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BREAKYL 600 MICROGRAM BUCCAL FILM

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Breakyl

PATIENT INFORMATION LEAFLET

2. BEFORE YOU USE BREAKYL Do not use Breakyl if
ou are allergic (hypersensitive) to fentanyl, or any of the other Y ingredients of Breakyl (for a full list of ingredients see Further i nformation at the end of this leaflet). ou are currently taking monoamine-oxidase (MAO) inhibitors (used Y for severe depression) or have done so in the past 2 weeks. ou suffer from severe breathing problems or severe obstructive Y lung conditions (like severe asthma). ou have not taken a prescribed opioid pain medicine every day on Y a regular schedule, for at least a week, to control your chronic pain. Among these are morphine, oxycodone, or transdermal fentanyl patches which may not be changed daily. If you have not been using these medicines you must not use Breakyl, because it may increase the risk of potentially fatal breathing problems (breathing could become dangerously slow and/or shallow, or even stop). Take special care with Breakyl If you have any of the following, talk to your doctor before starting Breakyl, as your doctor will need to take account of this when p rescribing your dose: our other opioid pain medicine taken for your chronic cancer pain Y is not stablilised yet ou are suffering from any condition that has an effect on your Y breathing. ou have a head injury or if your doctor has diagnosed an increased Y cranial pressure. You have an exceptionally slow heart rate or other heart problems. ou have low blood pressure, especially due to a low amount of Y fluid in the circulation. ou have liver or kidney problems, as these organs have an effect Y on the way in which your system breaks down the medicine. You are suffering from oral mucositis For more information see section 3. Breakyl contains fentanyl in an amount which can be fatal to a child. Therefore, Breakyl must be kept out of reach and sight of children at all times. If you are an athlete, be aware that this product may produce a p ositive reaction in anti-doping tests. Taking other medicines Please tell your doctor or pharmacist if you are taking or have ecently r taken any other medicines, including medicines obtained without a prescription. Do not use Breakyl if you are currently taking monoamine-oxidase (MAO) inhibitors (used for severe depression) or have done so in the past 2 weeks.

If you are taking any of the following talk to your doctor or pharmacist before starting Breakyl: Any medicine which might normally make you tired or sleepy, e.g.: sleeping pills, medicines to treat anxiety, nervousness, depression, medicines to treat tense or rigid muscle (muscle relaxants), medicines to treat allergies (antihistamines).

Using Breakyl with food and drink Avoid drinking alcohol, as alcohol may additionally sedate and depress your respiration. Do not drink grapefruit juice, as this may slow down the way your body breaks down fentanyl, which may result in increased or prolonged effects of Breakyl and may cause potentially fatal breathing problems. Avoid smoking, as this may reduce the efficacy of your medication. Pregnancy and breast-feeding

200 microgram, buccal film 400 microgram, buccal film 600 microgram, buccal film 800 microgram, buccal film 1200 microgram, buccal film Start 200, 400, 600 and 800 microgram, buccal film
Active substance: Fentanyl
Read all of this leaflet carefully before you start using this medicine. eep this leaflet. You may need to read it again. K f you have any further questions, ask your doctor or pharmacist. I his medicine has been prescribed for you. Do not pass it on to T others. It may harm them, even if their symptoms are the same as yours. f any of the side effects gets serious, or if you notice any side I effects not listed in this leaflet, please tell your doctor or p harmacist. In this leaflet: 1. What Breakyl is and what it is used for 2. Before you use Breakyl 3. How to use Breakyl 4. Possible side effects 5. How to store Breakyl 6. Further information

For dose titration your dose is gradually increased. When you have reached a dose, which provides you with adequate pain relief within 30 minutes and if any possibly occurring side effects are acceptable for you, you have identified the successful dose. It is important that you follow strictly the advice of your doctor. Usually, the following procedure will be used for the Dose Titration. Dose titration You should start with the initial dose of 200 micrograms of Breakyl. Contact your doctor, if your breakthrough pain is not relieved within 30minutes after application of the Breakyl dose. If you have tolerated the dose, your doctor will advise you to take the next higher Breakyl dose for a subsequent breakthrough pain episode. Your doctor may gradually increase the dose from 200 to 400 and 600 micrograms up to 800 micrograms. For this purpose Breakyl Start contains one unit of each strength: 200, 400, 600 and 800 micrograms. By applying a combination of Breakyl 200 microgram buccal films simultaneously, these higher doses may be achieved: 1 buccal film Breakyl 200 equals a dose of 200micrograms 2 buccal films Breakyl 200 equal a dose of 400micrograms 3 buccal films Breakyl 200 equal a dose of 600micrograms 4 buccal films Breakyl 200 equal a dose of 800micrograms In case the highest strength of Breakyl Start (800 micrograms) or the combination of 4 buccal films at one time (800 micrograms) is not s ufficient for pain relief, your doctor may prescribe Breakyl 1200 micrograms for you. This is the highest available strength of Breakyl. When you have identified the successful dose, your doctor will provide you with a prescription for this dose to treat subsequent breakthrough pain episodes by using this identified dose. Breakyl should only be used once per breakthrough pain episode and you should wait for at least 4 hours before using the next Breakyl dose. If you do not achieve adequate pain relief within 30 minutes after a pplication of a Breakyl dose, you may use another rescue medication for breakthrough pain, if your doctor told you so. Frequency of administration You should not take more than four Breakyl doses per day. Dose Readjustment

Methods of administration Breakyl buccal film is for oromucosal use. When you attach a Breakyl buccal film to the inside of your cheek, fentanyl is absorbed directly through the lining of your mouth, into the blood circulation. pen the Breakyl sachet immediately prior to use as indicated by O the instructions on the sachet; se your tongue to wet the inside of your cheek or rinse your mouth U with water to moisten the area for placement of Breakyl; f With dry hands, take the Breakyl buccal film between your orefinger and thumb with the pink side facing to the thumb (figure 1) Place the Breakyl buccal film inside your mouth, so that the pink side makes smooth contact with the inner lining of your cheek (figure 2); ress and hold it in place for a minimum of 5 seconds until it sticks P firmly. Now the white side should be visible (figure 3). W hen applying more than one Breakyl buccal film at the same time, make sure each film sticks directly to your oral mucosa. To avoid overlap, it is possible to apply films to both, left and right side of the buccal mucosa. The Breakyl buccal film should stay in place on its own after this period. You may drink liquids after 5 minutes.

Medicines that might interfere with the way, by which (the CYP3A4 isoenzyme in) your body breaks down Breakyl as these may increase the blood levels of fentanyl. This may result in increased or prolonged effects of Breakyl and may cause potentially fatal breathing problems. Such medicines are, e.g.: edicines to control viral infections, i.e. HIV infections (such as m ritonavir, indinavir, nelfinavir, saquinavir) edicines for the treatment of fungal infections (such as ketoconam zole, itraconazole, fluconazole) edicines for the treatment of bacterial infections (such as erythrom mycin, clarithromycin, telithromycin) edicines against severe nausea (such as aprepitant, dronabinol) m edicines for the treatment of cardiovascular diseases (such as m diltiazem, verapamil) medicines which inhibit gastric acid production (such as cimetidine) medicines for the treatment of depressions (such as fluoxetine) Medicines that may enhance the way, by which (the CYP3A4 i soenzyme in) your body breaks down fentanyl, thus decreasing the efficacy of Breakyl such as: sleeping pills or sedatives (such as phenobarbital) edicines to control epileptic convolutions/seizures (such as m c arbamazepine, phenytoin, oxcarbazepine) edicines to control viral proliferation (such as efavirenz, evirapine) m n nti-inflammatory or immunosuppressive medicines (such as a g lucocorticoids) medicines for the treatment of diabetes (such as pioglitazone) antibiotics for treatment of tuberculosis (such as rifabutin, rifampin) psycho-stimulating medicines (such as modafinil) edicines for the treatment of depressions (such as St. Johns m wort) If you stop therapy with, or decrease the dose of, such active s ubstances while using Breakyl, talk to your doctor. Your doctor will carefully monitor you for signs of opioid toxicity, and may adjust the dose of Breakyl accordingly. If you start taking active substances which reduce opiod activity, e.g. naloxone, or some strong pain killers like pentazocine, butorphanol, buprenorphine, nalbuphine, this may cause opiate withdrawal s ymptoms (e.g. anxiety, tremor, abdominal pain, and other symptoms).

Ask your doctor or pharmacist for advice before taking any medicine. Breakyl should not be used during pregnancy unless you have d iscussed this with your doctor. You should not use Breakyl during childbirth because fentanyl may cause respiratory depression in the new-born child. Fentanyl passes into breast milk and may cause sedation and respiratory depression in the breast-fed infant. Do not use Breakyl if you are breast-feeding unless you have discussed this with your doctor. Driving and using machines Please ask your doctor whether you may safely drive a car, or operate machinery a few hours after taking Breakyl. Opioid analgesics like fentanyl may impair the mental and/or physical ability required for the performance of potentially dangerous tasks. Do not drive or operate machinery if you are feeling sleepy or dizzy, have blurred or double vision, or have difficulty in concentrating while using Breakyl. Important information about some of the ingredients of Breakyl Breakyl contains propylene glycol (E 1520), sodium benzoate (E 211), methyl-parahydroxybenzoate (E 218), and ropyl-parahydroxybenzoate p (E 216). Sodium benzoate is mildly irritant to the skin, eyes and mucous membranes. Methyl-parahydroxybenzoate and propyl- parahydroxybenzoate may cause allergic reactions (possibly delayed). Propylene glycol may cause skin irritation.

Figure 1

Figure 2

Figure 3

The buccal film will usually dissolve completely within 15 to 30 minutes after application. In individual cases complete dissolution may take more than 30 minutes, but this does not affect fentanyl absorption. Avoid manipulating the buccal film with your tongue or fingers. You should not eat as long as the buccal film has not yet dissolved ompletely. c Do not chew or swallow Breakyl. If you do so, you will likely get less relief of your breakthrough pain.

1. WHAT BREAKYL IS AND WHAT IT IS USED FOR
The active ingredient, fentanyl, is a strong pain-relieving medicine known as an opioid. Breakyl is indicated for the management of b reakthrough cancer pain in adult patients. Breakthrough pain is a dditional sudden pain. This may occur although you have taken your regular opioid pain relieving medicine. Breakyl must only be used, if you are already taking and are used to regular opioid therapy like morphine, oxycodone, or transdermal f entanyl for a minimum of one week to treat your chronic cancer pain.

3. HOW TO USE BREAKYL
Always use Breakyl exactly as your doctor has told you. You should check with your doctor or pharmacist if you are not sure. Dosage When you start using Breakyl your doctor will work with you to find the dose that will relieve your breakthrough pain (dose titration). This is necessary because your individual successful dose of Breakyl cannot be predicted from the daily dose of opioids you are taking for reatment t of your chronic cancer pain, or from other medicines which you may have taken for treatment of breakthrough cancer pain.

You must inform your doctor immediately if you are experiencing more than four breakthrough pain episodes per day. Your doctor may wish to increase the dose of your medicine for your persistent cancer pain. When your persistent pain is controlled again, your doctor may need to adjust your dose of Breakyl. For best results, let your doctor know about your pain and how Breakyl is working for you so that the dose can be adjusted if needed. Do not change the doses of Breakyl or of your regular opioid therapy on your own. Changes in dosage must be directed and monitored by your doctor.

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If you use more Breakyl than you should The most common side effects of an adequate dose of Breakyl are feeling sleepy, sick or dizzy. If, after using Breakyl, you begin to feel very sleepy, remove the Breakyl buccal film or even parts of it from your mouth as quickly as possible and call another person to help you. A serious side effect of Breakyl is slow and/or shallow breathing. This can occur if your dose of Breakyl is too high or if you take too much Breakyl. At the beginning of treatment you and your caregiver should discuss with your doctor how to take immediate action if this occurs. Note to caregivers: If you see that the patient taking Breakyl has slow and/or shallow breathing or if you have a hard time waking the person up, take the following steps immediately: n case the Breakyl buccal film is still sticking to the inner cheek of I the patient remove the buccal film or even parts of it from the patients mouth as quickly as possible. all for emergency help. C ee further instructions for what to do if a child or adult accidenS tally takes Breakyl, as given below. If a child or adult accidentally takes Breakyl they may have the following symptoms: ery sleepy V izzy D eeling sick or vomiting F ot breathing or breathing is very slow and/or shallow. N If you think someone has accidentally taken Breakyl for whom it is not prescribed, follow these steps immediately: n case the Breakyl buccal film is still sticking to the inner cheek of I the individual, remove the buccal film or even parts of it from the individuals mouth as quickly as possible. f the person is asleep, awaken them by calling their name and I shaking their arm or shoulder. all for emergency help. C hile waiting for emergency help: W f the person seems to be breathing slowly, prompt them to I breathe every 5-10 seconds. f the person has stopped breathing, give mouth to mouth I r esuscitation until help arrives. If you stop using Breakyl You should discontinue Breakyl when no longer required. You should continue to take your regular opioid therapy to treat your persistent cancer pain as instructed by your doctor. If you stop all your opioid therapy, your doctor will take account of the Breakyl dose and consider a gradual opioid dose reduction to avoid abrupt withdrawal effects. If you have any further questions on the use of this product, ask your doctor or pharmacist.

4. POSSIBLE SIDE EFFECTS
Like all medicines, Breakyl can cause side effects, although not everybody gets them. The most serious side effects are shallow breathing, low blood p ressure and shock. If you become very sleepy or have slow and/or shallow breathing, you or your caregiver should contact your doctor immediately and call for emergency help. If the buccal film is still in place in your cheek, it or even parts of it should be removed as uickly q as possible. The most frequent adverse reactions observed were nausea, s omnolence, and dizziness. Because patients using Breakyl are also taking regular opioid therapy such as morphine, oxycodone or transdermal fentanyl, for their p ersistent pain, opioid side effects may arise from either medication. Thus, it is not possible to definitively separate the effects of Breakyl from those of the other opioids. The adverse events considered to be at least possibly-related to t reatment, were as follows: Common (affects 1 to 10 users in 100): xcessive tiredness/sleepiness, dizziness, headache, sedation e ight problems (e.g. blurred or double vision) s ausea/feeling sick, constipation, vomiting, dry mouth n tching of the skin i atigue f onfusion c Uncommon (affects 1 to 10 users in 1000): lood pressure increased b t aste alteration, inactivity, memory difficulties, disturbance in thinking low or shallow breathing, sinus congestion s iarrhoea, oral mucosal inflammation, gum bleeding, indigestion, d mouth ulcers, oral pain, painful swallowing nintentional loss of urine u ncreased sweating, tendency to bruise i uscle twitching, muscular weakness, pain in joints, muscular m pain, pain in extremity, pain in jaw ecreased appetite d ccidental injury (for example, falls) a lushing/feeling hot f eakness, chills, fever, thirst w eeling anxious or nervous, hallucinations, delusion, abnormal f dreams, sleeplessness, restlessness

Very rare (affects less than 1 user in 10,000): uscle jerks, abnormal sensations like tingling, numbness, m increased touchiness also around the mouth, difficulty coordinating movements reathing difficulties b bdominal pain, wind, abdominal bloating a ifficulty passing urine d kin rash s asodilatation v eneral feeling unwell g bnormal thinking, feeling detached, depression, mood swings, a excessive feeling of well being There is a risk of abuse or addiction with Breakyl. The risk is higher if you have ever been addicted to or abused other medicines, street drugs, or alcohol. However, addiction following therapeutic use of opioids is rare. If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

6. FURTHER INFORMATION
What Breakyl contains The active substance is fentanyl. Breakyl 200 microgram, buccal film One buccal film contains 200 micrograms fentanyl (as fentanyl citrate) Breakyl 400 microgram, buccal film One buccal film contains 400 micrograms fentanyl (as fentanyl citrate) Breakyl 600 microgram, buccal film One buccal film contains 600 micrograms fentanyl (as fentanyl citrate) Breakyl 800 microgram, buccal film One buccal film contains 800 micrograms fentanyl (as fentanyl citrate) Breakyl 1200 microgram, buccal film One buccal film contains 1200 micrograms fentanyl (as fentanyl citrate)

What Breakyl looks like and contents of the pack Breakyl is a soluble rectangular, flat, flexible buccal film with a pink side and a white side. The pink side contains the active substance fentanyl. The white side minimises fentanyl release into the saliva where it might be swallowed. Breakyl is a medicine that allows fentanyl to be delivered directly through the lining of your mouth, into the blood circulation. The following stencil shows the sizes of the available Breakyl strengths:

200

400
microgam

600
microgam

800
microgam

1200
microgam

5. HOW TO STORE BREAKYL
Keep Breakyl out of the reach and sight of children at all times. The amount of fentanyl contained in Breakyl can be fatal to a child or a person, who does not take regular opioid therapy. Breakyl should be kept in a safe locked storage place. Do not use Breakyl after the expiry date which is stated on the carton and each sachet as {MM.YYYY}. The expiry date refers to the last day of that month. Do not store above 30 C. Do not refrigerate. Store in the original package in order to protect from moisture. Do not use if the sachet has been damaged before opening. This medicine should not be disposed of via wastewater or household waste. If you are no longer using Breakyl, or if you have left over sachets in your home, ask your pharmacist how to dispose of these medicines no longer required. These measures will help to protect the environment and to avoid that unused medication is taken by children and/or persons, for whom it is not prescribed.

The other ingredients are Active layer: Propylene glycol (E 1520), sodium benzoate (E 211), methyl-parahydroxybenzoate (E 218), propyl-parahydroxybenzoate (E 216), ferric oxide (red) (E 172), anhydrous citric acid, all-rac-alpha-tocopheryl acetate, monobasic sodium phosphate (anhydrous), sodium hydroxide, Tribasic sodium phosphate (anhydrous), polycarbophil, hydroxypropyl cellulose, hydroxyethyl cellulose, Carmellose sodium. Backing layer: sodium benzoate (E 211), methyl-parahydroxybenzoate (E 218), propyl-parahydroxybenzoate (E 216), anhydrous citric acid, all-rac-alpha-tocopheryl acetate, hydroxypropyl cellulose, hydroxyethyl cellulose, titanium dioxide (E 171), saccharin sodium, peppermint oil.

microgam

Each buccal film is individually sealed in a child-resistant sachet. Breakyl is available in the following presentations: Breakyl 200 microgram: cartons with 3, 4, 10, 28 or 30 sachets with one buccal film each. Breakyl 400 microgram: cartons with 3, 4, 10, 28 or 30 sachets with one buccal film each. Breakyl 600 microgram: cartons with 3, 4, 10, 28 or 30 sachets with one buccal film each. Breakyl 800 microgram: cartons with 3, 4, 10, 28 or 30 sachets with one buccal film each. Breakyl 1200 microgram: cartons with 3, 4, 10, 28 or 30 sachets with one buccal film each. Breakyl Start: 4 sachets with one buccal film of 200, 400, 600 and 800 microgram each, in a carton. Not all pack sizes may be marketed. Marketing Authorisation Holder Meda Pharmaceuticals Ltd., Skyway House, Parsonage Road, Takeley, Bishops Stortford, CM22 6PU, UK Manufacturer MEDA Pharma GmbH & Co. KG Benzstr. 1 D-61352 Bad Homburg Germany This medicinal product is authorised in the Member States of the EEA under the following names: Norway: Buquel / Buquel Start all other Member States: Breakyl / Breakyl Start This leaflet was last revised in June 2011
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Source: Medicines and Healthcare Products Regulatory Agency

Disclaimer: Every effort has been made to ensure that the information provided here is accurate, up-to-date and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. This information has been compiled for use by healthcare practitioners and consumers in the United States. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective or appropriate for any given patient. If you have questions about the substances you are taking, check with your doctor, nurse or pharmacist.

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