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Tri-Mili

Generic Name: norgestimate and ethinyl estradiol
Dosage Form: tablets

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)].

Indications and Usage for Tri-Mili

Oral Contraceptive

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

Acne

Tri-Mili is indicated for the treatment of moderate acne vulgaris in females at least 15 years of age, who have no known contraindications to oral contraceptive therapy and have achieved menarche. Tri-Mili should be used for the treatment of acne only if the patient desires an oral contraceptive for birth control [see Clinical Studies (14)].

DOSAGE AND ADMINISTRATION

How to Start Tri-Mili

Tri-Mili is  available in blister pack [see How Supplied/Storage and Handling (16)]. Tri-Mili 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.

How to Take Tri-Mili


Table 1: Instructions for Administration of Tri-Mili
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:
  • Tri-Mili active tablets are white (Day 1 to Day 7), light blue (Day 8 to Day 15) and dark blue (Day 16 to Day 21).
 
  • Tri-Mili 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 Tri-Mili.
  • 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 Tri-Mili 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         Tri-Mili
Start Tri-Mili:
 
● 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 Tri-Mili after Abortion or Miscarriage


First-trimester


  • After a first-trimester abortion or miscarriage, Tri-Mili may be started immediately. An additional method of contraception is not needed if Tri-Mili is started immediately.
  • If Tri-Mili 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 Tri-Mili.

Second-trimester

  • Do not start until 4 weeks after a second-trimester abortion or miscarriage, due to the increased risk of thromboembolic disease.Start Tri-Mili, 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 Tri-Mili. [See Contraindications (4), Warnings and Precautions (5.1), and FDA-Approved Patient Labeling.]

Starting Tri-Mili 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.

 

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 7 white “active” pills, 7 light blue “active” pills, 7 dark blue “active” pills, and 7 green “reminder” pills. Refer to the sample of the blister pack below:


 

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 white pill from the blister pack the very next day.


4. Take the pills in each new package as before. Start with the white 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.

Missed Tablets

Table 2: Instructions for Missed Tri-Mili 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.

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].

Tri-Mili Use for Acne

The timing of initiation of dosing with Tri-Mili  for acne should follow the guidelines for use of Tri-Mili  as an oral contraceptive. Consult the DOSAGE AND ADMINISTRATION section (2.1) for instructions.

DOSAGE FORMS AND STRENGTHS

Tri-Mili tablets are available in blister packs. Each blister pack contains 28 tablets in the following order:


  • 7 white, round, biconvex, coated tablets, debossed with “S” on one side and “19” on other side of the tablet contains 0.180 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 light blue, round, biconvex, coated tablets, debossed with “S” on one side and “21” on other side of the tablet contains 0.215 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 dark blue, round, biconvex, coated tablets, 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 (non-hormonal placebo) debossed with “S” on one side and “24” on other side of the tablet contains inert ingredients

Contraindications

Do not prescribe Tri-Mili to women who are known to have the following conditions:


Warnings and Precautions

Thromboembolic Disorders and Other Vascular Problems

  • Stop Tri-Mili if an arterial thrombotic event or venous thromboembolic (VTE) event occurs.
  • Stop Tri-Mili 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 Tri-Mili  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 Tri-Mili 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.

Liver Disease

Impaired Liver Function


Do not use Tri-Mili 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 Tri-Mili if jaundice develops.


Liver Tumors


Tri-Mili 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.

High Blood Pressure

Tri-Mili 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 Tri-Mili 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.

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.

Carbohydrate and Lipid Metabolic Effects

Carefully monitor prediabetic and diabetic women who take Tri-Mili. 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.

Headache

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


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

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 Tri-Mili, the frequency and duration of breakthrough bleeding and/or spotting was assessed in 4,826 patients (35,546 evaluable cycles). A total of 231 (4.8%) women discontinued Tri-Mili, at least in part, due to bleeding or spotting. Based on data from the clinical trials, 13 to 38% of women using Tri-Mili 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 Tri-Mili 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.

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 Tri-Mili 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)].

Depression

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

Carcinoma of Breast and Cervix

  • Tri-Mili 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.

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.

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.

Hereditary Angioedema

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

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 Tri-Mili.

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:


  • Irregular uterine bleeding
  • Nausea
  • Breast tenderness
  • Headache

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 Tri-Mili was evaluated in 4,826 healthy women of child-bearing potential  who  participated  in  6  clinical  trials  and  received  at  least  1  dose  of Tri-Mili for contraception. Two trials were randomized active-controlled trials and 4 were uncontrolled open-label trials. In 3 trials, subjects were followed for up to 24 cycles; in 2 trials, subjects were followed for up to 12 cycles; and in 1 trial, subjects were followed for up to 6 cycles.


Common Adverse Reactions (≥ 2% of subjects): The most common adverse reactions reported by at least 2% of the 4,826 women were the following in order of decreasing incidence: headache/migraine (33.6%), breast issues (including breast pain, enlargement, and discharge) (8.0%), vaginal infection (7.1%), abdominal/gastrointestinal pain (5.6%), mood disorders (including mood alteration and depression) (3.8%), genital discharge (3.2%), and changes in weight (including weight fluctuation, increased or decreased) (2.5%).


Adverse Reactions Leading to Study Discontinuation: Over the trials, between 9 to 27% of subjects discontinued the trial due to an adverse reaction. The most common adverse reactions (≥1%) leading to discontinuation were: metrorrhagia (4.3%), nausea/vomiting (2.8%), headache/migraine (2.4%), mood disorders (including depression and mood altered) (1.1%), and weight increased (1.1%).


Serious Adverse Reactions: breast cancer (1 subject), carcinoma of the cervix in situ (1 subject), hypertension (1 subject), and migraine (2 subjects).

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.

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 Tri-Mili.

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]).

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.

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.

USE IN SPECIFIC POPULATIONS

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.

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.

Pediatric Use

Safety and efficacy of Tri-Mili 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.


There was no significant difference between Tri-Mili tablets and placebo in mean change in total lumbar spine (L1-L4) and total hip bone mineral density between baseline and Cycle 13 in 123 adolescent females with anorexia nervosa in a double-blind, placebo-controlled, multicenter, one-year treatment duration clinical trial for the Intent To Treat (ITT) population.

Geriatric Use

Tri-Mili has not been studied in postmenopausal women and is not indicated in this population.

Hepatic Impairment

The pharmacokinetics of Tri-Mili 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).]

Renal Impairment

The pharmacokinetics of Tri-Mili has not been studied in women with renal impairment.

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.

Tri-Mili Description

Tri-Mili 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).


Each active white tablet contains 0.180 mg of norgestimate USP and 0.035 mg of ethinyl estradiol USP. Inactive ingredients include croscarmellose sodium, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, and titanium dioxide.


Each active light blue tablet contains 0.215 mg of norgestimate USP and 0.035 mg of ethinyl estradiol USP. Inactive ingredients include croscarmellose sodium, FD&C #2/Indigo carmine aluminum lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, and titanium dioxide.


Each active dark blue tablet contains 0.250 mg of norgestimate USP and 0.035 mg of ethinyl estradiol USP. Inactive ingredients include croscarmellose sodium, FD&C #2/Indigo carmine aluminum lake, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, and titanium dioxide.


Each green tablet contains only inert ingredients, as follows: anhydrous lactose, FD&C Blue No. 2 aluminum lake, ferric oxide yellow, magnesium stearate, microcrystalline cellulose, and povidone.


Tri-Mili - Clinical Pharmacology

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.


  • Acne

Acne is a skin condition with a multifactorial etiology, including androgen stimulation of sebum production. While the combination of ethinyl estradiol and norgestimate increases sex hormone-binding globulin (SHBG) and decreases free testosterone, the relationship between these changes and a decrease in the severity of facial acne in otherwise healthy women with this skin condition has not been established.


Pharmacodynamics

No specific pharmacodynamic studies were conducted with Tri-Mili.

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 Tri-Mili. 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 Tri-Mili  During a Three CycleStudy
Analyte
Cycle
Day
Cmax
tmax (h)
AUC0-24h
t1/2 (h)
NGMN
3
7
1.80 (0.46)
1.42 (0.73)
15.0 (3.88)
NC
 
 
14
2.12 (0.56)
1.21 (0.26)
16.1 (4.97)
NC
 
 
21
2.66 (0.47)
1.29 (0.26)
21.4 (3.46)
22.3 (6.54)
NG
3
7
1.94 (0.82)
3.15 (4.05)
34.8 (16.5)
NC
 
 
14
3.00 (1.04)
2.21 (2.03)
55.2 (23.5)
NC
 
 
21
3.66 (1.15)
2.58 (2.97)
69.3 (23.8)
40.2 (15.4)
EE
3
7
124 (39.5)
1.27 (0.26)
1130 (420)
NC
 
 
14
128 (38.4)
1.32 (0.25)
1130 (324)
NC
 
 
21
126 (34.7)
1.31 (0.56)
1090 (359)
15.9 (4.39)

Food Effect

The effect of food on the pharmacokinetics of Tri-Mili 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% (45to 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.

Nonclinical Toxicology

Carcinogenesis,  Mutagenesis,  Impairment of Fertility

[See Warnings and Precautions (5.2, 5.10) and Use in Specific Populations (8.1).]

Clinical Studies

Contraception

In four clinical trials with Tri-Mili, 4,756 women aged 15 to 41 years were studied for 24 cycles, providing a total of 45,244 cycles of exposure. The racial demographic was about 87 to 90% Caucasian, 6 to 10% African-American, with the remainder Asian (≤1%) or Other (2 to 5%). There were no exclusions on the basis of weight; the weight range for women treated was 80 to 310 lbs, with a mean weight of about 132 lbs. The pregnancy rate was approximately 1 pregnancy per 100 women-years.

Acne

Tri-Mili was evaluated for the treatment of acne vulgaris in two randomized, double-blind, placebo-controlled, multicenter, six- (28 day) cycle studies. Two hundred twenty-one patients received Tri-Mili and 234 patients received placebo. Mean age at enrollment for both groups was 28 years. At the end of 6 months, the mean total lesion count changed from 55 to 31 (42% reduction) in patients treated with Tri-Mili and from 54 to 38 (27% reduction) in patients similarly treated with placebo. Table 4 summarizes the changes in lesion count for each type of lesion. Based on the investigator’s global assessment conducted at the final visit, patients treated with Tri-Mili showed a statistically significant improvement in total lesions compared to those treated with placebo.

Table 4: Acne Vulgaris Indication. Combined Results: Two Multicenter, Placebo-Controlled Trials. Observed Means at Six Months (LOCF)* and at Baseline. Intent-to-Treat Population.
*LOCF: Last Observation Carried Forward
 
Tri-Mili
(N=221)
Placebo
(N=234)
Difference in Counts between Tri-Mili
  and Placebo at 6 Months
# of Lesions
Counts
% Reduction
Counts
% Reduction
 
INFLAMMATORY LESIONS
 
 
 
 
 
  Baseline Mean
19
 
19
 
 
  Sixth Month Mean
10
48%
13
30%
3 (95% CI: -1.2, 5.1)
NON-INFLAMMATORY LESIONS
 
 
 
 
 
  Baseline Mean
36
 
35
 
 
  Sixth Month Mean
22
34%
25
21%
3 (95% CI: -0.2, 7.8)
TOTAL LESIONS
 
 
 
 
 
  Baseline Mean
55
 
54
 
7 (95% CI: 2.0, 11.9) 
  Sixth Month Mean
31
42%
38
27%

How Supplied/Storage and Handling

How Supplied

Tri-Mili tablets are available in a blister pack.


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


  • 7 white, round, biconvex, coated tablets, debossed with “S” on one side and “19” on other side of the tablet contains 0.180 mg norgestimate USP and 0.035 mg ethinyl estradiol USP
  • 7 light blue, round, biconvex, coated tablets, debossed with “S” on one side and “21” on other side of the tablet contains 0.215 mg norgestimate USP and 0.035 mg ethinyl estradiol USP
  • 7 dark blue, round, biconvex, coated tablets, debossed with “S” on one side and “22” on other side of the tablet contains 0.250 mg norgestimate USP and 0.035 mg ethinyl estradiol USP
  • 7 green, round, mottled biconvex, uncoated tablets (non-hormonal Placebo), debossed with “S” on one side and “24” on other side of the tablet.

The blister packs are available in the following packages:


•  The blister packs are packaged in mono cartons


            Carton of 1 Blister Pack                                         NDC 65862-777-28
            Carton of 3 Blister packaged in mono cartons       NDC 65862-777-85
            Carton of 6 Blister packaged in mono cartons       NDC 65862-777-86

           

•  The blister packs are packed in pouches and the pouches are packaged in cartons

           

            Carton of 1 Pouch                                       NDC 65862-777-87
            Carton of 3 Pouches                                    NDC 65862-777-88
            Carton of 6 Pouches                                    NDC 65862-777-92 

Keep out of reach of children.

Storage Conditions

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

Patient Counseling Information

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

Counsel patients about the following information:


  • Cigarette smoking increases the risk of serious cardiovascular events from COC use, and that women who are over 35 years old and smoke should not use COCs [see  Boxed Warning].
  • Increased risk of VTE compared to non-users of COCs is greatest after initially starting a COC or restarting (following a 4-week or greater pill-free interval) the same or a different COC [see Warnings and Precautions (5.1)].
  • Tri-Mili does not protect against HIV infection (AIDS) and other sexually transmitted infections.
  • Tri-Mili is not to be used during pregnancy; if pregnancy occurs during use of Tri-Mili instruct the patient to stop further use [see Warnings and Precautions (5.8)].
  • Take one tablet daily by mouth at the same time every day. Instruct patients what to do in the event tablets are missed [see Dosage and Administration (2.2)].
  • Use a back-up or alternative method of contraception when enzyme inducers are used with Tri-Mili [see Drug Interactions (7.1)].
  • COCs may reduce breast milk production; this is less likely to occur if breastfeeding is well established [see Use in Specific Populations (8.3)].
  • Women who start COCs postpartum, and who have not yet had a period, should use an additional method of contraception until they have taken an active tablet for 7 consecutive days [see Dosage and Administration (2.2)].
  • Amenorrhea may occur. Consider pregnancy in the event of amenorrhea at the time of the first missed period. Rule out pregnancy in the event of amenorrhea in two or more consecutive cycles [see Warnings and Precautions (5.7)].

Manufactured for:
Aurobindo Pharma USA, Inc.
2400 Route 130 North
Dayton, NJ 08810

Manufactured by:
Aurobindo Pharma Limited
Unit-VII (SEZ)
Mahaboob Nagar (Dt)-509302
India

Issued: November 2015

Patient Information

Tri-Mili (trahy-mil-ee)
(norgestimate and ethinyl estradiol tablets USP)

What is the most important information I should know about Tri-Mili?


Do not use Tri-Mili 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 Tri-Mili?


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

Tri-Mili is also used to treat moderate acne vulgaris in females 15 years of age and older, who have no known history of allergies or problems taking birth control pills, and have started their menstrual cycle (“period”). Tri-Mili should only be used to treat acne in women who want to take birth control pills to prevent pregnancy.

How does Tri-Mili 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 Tri-Mili.

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.



Who should not take Tri-Mili?

D
o not take Tri-Mili if you:


  • smoke and are over 35 years of age
  • had blood clots in your arms, legs, lungs, or eyes
  • had a problem with your blood that makes it clot more than normal
  • have certain heart valve problems or irregular heart beat that increases your risk of having blood clots
  • had a stroke
  • had a heart attack
  • have high blood pressure that cannot be controlled by medicine
  • have diabetes with kidney, eye, nerve, or blood vessel damage
  • have certain kinds of severe migraine headaches with aura, numbness, weakness or changes in vision, or any migraine headaches if you are over 35 years of age
  • have liver problems, including liver tumors
  • have any unexplained vaginal bleeding
  • are pregnant
  • had breast cancer or any cancer that is sensitive to female hormones

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

What should I tell my healthcare provider before taking Tri-Mili?


Tell your healthcare provider if you:


  • are pregnant or think you may be pregnant
  • are depressed now or have been depressed in the past
  • had  yellowing  of your  skin  or  eyes  (jaundice)  caused  by  pregnancy (cholestasis of pregnancy)
  • are breastfeeding or plan to breastfeed. Tri-Mili may decrease the amount of breast milk you make. A small amount of the hormones in Tri-Mili may pass into your  breast milk. Talk to your healthcare provider about the best birth control method for you while breastfeeding.

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

Tri-Mili may affect the way other medicines work, and other medicines may affect how well Tri-Mili 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 Tri-Mili? 

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

What are the possible serious side effects of Tri-Mili?


  • Like pregnancy, Tri-Mili may cause serious side effects, including blood clots in your lungs, heart attack, or a stroke that may lead to death. Some other examples of serious blood clots include blood clots in the legs or eyes.

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:


  • first start taking birth control pills
  • restart the same or different birth control pills after not using them for a month or more

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


  • leg pain that will not go away     
  • sudden severe shortness of breath
  • sudden change in vision or blindness
  • chest pain
  • a sudden, severe headache unlike your usual headaches
  • weakness or numbness in your arm or leg
  • trouble speaking

Other serious side effects include:


  • liver problems, including:
    • rare liver tumors
    • jaundice (cholestasis), especially if you previously had cholestasis of pregnancy. Call your healthcare provider if you have yellowing of your skin or eyes.
  • high blood pressure. You should see your healthcare provider for a yearly check of your blood pressure.
  • gallbladder problems
  • changes in the sugar and fat (cholesterol and triglycerides) levels in your blood
  • new or worsening headaches including migraine headaches
  • irregular or unusual vaginal bleeding and spotting between your menstrual periods, especially during the first 3 months of taking Tri-Mili.
  • depression
  • possible cancer in your breast and cervix
  • swelling of your skin especially around your mouth, eyes, and in your throat (angioedema). Call your healthcare provider if you have a swollen face, lips, mouth tongue or throat, which may lead to difficulty swallowing or breathing. Your chance of having angioedema is higher is you have a history of angioedema.
  • dark patches of skin around your forehead, nose, cheeks and around your mouth, especially during pregnancy (chloasma). Women who tend to get chloasma should avoid spending a long time in sunlight, tanning booths, and under sun lamps while taking Tri-Mili. Use sunscreen if you have to be in the sunlight.

What are the most common side effects of Tri-Mili?


  • headache (migraine)
  • breast pain or tenderness, enlargement or discharge
  • stomach pain, discomfort, and gas
  • vaginal infections and discharge
  • mood changes, including depression
  • nervousness
  • changes in weight
  • skin rash

These are not all the possible side effects of Tri-Mili. 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 Tri-Mili?


  • If you are scheduled for any lab tests, tell your healthcare provider you are taking Tri-Mili. Certain blood tests may be affected by Tri-Mili.
  • Tri-Mili does not protect against HIV infection (AIDS) and other sexually transmitted infections.

How should I store Tri-Mili?


  • Store Tri-Mili at room temperature between 20° to 25°C (68° to 77°F).
  • Keep Tri-Mili and all medicines out of the reach of children.
  • Store away from light.

General information about the safe and effective use of Tri-Mili.

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

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

For more information, call Aurobindo Pharma USA, Inc. at 1-866-850-2876

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 Tri-Mili?


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 Tri-Mili, 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 Tri-Mili?


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

Inactive ingredients:

White pills: croscarmellose sodium, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, and titanium dioxide.

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

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

Tri-Mili (trahy-mil-ee)
(norgestimate and ethinyl estradiol tablets USP)

Impo
rtant Information about taking Tri-Mili


  • Take 1 pill every day at the same time. Take the pills in the order directed on your blister pack.
  • Do not skip your pills, even if you do not have sex often. If you miss pills (including starting the pack late) you could get pregnant. The more pills you miss, the more likely you are to get pregnant.
  • If you have trouble remembering to take Tri-Mili, talk to your healthcare provider. When you first start taking Tri-Mili, spotting or light bleeding in between your periods may occur. Contact your healthcare provider if this does not go away after a few months.
  • You may feel sick to your stomach (nauseous), especially during the first few months of taking Tri-Mili. If you feel sick to your stomach, do not stop taking the pill. The problem will usually go away. If your nausea does not go away, call your healthcare provider.
  • Missing pills can also cause spotting or light bleeding, even when you take the missed pills later. On the days you take 2 pills to make up for missed pills (see What should I do if I miss any Tri-Mili pills? below), you could also feel a little sick to your stomach.
  • It is not uncommon to miss a period. However, if you miss a period and have not taken Tri-Mili according to directions, or miss 2 periods in a row, or feel like you may be pregnant, call your healthcare provider. If you have a positive pregnancy test, you should stop taking Tri-Mili.
  • If you have vomiting or diarrhea within 3 to 4 hours of taking your pill, take another pill of the same color from your extra blister pack. If you do not have an extra blister pack, take the next pill in your blister pack. Continue taking all your remaining pills in order. Start the first pill of your next blister pack the day after finishing your current blister pack. This will be 1 day earlier than originally scheduled. Continue on your new schedule.
  • If you have vomiting or diarrhea for more than 1 day, your birth control pills may not work as well. Use an additional birth control method, like condoms and a spermicide, until you check with your healthcare provider.
  • Stop taking Tri-Mili at least 4 weeks before you have major surgery and do not restart after the surgery without asking your healthcare provider. Be sure to use other forms of contraception (like condoms and spermicide) during this time period.

Before you start taking Tri-Mili:


  • Decide what time of day you want to take your pill. It is important to take it at the same time every day and in the order as directed on your blister pack.
  • Have backup contraception (condoms and spermicide) available and if possible, an extra full pack of pills as needed.

When should I start taking Tri-Mili?

If you start taking Tri-Mili and you have not used a hormonal birth control method before:


  • There are 2 ways to start taking your birth control pills. You can either start on a Sunday (Sunday Start) or on the first day (Day 1) of your natural menstrual period (Day 1 Start). Your healthcare provider should tell you when to start taking your birth control pill.
  • If you use the Sunday Start, use non-hormonal back-up contraception such as condoms and spermicide for the first 7 days that you take Tri-Mili. You do not need back-up contraception if you use the Day 1 Start.

If you start taking Tri-Mili and you are switching from another birth control pill:


  • Start your new Tri-Mili pack on the same day that you would start the next pack of your previous birth control method.
  • Do not continue taking the pills from your previous birth control pack.

If you start taking Tri-Mili and previously used a vaginal ring or transdermal patch:


  • Start using Tri-Mili on the day you would have reapplied the next ring or patch.

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


  • Start taking Tri-Mili on the day of removal of your implant or on the day when you would have had your next injection.

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


  • Start taking Tri-Mili on the day of removal of your IUD or IUS.
  • You do not need back-up contraception if your IUD or IUS is removed on the first day (Day 1) of your period.  If your IUD or IUS is removed on any other day, use non-hormonal back-up contraception such as condoms and spermicide for the first 7 days that you take Tri-Mili.

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 Tri-Mili?”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.

  • Take pill 1 on the Sunday after your period starts.
  • If your period starts on a Sunday, take pill “1” that day and refer to Day 1 Start instructions below.
  • Take 1 pill every day in the order on the blister pack at the same time each day for 28 days.
  • After taking the last pill on Day 28 from the blister pack, start taking the first pill from a new pack, on the same day of the week as the first pack (Sunday). Take the first pill in the new pack whether or not you are having your period.
  • Use non-hormonal back-up contraception such as condoms and spermicide for the first 7 days of the first cycle that you take Tri-Mili.

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.


  • Take 1 pill every day in the order of the blister pack, at the same time each day, for 28 days.
  • After taking the last pill on Day 28 from the blister pack, start taking the first pill from a new pack, on the same day of the week as the first pack. Take the first pill in the new pack whether or not you are having 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.



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 7 white “active” pills, 7 light blue “active” pills, 7 dark blue “active” pills, and 7 green “reminder” pills. Refer to the sample of the blister pack below:



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 white pill from the blister pack the very next day.

4. Take the pills in each new package as before. Start with the white 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 Tri-Mili pills?

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


  • Take it as soon as you remember. Take the next pill at your regular time. This means you may take 2 pills in 1 day.
  • Then continue taking 1 pill every day until you finish the pack.
  • You do not need to use a back-up birth control method if you have sex.

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


  • Take the 2 missed pills as soon as possible and the next 2 pills the next day.
  • Then continue to take 1 pill every day until you finish the pack.
  • Use a non-hormonal birth control method (such as a condom and spermicide) as a back-up if you have sex during the first 7 days after missing your pills.

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 are a Day 1 Starter:
    • Throw out the rest of the pill pack and start a new pack that same day.
    • You may not have your period this month but this is expected. However, if you miss your period 2 months in a row, call your healthcare provider because you might be pregnant.
    • You could become pregnant if you have sex during the first 7 days after you restart your pills. You MUST use a non-hormonal birth control method (such as a condom and spermicide) as a back-up if you have sex during the first 7 days after you restart your pills.
  • If you are a Sunday Starter:
    • Keep taking 1 pill every day until Sunday. On Sunday, throw out the rest of the pack and start a new pack of pills that same day.
    • Use a non-hormonal birth control method (such as a condom and spermicide) as a back-up if you have sex during the first 7 days after you restart your pills.

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

Manufactured for:
Aurobindo Pharma USA, Inc.
2400 Route 130 North
Dayton, NJ 08810

Manufactured by:
Aurobindo Pharma Limited
Unit-VII (SEZ)
Mahaboob Nagar (Dt)-509302
India

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

Issued: November 2015

PACKAGE LABEL-PRINCIPAL DISPLAY PANEL- Pouch Label

                                                                    NDC 65862-777-28 
                            Tri - MiliTM
(norgestimate and ethinyl estradiol tablets USP)
0.180 mg/0.035 mg, 0.215 mg/0.035 mg, 0.250 mg/0.035 mg

Each 7 white coated tablets contain norgestimate
USP 0.180 mg and ethinyl estradiol USP 0.035 mg.
Each 7 light blue coated tablets contain
norgestimate USP 0.215 mg and ethinyl estradiol
USP 0.035 mg. Each 7 dark blue coated tablets
contain norgestimate USP 0.250 mg and ethinyl
estradiol USP 0.035 mg. Each 7 green tablets
contain 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.

Rx only                                   One Blister Card of 28 tablets each
                                                                                AUROBINDO

PACKAGE LABEL-PRINCIPAL DISPLAY PANEL-Pouch Carton Label

                                                                                            NDC 65862-777-92

                                Tri - MiliTM
(norgestimate and ethinyl estradiol tablets USP)
0.180 mg/0.035 mg, 0.215 mg/0.035 mg, 0.250 mg/0.035 mg

Each 7 white coated tablets contain norgestimate USP 0.180 mg and ethinyl
estradiol USP 0.035 mg. Each 7 light blue coated tablets contain norgestimate
USP 0.215 mg and ethinyl estradiol USP 0.035 mg. Each 7 dark blue coated
tablets contain norgestimate USP 0.250 mg and ethinyl estradiol USP 0.035 mg.
Each 7 green tablets contain 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.

Rx only                                                         Six Blister Cards of 28 tablets each


Tri-Mili 
norgestimate and ethinyl estradiol kit
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:65862-777
Packaging
# Item Code Package Description
1 NDC:65862-777-28 1 BLISTER PACK in 1 CARTON
1 1 KIT in 1 BLISTER PACK
2 NDC:65862-777-85 3 BLISTER PACK in 1 CARTON
2 1 KIT in 1 BLISTER PACK
3 NDC:65862-777-86 6 BLISTER PACK in 1 CARTON
3 1 KIT in 1 BLISTER PACK
4 NDC:65862-777-87 1 POUCH in 1 CARTON
4 1 KIT in 1 POUCH
5 NDC:65862-777-88 3 POUCH in 1 CARTON
5 1 KIT in 1 POUCH
6 NDC:65862-777-92 6 POUCH in 1 CARTON
6 1 KIT in 1 POUCH
Quantity of Parts
Part # Package Quantity Total Product Quantity
Part 1
Part 2
Part 3
Part 4
Part 1 of 4
Tri-Mili 
norgestimate and ethinyl estradiol tablet, coated
Product Information
     
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NORGESTIMATE (NORGESTIMATE) NORGESTIMATE 0.180 mg
ETHINYL ESTRADIOL (ETHINYL ESTRADIOL) ETHINYL ESTRADIOL 0.035 mg
Inactive Ingredients
Ingredient Name Strength
CROSCARMELLOSE SODIUM  
HYPROMELLOSE 2910 (5 MPA.S)  
LACTOSE MONOHYDRATE  
MAGNESIUM STEARATE  
CELLULOSE, MICROCRYSTALLINE  
POLYETHYLENE GLYCOL 400  
TITANIUM DIOXIDE  
Product Characteristics
Color WHITE Score no score
Shape ROUND (Biconvex) Size 5mm
Flavor Imprint Code S;19
Contains         
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205441 07/06/2016
Part 2 of 4
Tri-Mili 
norgestimate and ethinyl estradiol tablet, coated
Product Information
     
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NORGESTIMATE (NORGESTIMATE) NORGESTIMATE 0.215 mg
ETHINYL ESTRADIOL (ETHINYL ESTRADIOL) ETHINYL ESTRADIOL 0.035 mg
Inactive Ingredients
Ingredient Name Strength
CROSCARMELLOSE SODIUM  
FD&C BLUE NO. 2  
HYPROMELLOSE 2910 (6 MPA.S)  
LACTOSE MONOHYDRATE  
MAGNESIUM STEARATE  
CELLULOSE, MICROCRYSTALLINE  
POLYETHYLENE GLYCOL 400  
TITANIUM DIOXIDE  
Product Characteristics
Color BLUE (Light Blue) Score no score
Shape ROUND (Biconvex) Size 5mm
Flavor Imprint Code S;21
Contains         
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205441 07/06/2016
Part 3 of 4
Tri-Mili 
norgestimate and ethinyl estradiol tablet, coated
Product Information
     
Route of Administration ORAL DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
NORGESTIMATE (NORGESTIMATE) NORGESTIMATE 0.250 mg
ETHINYL ESTRADIOL (ETHINYL ESTRADIOL) ETHINYL ESTRADIOL 0.035 mg
Inactive Ingredients
Ingredient Name Strength
CROSCARMELLOSE SODIUM  
FD&C BLUE NO. 2  
HYPROMELLOSE 2910 (6 MPA.S)  
LACTOSE MONOHYDRATE  
MAGNESIUM STEARATE  
CELLULOSE, MICROCRYSTALLINE  
POLYETHYLENE GLYCOL 400  
TITANIUM DIOXIDE  
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 ANDA205441 07/06/2016
Part 4 of 4
INERT 
inert tablet
Product Information
     
Route of Administration ORAL DEA Schedule     
Inactive Ingredients
Ingredient Name Strength
ANHYDROUS LACTOSE  
FD&C BLUE NO. 2  
FERRIC OXIDE YELLOW  
MAGNESIUM STEARATE  
CELLULOSE, MICROCRYSTALLINE  
POVIDONE K29/32  
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 ANDA205441 07/06/2016
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
ANDA ANDA205441 07/06/2016
Labeler - Aurobindo Pharma Limited (650082092)
Establishment
Name Address ID/FEI Operations
Aurobindo Pharma Limited 650381903 ANALYSIS(65862-777), MANUFACTURE(65862-777)
Revised: 07/2016
 
Aurobindo Pharma Limited
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