Start the injection (Fig. I)

• To start the injection, press the injector firmly all the way down. 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 holding 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 holding the injector firmly against the skin for 5 seconds.
• The injection is complete when:
  • a second click is heard shortly after the first;
  • or: the blue plunger rod has stopped moving and completely fills the viewing window;
  • or: 5 seconds have passed. Fig. J

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 yellow residue of medication remains visible. If yellow medication is still visible in the window, a full dose may not have been delivered. In this case, or if you have any other Fig. K concerns, contact a healthcare professional.

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

10. Dress the injection site (Fig. L)

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

Do not rub the injection site.
Fig. L

11. Disposing of the injector (Fig. M)
Each injector may only be used
once. Do not reattach the protective cap to
the injector.
Used injectors and protective caps
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 medication and the prefilled automatic injector must
  comply with local regulations.

• Discard used materials into a household waste container. The cardboard box can be disposed of in paper recycling.

Prefilled automatic injectors containing
Metex PEN that have expired, are no longer
needed, or are not suitable for use must be
disposed of safely.