VYLIBRA- norgestimate and ethinyl estradiol 
Afaxys Pharma, LLC

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HIGHLIGHTS OF PRESCRIBING INFORMATION

These highlights do not include all the information needed to use VyLibra safely and effectively. See full prescribing information for VyLibra.

VyLibra TM (norgestimate and ethinyl estradiol) tablets, for oral use
Initial U.S. Approval: 1989

WARNING: CIGARETTE SMOKING and SERIOUS CARDIOVASCULAR EVENTS

See full prescribing information for complete boxed warning.

  • VyLibra is contraindicated in women over 35 years old who smoke. (4)
  • Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptives (COC) use. (4)

RECENT MAJOR CHANGES

Contraindications (4)                                                                  08/2017

Warnings and Precautions (5.3)                                                08/2017

INDICATIONS AND USAGE

VyLibra is estrogen/progestin COCs, indicated for use by women to prevent pregnancy. (1.1)

DOSAGE AND ADMINISTRATION

  • Take one tablet daily by mouth at the same time every day. (2.2)
  • Take tablets in the order directed on the blister pack. (2.2)
  • Do not skip or delay tablet intake. (2.2)

DOSAGE FORMS AND STRENGTHS

VyLibra consists of 28 round, biconvex tablets in the following order (3):

  • 21 dark blue, coated tablets each containing 0.250 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 green, uncoated tablets (inert)

CONTRAINDICATIONS

  • A high risk of arterial or venous thrombotic diseases (4)
  • Liver tumors or liver disease (4)  
  • Undiagnosed abnormal uterine bleeding (4)
  • Pregnancy (4)
  • Breast cancer or other estrogen- or progestin-sensitive cancer (4)
  • Co-administration with Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir (4

WARNINGS AND PRECAUTIONS

  • Thromboembolic Disorders and Other Vascular Problems: Stop VyLibra if a thrombotic event occurs. Stop at least 4 weeks before and through 2 weeks after major surgery. Start no earlier than 4 weeks after delivery, in women who are not breastfeeding. (5.1)
  • Liver disease: Discontinue VyLibra if jaundice occurs. (5.2)
  • High blood pressure: If used in women with well-controlled hypertension, monitor blood pressure and stop VyLibra if blood pressure rises significantly. (5.4)
  • Carbohydrate and lipid metabolic effects: Monitor prediabetic and diabetic women taking VyLibra. Consider an alternate contraceptive method for women with uncontrolled dyslipidemia. (5.6)
  • Headache: Evaluate significant change in headaches and discontinue VyLibra if indicated. (5.7)
  • Bleeding Irregularities and Amenorrhea: Evaluate irregular bleeding or amenorrhea. (5.8)

ADVERSE REACTIONS

The most common adverse reactions reported during clinical trials (≥2%) were: headache/migraine, abdominal/gastrointestinal pain, vaginal infection, genital discharge, breast issues (including breast pain, discharge, and enlargement), mood disorders (including depression and mood altered), flatulence, nervousness, rash. (6.1)


To report SUSPECTED ADVERSE REACTIONS, contact Afaxys Pharma LLC at 1-855-888-2467 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

DRUG INTERACTIONS

Drugs or herbal products that induce certain enzymes including CYP3A4, may decrease the effectiveness of COCs or increase breakthrough bleeding. Counsel patients to use a back-up or alternative method of contraception when enzyme inducers are used with COCs. (7.1)

USE IN SPECIFIC POPULATIONS

Nursing mothers: Not recommended; can decrease milk production. (8.3) 

See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.

Revised: 11/2017

FULL PRESCRIBING INFORMATION: CONTENTS*

WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS

1 INDICATIONS AND USAGE

1.1 Oral Contraceptive

2 DOSAGE AND ADMINISTRATION

2.1 How to Start VyLibra

2.2 How to Take VyLibra

2.3 Missed Tablets

2.4 Advice in Case of Gastrointestinal Disturbances

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Thromboembolic Disorders and Other Vascular Problems

5.2 Liver Disease

5.3 Risk of Liver Enzyme Elevations with Concomitant Hepatitis C Treatment

5.4 High Blood Pressure

5.5 Gallbladder Disease

5.6 Carbohydrate and Lipid Metabolic Effects

5.7 Headache

5.8 Bleeding Irregularities and Amenorrhea

5.9 COC Use Before or During Early Pregnancy

5.10 Depression

5.11 Carcinoma of Breast and Cervix

5.12 Effect on Binding Globulins

5.13 Monitoring

5.14 Hereditary Angioedema

5.15 Chloasma

6 ADVERSE REACTIONS

6.1 Clinical Trial Experience

6.2 Postmarketing Experience

7 DRUG INTERACTIONS

7.1 Effects of Other Drugs on Combined Oral Contraceptives

7.2 Effects of Combined Oral Contraceptives on Other Drugs

7.3 Interference with Laboratory Tests

7.4 Concomitant Use with HCV Combination Therapy – Liver Enzyme Elevation

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

8.3 Nursing Mothers

8.4 Pediatric Use

8.5 Geriatric Use

8.6 Hepatic Impairment

8.7 Renal Impairment

10 OVERDOSAGE

11 DESCRIPTION

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.2 Pharmacodynamics

12.3 Pharmacokinetics

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

14 CLINICAL STUDIES

14.1 Contraception

16 HOW SUPPLIED/STORAGE AND HANDLING

16.1 How Supplied

16.2 Storage Conditions

17 PATIENT COUNSELING INFORMATION

*
Sections or subsections omitted from the full prescribing information are not listed.

FULL PRESCRIBING INFORMATION

WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS

Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptive (COC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, COCs are contraindicated in women who are over 35 years of age and smoke [see Contraindications (4)].

1 INDICATIONS AND USAGE

1.1 Oral Contraceptive

VyLibra tablets are indicated for use by females of reproductive potential to prevent pregnancy [see Clinical Studies (14)].

2 DOSAGE AND ADMINISTRATION

2.1 How to Start VyLibra

VyLibra is available in blister pack [see How Supplied/Storage and Handling (16)]. VyLibra may be started using either a Day 1 start or a Sunday start (see Table 1). For the first cycle of a Sunday Start regimen, an additional method of contraception should be used until after the first 7 consecutive days of administration.

2.2 How to Take VyLibra

Table 1: Instructions for Administration of VyLibra
Starting COCs in women not currently using hormonal contraception (Day 1 Start or Sunday Start)
 

Important:
Consider the possibility of ovulation and conception prior to initiation of this product.
 
Tablet Color:
  • VyLibra active tablets are dark blue (Day 1 to Day 21).
  • VyLibra has green inactive tablets (Day 22 to Day 28).
Day 1 Start:
  • Take first active tablet without regard to meals on the first day of menses.
  • Take subsequent active tablets once daily at the same time each day for a total of 21 days.
  • Take one green inactive tablet daily for 7 days and at the same time of day that active tablets were taken.
  • Begin each subsequent pack on the same day of the week as the first cycle pack (i.e., on the day after taking the last inactive tablet)
Sunday Start:
  • Take first active tablet without regard to meals on the first Sunday after the onset of menses. Due to the potential risk of becoming pregnant, use additional non-hormonal contraception (such as condoms and spermicide) for the first seven days of the patient’s first cycle pack of VyLibra.
  • Take subsequent active tablets once daily at the same time each day for a total of 21 days.
  • Take one green inactive tablet daily for the following 7 days and at the same time of day that active tablets were taken.
  • Begin each subsequent pack on the same day of the week as the first cycle pack (i.e., on the Sunday after taking the last inactive tablet) and additional non-hormonal contraceptive is not needed.
Switching to VyLibra from another oral contraceptive
Start on the same day that a new pack of the previous oral contraceptive would have started.
Switching from another contraceptive method to VyLibra
Start VyLibra:
 ● Transdermal patch
 ● On the day when next application would have been scheduled
 ● Vaginal ring
 ● On the day when next insertion would have been scheduled
 ● Injection
 ● On the day when next injection would have been scheduled
 ● Intrauterine contraceptive
 ● On the day of removal
 ● If the IUD is not removed on first day of the patient’s menstrual cycle, additional non-hormonal contraceptive (such as condoms and spermicide) is needed for the first seven days of the first cycle pack.
 ● Implant
 ● On the day of removal
Complete instructions to facilitate patient counseling on proper tablet usage are located in the FDA-Approved Patient Labeling.

Starting VyLibra after Abortion or Miscarriage

First-trimester


  • After a first-trimester abortion or miscarriage, VyLibra may be started immediately. An additional method of contraception is not needed if VyLibra is started immediately.
  • If VyLibra is not started within 5 days after termination of the pregnancy, the patient should use additional non-hormonal contraception (such as condoms and spermicide) for the first seven days of her first cycle pack of VyLibra.

 Second-trimester


  • Do not start until 4 weeks after a second-trimester abortion or miscarriage, due to the increased risk of thromboembolic disease. Start VyLibra, following the instructions in Table 1 for Day 1 or Sunday start, as desired. If using Sunday start, use additional non-hormonal contraception (such as condoms and spermicide) for the first seven days of the patient’s first cycle pack of VyLibra. [see Contraindications (4), Warnings and Precautions (5.1), and FDA-Approved Patient Labeling.]

Starting VyLibra after Childbirth


How to Use the Blister Pack:

There are two ways to start taking birth control pills, Sunday Start or Day 1 Start. Your healthcare professional will tell you which to use.


1. Pick the Days of the Week Sticker that starts the first day of your period. (This is the day you begin bleeding or spotting, even if it is midnight when bleeding begins.) When you have picked the right sticker, throw away the others and place the sticker on the blister pack over the preprinted days of the week and make sure it lines up with the pills.


fig1

2. Your blister pack containing 28 individually sealed pills. Note that the pills are arranged in four numbered rows of 7 pills, with the pre-printed days of the week printed above them. There are 21 dark blue “active” pills and 7 green “reminder” pills. Refer to the sample of the blister pack below:


fig2

3. After taking the last green pill, start a new blister pack the very next day no matter when your period started. You will be taking a pill every day without interruption. Anytime you start the pills later than directed, protect yourself by using another method of birth control until you have taken a pill a day for seven consecutive days. After taking the last green pill, start taking the first dark blue pill from the blister pack the very next day.

4. Take the pills in each new package as before. Start with the dark blue pill on row #1 and take one pill each day, left to right, until the last green pill has been taken.

Three Ways to Remember in What Order to take the Pills

1. Follow the sticker with the days of the week (placed above the pills).
2. Always go from left to right.
3. Always finish all your pills.

2.3 Missed Tablets

Table 2: Instructions for Missed VyLibra Tablets
  • If one active tablet is missed in Weeks 1, 2, or 3
Take the tablet as soon as possible. Continue taking one tablet a day until the pack is finished.
  • If two active tablets are missed in Week 1 or Week 2
Take the two missed tablets as soon as possible and the next two active tablets the next day. Continue taking one tablet a day until the pack is finished. Additional non-hormonal contraception (such as condoms and spermicide) should be used as back-up if the patient has sex within 7 days after missing tablets.
  • If two active tablets are missed in the third week or three or more active tablets are missed in a row in Weeks 1, 2, or 3
Day 1 start: Throw out the rest of the pack and start a new pack that same day.
Sunday start: Continue taking one tablet a day until Sunday, then throw out the rest of the pack and start a new pack that same day. Additional non-hormonal contraception (such as condoms and spermicide) should be used as back-up if the patient has sex within 7 days after missing tablets.

2.4 Advice in Case of Gastrointestinal Disturbances

In case of severe vomiting or diarrhea, absorption may not be complete and additional contraceptive measures should be taken. If vomiting or diarrhea occurs within 3 to 4 hours after taking an active tablet, handle this as a missed tablet [see FDA-Approved Patient Labeling].

3 DOSAGE FORMS AND STRENGTHS

VyLibra tablets are available in blister packs. Each blister pack contains 28 tablets in the following order:


4 CONTRAINDICATIONS

Do not prescribe VyLibra to women who are known to have the following conditions:


5 WARNINGS AND PRECAUTIONS

5.1 Thromboembolic Disorders and Other Vascular Problems

  • Stop VyLibra if an arterial thrombotic event or venous thromboembolic (VTE) event occurs.
  • Stop VyLibra if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions. Evaluate for retinal vein thrombosis immediately [see Adverse Reactions (6.2)].
  • If feasible, stop VyLibra at least 4 weeks before and through 2 weeks after major surgery or other surgeries known to have an elevated risk of VTE as well as during and following prolonged immobilization.
  • Start VyLibra no earlier than 4 weeks after delivery, in women who are not breastfeeding. The risk of postpartum VTE decreases after the third postpartum week, whereas the risk of ovulation increases after the third postpartum week.
  • The use of COCs increases the risk of VTE. However, pregnancy increases the risk of VTE as much or more than the use of COCs. The risk of VTE in women using COCs is 3 to 9 cases per 10,000 woman-years. The risk of VTE is highest during the first year of use of COCs and when restarting hormonal contraception after a break of 4 weeks or longer. The risk of thromboembolic disease due to COCs gradually disappears after use is discontinued.
  • Use of COCs also increases the risk of arterial thromboses such as strokes and myocardial infarctions, especially in women with other risk factors for these events. COCs have been shown to increase both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes). This risk increases with age, particularly in women over 35 years of age who smoke.
  • Use COCs with caution in women with cardiovascular disease risk factors.

5.2 Liver Disease

Impaired Liver Function

Do not use VyLibra in women with liver disease, such as acute viral hepatitis or severe (decompensated) cirrhosis of liver [see Contraindications (4)]. Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal and COC causation has been excluded. Discontinue VyLibra if jaundice develops.

Liver Tumors

VyLibra is contraindicated in women with benign and malignant liver tumors [see Contraindications (4)]. Hepatic adenomas are associated with COC use. An estimate of the attributable risk is 3.3 cases/100,000 COC users. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage.

Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (>8 years) COC users. However, the risk of liver cancers in COC users is less than one case per million users.

5.3 Risk of Liver Enzyme Elevations with Concomitant Hepatitis C Treatment

During clinical trials with the Hepatitis C combination drug regimen that contains ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, ALT elevations greater than 5 times the upper limit of normal (ULN), including some cases greater than 20 times the ULN, were significantly more frequent in women using ethinyl estradiol-containing medications, such as COCs. Discontinue VyLibra prior to starting therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir [see Contraindications (4)]. VyLibra can be restarted approximately 2 weeks following completion of treatment with the Hepatitis C combination drug regimen.

5.4 High Blood Pressure

VyLibra is contraindicated in women with uncontrolled hypertension or hypertension with vascular disease [see Contraindications (4)]. For women with well-controlled hypertension, monitor blood pressure and stop VyLibra if blood pressure rises significantly.

An increase in blood pressure has been reported in women taking COCs, and this increase is more likely in older women with extended duration of use. The incidence of hypertension increases with increasing concentrations of progestin.

5.5 Gallbladder Disease

Studies suggest a small increased relative risk of developing gallbladder disease among COC users. Use of COCs may worsen existing gallbladder disease. A past history of COC-related cholestasis predicts an increased risk with subsequent COC use. Women with a history of pregnancy-related cholestasis may be at an increased risk for COC related cholestasis.

5.6 Carbohydrate and Lipid Metabolic Effects

Carefully monitor prediabetic and diabetic women who take VyLibra. COCs may decrease glucose tolerance.

Consider alternative contraception for women with uncontrolled dyslipidemia. A small proportion of women will have adverse lipid changes while on COCs.

Women with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using COCs.

5.7 Headache

If a woman taking VyLibra develops new headaches that are recurrent, persistent, or severe, evaluate the cause and discontinue VyLibra if indicated.

Consider discontinuation of VyLibra in the case of increased frequency or severity of migraine during COC use (which may be prodromal of a cerebrovascular event).

5.8 Bleeding Irregularities and Amenorrhea

Unscheduled Bleeding and Spotting

Unscheduled (breakthrough or intracyclic) bleeding and spotting sometimes occur in patients on COCs, especially during the first three months of use. If bleeding persists or occurs after previously regular cycles, check for causes such as pregnancy or malignancy. If pathology and pregnancy are excluded, bleeding irregularities may resolve over time or with a change to a different contraceptive product.

In clinical trials of VyLibra, the frequency and duration of breakthrough bleeding and/or spotting was assessed in 1,647 patients (21,275 evaluable cycles). A total of 100 (7.5%) women discontinued VyLibra, at least in part, due to bleeding or spotting. Based on data from the clinical trials, 14 to 34% of women using VyLibra experienced unscheduled bleeding per cycle in the first year. The percent of women who experienced breakthrough/unscheduled bleeding tended to decrease over time.

Amenorrhea and Oligomenorrhea

Women who use VyLibra may experience amenorrhea. Some women may experience amenorrhea or oligomenorrhea after discontinuation of COCs, especially when such a condition was pre-existent.

If scheduled (withdrawal) bleeding does not occur, consider the possibility of pregnancy. If the patient has not adhered to the prescribed dosing schedule (missed one or more active tablets or started taking them on a day later than she should have), consider the possibility of pregnancy at the time of the first missed period and take appropriate diagnostic measures. If the patient has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy.

5.9 COC Use Before or During Early Pregnancy

Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy. Studies also do not suggest a teratogenic effect, particularly in so far as cardiac anomalies and limb reduction defects are concerned, when oral contraceptives are taken inadvertently during early pregnancy. Discontinue VyLibra use if pregnancy is confirmed.

Administration of COCs to induce withdrawal bleeding should not be used as a test for pregnancy [see Use in Specific Populations (8.1)].

5.10 Depression

Carefully observe women with a history of depression and discontinue VyLibra if depression recurs to a serious degree.

5.11 Carcinoma of Breast and Cervix

  • VyLibra is contraindicated in women who currently have or have had breast cancer because breast cancer may be hormonally sensitive [see Contraindications (4)].

There is substantial evidence that COCs do not increase the incidence of breast cancer. Although some past studies have suggested that COCs might increase the incidence of breast cancer, more recent studies have not confirmed such findings.


  • Some studies suggest that COC use has been associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors.

5.12 Effect on Binding Globulins

The estrogen component of COCs may raise the serum concentrations of thyroxine-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin. The dose of replacement thyroid hormone or cortisol therapy may need to be increased.

5.13 Monitoring

A woman who is taking COCs should have a yearly visit with her healthcare provider for a blood pressure check and for other indicated healthcare.

5.14 Hereditary Angioedema

In women with hereditary angioedema, exogenous estrogens may induce or exacerbate symptoms of angioedema.

5.15 Chloasma

Chloasma may occasionally occur, especially in women with a history of chloasma gravidarum. Women with a tendency to chloasma should avoid exposure to the sun or ultraviolet radiation while taking VyLibra.

6 ADVERSE REACTIONS

The following serious adverse reactions with the use of COCs are discussed elsewhere in labeling:



Adverse reactions commonly reported by COC users are:


6.1 Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.


The safety of VyLibra was evaluated in 1,647 healthy women of child-bearing potential who participated in 3 clinical trials and received at least 1 dose of VyLibra for contraception. Two trials were randomized active-controlled trials and 1 was an uncontrolled open-label trial. In all 3 trials, subjects were followed for up to 24 cycles.


Common Adverse Reactions (≥ 2% of subjects): The most common adverse reactions reported by at least 2% of the 1,647 women were the following in order of decreasing incidence: headache/migraine (32.9%), abdominal/gastrointestinal pain (7.8%), vaginal infection (8.4%), genital discharge (6.8%), breast issues (including breast pain, discharge, and enlargement) (6.3%), mood disorders (including depression and mood altered) (5.0%), flatulence (3.2%), nervousness (2.9%), and rash (2.6%).


Adverse Reactions Leading to Study Discontinuation: Over the three trials, between 11 to 21% of subjects discontinued the trial due to an adverse reaction. The most common adverse reactions (≥1%) leading to discontinuation were: metrorrhagia (6.9%), nausea/vomiting (5.0%), headache (4.1%), mood disorders (including depression and mood altered) (2.4%), premenstrual syndrome (1.7%), hypertension (1.4%), breast pain (1.4%), nervousness (1.3%), amenorrhea (1.1%), dysmenorrhea (1.1%), weight increased (1.1%), and flatulence (1.1%).


Serious Adverse Reactions: breast cancer (1 subject), mood disorders including depression, irritability, and mood swings (1 subject), myocardial infarction (1 subject), and venous thromboembolic events including pulmonary embolism (1 subject) and deep vein thrombosis (DVT) (1 subject).

6.2 Postmarketing Experience

The following additional adverse drug reactions have been reported from worldwide postmarketing experience with norgestimate/ethinyl estradiol. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Infections and Infestations
: Urinary tract infection;

Neoplasms Benign, Malignant and Unspecified (Incl. Cysts and Polyps)
: Breast cancer, benign breast neoplasm, hepatic adenoma, focal nodular hyperplasia, breast cyst;

Immune System Disorders
: Hypersensitivity;

Metabolism and Nutrition Disorders
: Dyslipidemia;

Psychiatric Disorders
: Anxiety, insomnia;

Nervous System Disorders
: Syncope, convulsion, paresthesia, dizziness;

Eye Disorders
: Visual impairment, dry eye, contact lens intolerance;

Ear and Labyrinth Disorders
: Vertigo;

Cardiac Disorders
: Tachycardia, palpitations;

Vascular Events
: Deep vein thrombosis, pulmonary embolism, retinal vascular thrombosis, hot flush;

Arterial Events:
Arterial thromboembolism, myocardial infarction, cerebrovascular accident;

Respiratory, Thoracic and Mediastinal Disorders
: Dyspnea;

Gastrointestinal Disorders
: Pancreatitis, abdominal distension, diarrhea, constipation;

Hepatobiliary Disorders:
Hepatitis;

Skin and Subcutaneous Tissue Disorders
: Angioedema, erythema nodosum, hirsutism, night sweats, hyperhidrosis, photosensitivity reaction, urticaria, pruritus, acne;

Musculoskeletal, Connective Tissue, and Bone Disorders
: Muscle spasms, pain in extremity, myalgia, back pain;

Reproductive System and Breast Disorders
: Ovarian cyst, suppressed lactation, vulvovaginal dryness;

General Disorders and Administration Site Conditions
: Chest pain, asthenic conditions.

7 DRUG INTERACTIONS

Consult the labeling of concurrently used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.

No drug-drug interaction studies were conducted with VyLibra.

7.1 Effects of Other Drugs on Combined Oral Contraceptives

Substances decreasing the plasma concentrations of COCs:

Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the plasma concentrations of COCs and potentially diminish the effectiveness of COCs or increase breakthrough bleeding. Some drugs or herbal products that may decrease the effectiveness of hormonal contraceptives include phenytoin, barbiturates, carbamazepine, bosentan, felbamate, griseofulvin, oxcarbazepine, rifampicin, topiramate, rifabutin, rufinamide, aprepitant, and products containing St. John’s wort. Interactions between hormonal contraceptives and other drugs may lead to breakthrough bleeding and/or contraceptive failure. Counsel women to use an alternative method of contraception or a back-up method when enzyme inducers are used with COCs, and to continue back-up contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.

Colesevelam:
Colesevelam, a bile acid sequestrant, given together with a COC, has been shown to significantly decrease the AUC of EE. The drug interaction between the contraceptive and colesevelam was decreased when the two drug products were given 4 hours apart.

Substances increasing the plasma concentrations of COCs:

Co-administration of atorvastatin or rosuvastatin and certain COCs containing ethinyl estradiol (EE) increase AUC values for EE by approximately 20 to 25%. Ascorbic acid and acetaminophen may increase plasma EE concentrations, possibly by inhibition of conjugation. CYP3A4 inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase plasma hormone concentrations.

Human immunodeficiency virus (HIV)/Hepatitis C virus (HCV) protease inhibitors and non-nucleoside reverse transcriptase inhibitors:

Significant changes (increase or decrease) in the plasma concentrations of estrogen and/or progestin have been noted in some cases of co-administration with HIV protease inhibitors (decrease [e.g., nelfinavir, ritonavir, darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir] or increase [e.g., indinavir and atazanavir/ritonavir])/HCV protease inhibitors (decrease [e.g., boceprevir and telaprevir]) or with non-nucleoside reverse transcriptase inhibitors (decrease [e.g., nevirapine] or increase [e.g., etravirine]).

7.2 Effects of Combined Oral Contraceptives on Other Drugs

  • COCs containing EE may inhibit the metabolism of other compounds (e.g., cyclosporine, prednisolone, theophylline, tizanidine, and voriconazole) and increase their plasma concentrations.
  • COCs have been shown to decrease plasma concentrations of acetaminophen, clofibric acid, morphine, salicylic acid, temazepam and lamotrigine. Significant decrease in plasma concentration of lamotrigine has been shown, likely due to induction of lamotrigine glucuronidation. This may reduce seizure control; therefore, dosage adjustments of lamotrigine may be necessary.

Women on thyroid hormone replacement therapy may need increased doses of thyroid hormone because the serum concentration of thyroid-binding globulin increases with use of COCs.

7.3 Interference with Laboratory Tests

The use of contraceptive steroids may influence the results of certain laboratory tests, such as coagulation factors, lipids, glucose tolerance, and binding proteins.

7.4 Concomitant Use with HCV Combination Therapy – Liver Enzyme Elevation

Do not co-administer VyLibra with HCV drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to potential for ALT elevations [see Warnings and Precautions (5.3)].

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

There is little or no increased risk of birth defects in women who inadvertently use COCs during early pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb reduction defects) following exposure to low dose COCs prior to conception or during early pregnancy.

Do not administer COCs to induce withdrawal bleeding as a test for pregnancy. Do not use COCs during pregnancy to treat threatened or habitual abortion.

8.3 Nursing Mothers

Advise the nursing mother to use other forms of contraception, when possible, until she has weaned her child. COCs can reduce milk production in breastfeeding mothers. This is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women. Small amounts of oral contraceptive steroids and/or metabolites are present in breast milk.

8.4 Pediatric Use

Safety and efficacy of VyLibra Tablets have been established in women of reproductive age. Efficacy is expected to be the same for post-pubertal adolescents under the age of 18 and for users 18 years and older. Use of this product before menarche is not indicated.

8.5 Geriatric Use

VyLibra has not been studied in postmenopausal women and are not indicated in this population.

8.6 Hepatic Impairment

The pharmacokinetics of VyLibra has not been studied in subjects with hepatic impairment. However, steroid hormones may be poorly metabolized in patients with hepatic impairment. Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal and COC causation has been excluded. [See Contraindications (4) and Warnings and Precautions (5.2).]

8.7 Renal Impairment

The pharmacokinetics of VyLibra has not been studied in women with renal impairment.

10 OVERDOSAGE

There have been no reports of serious ill effects from overdosage of oral contraceptives, including ingestion by children. Overdosage may cause withdrawal bleeding in females and nausea.

11 DESCRIPTION

VyLibra is a combination oral contraceptive containing the progestational compound norgestimate and the estrogenic compound ethinyl estradiol. Norgestimate is designated as (18,19-Dinor-17-pregn-4-en-20-yn-3-one,17-(acetyloxy)-13-ethyl-, oxime,(17α)-(+)-) and ethinyl estradiol is designated as (19-nor-17α-pregna,1,3,5(10)-trien-20-yne-3,17-diol).


Chemical Structure

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

  • Oral Contraception

COCs lower the risk of becoming pregnant primarily by suppressing ovulation. Other possible mechanisms may include cervical mucus changes that inhibit sperm penetration and endometrial changes that reduce the likelihood of implantation.

12.2 Pharmacodynamics

No specific pharmacodynamic studies were conducted with VyLibra.

12.3 Pharmacokinetics

Absorption

Norgestimate (NGM) and EE are rapidly absorbed following oral administration. NGM is rapidly and completely metabolized by first pass (intestinal and/or hepatic) mechanisms to norelgestromin (NGMN) and norgestrel (NG), which are the major active metabolites of norgestimate.

Peak serum concentrations of NGMN and EE are generally reached by 2 hours after administration of VyLibra. Accumulation following multiple dosing of the 250 mcg NGM / 35 mcg EE dose is approximately 2-fold for NGMN and EE compared with single dose administration. The pharmacokinetics of NGMN is dose-proportional following NGM doses of 180 mcg to 250 mcg. Steady-state concentration of EE is achieved by Day 7 of each dosing cycle. Steady-state concentrations of NGMN and NG are achieved by Day 21. Non-linear accumulation (approximately 8 fold) of NG is observed as a result of high-affinity binding to SHBG, which limits its biological activity (Table 3).

Table 3: Summary of NGMN, NG and EE pharmacokinetic parameters.
Cmax = peak serum concentration, tmax = time to reach peak serum concentration, AUC0-24h = area under serum concentration vs. time curve from 0 to 24 hours, t1/2 = elimination half-life, NC = not calculated.
NGMN and NG: Cmax = ng/mL, AUC0-24h = h•ng/mL
EE: Cmax = pg/mL, AUC0-24h = h•pg/mL
 Mean (SD) Pharmacokinetic Parameters of VyLibra During a Three Cycle Study
 Analyte
 Cycle
 Day
 Cmax
 tmax (h)
 AUC0-24h
 t1/2 (h)
 NGMN
 1
 1
 1.78 (0.397)
 1.19 (0.250)
 9.90 (3.25)
 18.4 (5.91)
 
 3
 21
 2.19 (0.655)
 1.43 (0.680)
 18.1 (5.53)
 24.9 (9.04)
 NG
 1
 1
 0.649 (0.49)
 1.42 (0.69)
 6.22 (2.46)
 37.8 (14.0)
 
 3
 21
 2.65 (1.11)
 1.67 (1.32)
 48.2 (20.5)
 45.0 (20.4)
 EE
 1
 1
 92.2 (24.5)
 1.2 (0.26)
 629 (138)
 10.1 (1.90)
 
 3
 21
 147 (41.5)
 1.13 (0.23)
 1210 (294)
 15 (2.36)

Food Effect

The effect of food on the pharmacokinetics of VyLibra has not been studied.

Distribution

NGMN and NG are highly bound (>97%) to serum proteins. NGMN is bound to albumin and not to SHBG, while NG is bound primarily to SHBG. EE is extensively bound (>97%) to serum albumin and induces an increase in the serum concentrations of SHBG.

Metabolism

NGM is extensively metabolized by first-pass mechanisms in the gastrointestinal tract and/or liver. NGM’s primary active metabolite is NGMN. Subsequent hepatic metabolism of NGMN occurs and metabolites include NG, which is also active, and various hydroxylated and conjugated metabolites. Although NGMN and its metabolites inhibit a variety of P450 enzymes in human liver microsomes, under the recommended dosing regimen, the in vivo concentrations of NGMN and its metabolites, even at the peak serum levels, are relatively low compared to the inhibitory constant (Ki). EE is also metabolized to various hydroxylated products and their glucuronide and sulfate conjugates.

Excretion

The metabolites of NGMN and EE are eliminated by renal and fecal pathways. Following administration of 14C-norgestimate, 47% (45 to 49%) and 37% (16 to 49%) of the administered radioactivity was eliminated in the urine and feces, respectively. Unchanged NGM was not detected in the urine. In addition to 17-deacetyl norgestimate, a number of metabolites of NGM have been identified in human urine following administration of radiolabeled NGM. These include 18, 19-Dinor-17-pregn-4-en-20-yn-3-one,17-hydroxy-13-ethyl,(17α)-(-);18,19-Dinor-5β-17-pregnan-20-yn,3α,17β-dihydroxy-13-ethyl,(17α), various hydroxylated metabolites and conjugates of these metabolites.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

[See Warnings and Precautions (5.25.11) and Use in Specific Populations (8.1).]

14 CLINICAL STUDIES

14.1 Contraception

In three U.S. clinical trials with VyLibra, 1,651 women aged 18 to 38 years were studied for up to 24 cycles, proving a total of 24,272 cycles of exposure. The racial demographic was about 73 to 86% Caucasian, 8 to 13% African-American, 6 to 14% Hispanic with the remainder Asian or Other (≤1%). There were no exclusions on the basis of weight; the weight range for women treated was 82 to 303 lbs, with a mean weight of about 135 lbs. The pregnancy rate was approximately 1 pregnancy per 100 women-years.

16 HOW SUPPLIED/STORAGE AND HANDLING

16.1 How Supplied

VyLibra  (norgestimate and ethinyl estradiol tablets USP 0.250 mg/0.035 mg) are available in a blister pack.


Each blister pack (28 tablets) contains in the following order:


  • 21 dark blue, round, biconvex, coated tablet debossed with “S” on one side and “22” on other side of the tablet contains 0.250 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 green round, mottled, biconvex, uncoated tablets, debossed with “S” on one side and “24” on other side of the tablet contains inert ingredients

The blister packs are available in the following packages:

  • The Blister Packs are packaged in mono cartons

Carton of 1 Blister Pack                                                                NDC 50102-235-11

Carton of 3 Blister Packs packaged in mono cartons             NDC 50102-235-13

16.2 Storage Conditions

  • Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature].
  • Protect from light.
  • Keep out of the reach of children.

17 PATIENT COUNSELING INFORMATION

See FDA-approved patient labeling (Patient Information and Instructions for Use).

Counsel patients about the following information:

Patient Information

VyLibra (Norgestimate and Ethinyl Estradiol Tablets USP 0.250 mg/0.035 mg)

What is the most important information I should know about VyLibra?

Do not use VyLibra if you smoke cigarettes and are over 35 years old.
Smoking increases your risk of serious cardiovascular side effects from hormonal birth control pills, including death from heart attack, blood clots or stroke. This risk increases with age and the number of cigarettes you smoke.

What is VyLibra

VyLibra is a birth control pill (oral contraceptive) used by women to prevent pregnancy.

How does 
VyLibra work for contraception?

Your chance of getting pregnant depends on how well you follow the directions for taking your birth control pills. The better you follow the directions, the less chance you have of getting pregnant.

Based on the results of clinical studies, about 1 out of 100 women may get pregnant during the first year they use VyLibra.

The following chart shows the chance of getting pregnant for women who use different methods of birth control. Each box on the chart contains a list of birth control methods that are similar in effectiveness. The most effective methods are at the top of the chart. The box on the bottom of the chart shows the chance of getting pregnant for women who do not use birth control and are trying to get pregnant.

fig3

Who should not take
VyLibra?

Do not take VyLibra if you:


If any of these conditions happen while you are taking VyLibra, stop taking VyLibra right away and talk to your healthcare provider. Use non-hormonal contraception when you stop taking VyLibra.

What should I tell my healthcare provider before taking VyLibra?

Tell your healthcare provider if you:


Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements.

VyLibra may affect the way other medicines work, and other medicines may affect how well VyLibra works.

Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine.

How should I take VyLibra?

Read the Instructions for Use
at the end of this Patient Information.

What are the possible serious side effects of VyLibra?


Serious blood clots can happen especially if you smoke, are obese, or are older than 35 years of age. Serious blood clots are more likely to happen when you:


Call your healthcare provider or go to a hospital emergency room right away if you have:

Other serious side effects include:

What are the most common side effects of VyLibra?


These are not all the possible side effects of VyLibra. For more information, ask your healthcare provider or pharmacist.

You may report side effects to the FDA at 1-800-FDA-1088.

What else should I know about taking VyLibra?


How should I store VyLibra?


General information about the safe and effective use of VyLibra.

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use VyLibra for a condition for which it was not prescribed. Do not give VyLibra to other people, even if they have the same symptoms that you have.

This Patient Information summarizes the most important information about VyLibra. You can ask your pharmacist or healthcare provider for information about VyLibra that is written for health professionals.

For more information, call Afaxys Pharma LLC at 1-855-888-2467

Do birth control pills cause cancer?

Birth control pills do not seem to cause breast cancer. However, if you have breast cancer now, or have had it in the past, do not use birth control pills because some breast cancers are sensitive to hormones.

Women who use birth control pills may have a slightly higher chance of getting cervical cancer. However, this may be due to other reasons such as having more sexual partners.

What if I want to become pregnant?

You may stop taking the pill whenever you wish. Consider a visit with your healthcare provider for a pre-pregnancy checkup before you stop taking the pill.

What should I know about my period when taking VyLibra?

Your periods may be lighter and shorter than usual. Some women may miss a period. Irregular vaginal bleeding or spotting may happen while you are taking VyLibra, especially during the first few months of use. This usually is not a serious problem. It is important to continue taking your pills on a regular schedule to prevent a pregnancy.

What are the ingredients in VyLibra?

Active ingredients:
Each dark blue pill contains norgestimate and ethinyl estradiol.

Inactive ingredients:

Dark blue pills: croscarmellose sodium, FD&C #2/Indigo carmine aluminum lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, and titanium dioxide.

Green pills: Anhydrous lactose, FD&C Blue No. 2 aluminum lake, ferric oxide yellow, magnesium stearate, microcrystalline cellulose, and povidone.

Instructions For Use

VyLibra (Norgestimate and Ethinyl Estradiol Tablets USP 0.250 mg/0.035 mg)

Important Information about taking VyLibra

Before you start taking VyLibra:


When should I start taking VyLibra?

If you start taking VyLibra and you have not used a hormonal birth control method before:


If you start taking VyLibra and you are switching from another birth control pill:


If you start taking VyLibra and previously used a vaginal ring or transdermal patch:


If you start taking VyLibra and you are switching from a progestin-only method such as an implant or injection:


If you start taking VyLibra and you are switching from an intrauterine device or system (IUD or IUS):


Keep a calendar to track your period:

If this is the first time
you are taking birth control pills, read, “When should I start taking VyLibra?” above. Follow these instructions for either a Sunday Start or a Day 1 Start.

Sunday Start:

You will use a Sunday Start if your healthcare provider told you to take your first pill on a Sunday.


Day 1 Start:


You will use a Day 1 Start if your doctor told you to take your first pill (Day 1) on the first day of your period.


How to Use the Blister Pack:

There are two ways to start taking birth control pills, Sunday Start or Day 1 Start. Your healthcare professional will tell you which to use.

1. Pick the Days of the Week Sticker that starts the first day of your period. (This is the day you begin bleeding or spotting, even if it is midnight when bleeding begins.) When you have picked the right sticker, throw away the others and place the sticker on the blister pack over the preprinted days of the week and make sure it lines up with the pills.


fig4


2. Your blister pack containing 28 individually sealed pills. Note that the pills are arranged in four numbered rows of 7 pills, with the pre-printed days of the week printed above them. There are 21 dark blue “active” pills and 7 green “reminder” pills. Refer to the sample of the blister pack below:


fig5


3. After taking the last green pill, start a new blister pack the very next day no matter when your period started. You will be taking a pill every day without interruption. Anytime you start the pills later than directed, protect yourself by using another method of birth control until you have taken a pill a day for seven consecutive days. After taking the last green pill, start taking the first dark blue pill from the blister pack the very next day.

4. Take the pills in each new package as before. Start with the dark blue pill on row #1 and take one pill each day, left to right, until the last green pill has been taken.

Three Ways to Remember in What Order to take the Pills

1. Follow the sticker with the days of the week (placed above the pills).
2. Always go from left to right.
3. Always finish all your pills.

What should I do if I miss any 
VyLibra pills?

If you miss 1 pill in Weeks 1, 2, or 3, follow these steps:


If you miss 2 pills in Week 1 or Week 2 of your pack, follow these steps:


If you miss 2 pills in a row in Week 3, or you miss 3 or more pills in a row during Weeks 1, 2, or 3 of the pack, follow these steps:


If you have any questions or are unsure about the information in this leaflet, call your healthcare provider.

Manufactured For:
Afaxys Pharma LLC
Charleston, SC, 29403, USA.
Made in India

Code: TS/DRUGS/22/2009

This Patient Information and Instructions for Use has been approved by the U.S. Food and Drug Administration.

Issued: 11/2017

PACKAGE LABEL-PRINCIPAL DISPLAY PANEL - 0.250 mg/0.035 mg Pouch Carton Label

NDC 50102-235-11

VyLibraTM

(norgestimate and ethinyl estradiol tablets USP)

0.250 mg/0.035 mg

Each dark blue coated tablet contains norgestimate USP 0.250 mg and ethinyl

estradiol USP 0.035 mg. Each green tablet contains inert ingredients.

This product (like all oral contraceptives) is intended to prevent pregnancy. It does not protect against HIV infection (AIDS) and other sexually transmitted diseases. One Blister Card of 28 tablets each


PACKAGE LABEL-PRINCIPAL DISPLAY PANEL - 0.250 mg/0.035 mg Pouch Carton Label
VYLIBRA 
norgestimate and ethinyl estradiol kit
Product Information
Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:50102-235
Packaging
# Item Code Package Description Marketing Start Date Marketing End Date
1 NDC:50102-235-11 1 in 1 CARTON 07/07/2016
1 1 in 1 BLISTER PACK; Type 0: Not a Combination Product
2 NDC:50102-235-13 3 in 1 CARTON 07/07/2016
2 1 in 1 BLISTER PACK; Type 0: Not a Combination Product
Quantity of Parts
Part # Package Quantity Total Product Quantity
Part 1 21 
Part 2
Part 1 of 2
VYLIBRA 
norgestimate and ethinyl estradiol tablet, coated
Product Information
Route of Administration ORAL
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NORGESTIMATE (UNII: C291HFX4DY) (NORGESTIMATE - UNII:C291HFX4DY) NORGESTIMATE 0.250 mg
ETHINYL ESTRADIOL (UNII: 423D2T571U) (ETHINYL ESTRADIOL - UNII:423D2T571U) ETHINYL ESTRADIOL 0.035 mg
Inactive Ingredients
Ingredient Name Strength
CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)  
HYPROMELLOSE 2910 (6 MPA.S) (UNII: 0WZ8WG20P6)  
LACTOSE MONOHYDRATE (UNII: EWQ57Q8I5X)  
MAGNESIUM STEARATE (UNII: 70097M6I30)  
MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
POLYETHYLENE GLYCOL 400 (UNII: B697894SGQ)  
TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
Product Characteristics
Color BLUE (Dark Blue) Score no score
Shape ROUND (Biconvex) Size 5mm
Flavor Imprint Code S;22
Contains     
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205449 07/07/2016
Part 2 of 2
INERT 
inert tablet
Product Information
Route of Administration ORAL
Inactive Ingredients
Ingredient Name Strength
ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)  
FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
MAGNESIUM STEARATE (UNII: 70097M6I30)  
MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
POVIDONE K29/32 (UNII: 390RMW2PEQ)  
Product Characteristics
Color GREEN Score no score
Shape ROUND (Mottled Biconvex) Size 5mm
Flavor Imprint Code S;24
Contains     
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205449 07/07/2016
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205449 07/07/2016
Labeler - Afaxys Pharma, LLC (080508656)
Registrant - Aurobindo Pharma Limited (650082092)
Establishment
Name Address ID/FEI Business Operations
Aurobindo Pharma Limited 650381903 ANALYSIS(50102-235) , MANUFACTURE(50102-235)

Revised: 12/2017
Document Id: 13bdc226-ecf8-4fd7-aa0e-ec19b6b74fc3
Set id: 13bdc226-ecf8-4fd7-aa0e-ec19b6b74fc3
Version: 1
Effective Time: 20171222
 
Afaxys Pharma, LLC