NORGESTIMATE AND ETHINYL ESTRADIOL kit

Norgestimate and Ethinyl Estradiol by

Drug Labeling and Warnings

Norgestimate and Ethinyl Estradiol by is a Prescription medication manufactured, distributed, or labeled by Akorn, Inc.. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

• HIGHLIGHTS OF PRESCRIBING INFORMATION

  These highlights do not include all the information needed to use Norgestimate and Ethinyl Estradiol Tablets USP safely and effectively. See full prescribing information for Norgestimate and Ethinyl Estradiol Tablets USP.
  Norgestimate and Ethinyl Estradiol Tablets USP, for oral use
  Initial U.S. Approval: 1989

  WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS

  See full prescribing information for complete boxed warning.

  • Norgestimate and Ethinyl Estradiol Tablets USP are 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): 09/2017
  • Warnings and Precautions (5.3): 09/2017

  INDICATIONS AND USAGE

  Norgestimate and Ethinyl Estradiol Tablets USP are estrogen/progestin COCs, indicated for use by women to prevent pregnancy. (1.1)

  Norgestimate and Ethinyl Estradiol Tablets USP are also 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.

  Norgestimate and Ethinyl Estradiol Tablets USP should be used for the treatment of acne only if the patient desires an oral contraceptive for birth control. (1.2)

  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

  Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg) consist of 28 round tablets in the following order (3):

  • 21 dark blue tablets each containing 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 white tablets (inert)

  Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) consist of 28 round tablets in the following order (3):

  • 7 light blue tablets each containing 0.18 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 medium blue tablets each containing 0.215 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 dark blue tablets each containing 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
  • 7 white 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP if jaundice occurs. (5.2)
  • High blood pressure: If used in women with well-controlled hypertension, monitor blood pressure and stop Norgestimate and Ethinyl Estradiol Tablets USP if blood pressure rises significantly. (5.4)
  • Carbohydrate and lipid metabolic effects: Monitor prediabetic and diabetic women taking Norgestimate and Ethinyl Estradiol Tablets USP. Consider an alternate contraceptive method for women with uncontrolled dyslipidemia. (5.6)
  • Headache: Evaluate significant change in headaches and discontinue Norgestimate and Ethinyl Estradiol Tablets USP 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:

  Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg): 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)

  Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg): headache/migraine, breast issues (including breast pain, enlargement, and discharge), vaginal infection, abdominal/gastrointestinal pain, mood disorders (including mood alteration and depression), genital discharge, changes in weight (including weight increased or decreased). (6.1)

  To report SUSPECTED ADVERSE REACTIONS, contact Akorn, Inc. at 1-800-932-5676 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: 10/2017

• Table of Contents

  FULL PRESCRIBING INFORMATION: CONTENTS*

  WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS

  1 INDICATIONS AND USAGE

  1.1 Oral Contraceptive

  1.2 Acne

  2 DOSAGE AND ADMINISTRATION

  2.1 How to Start Norgestimate and Ethinyl Estradiol Tablets USP

  2.2 How to Take Norgestimate and Ethinyl Estradiol Tablets USP

  2.3 Missed Tablets

  2.4 Advice in Case of Gastrointestinal Disturbances

  2.5 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) Use for Acne

  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

  14.2 Acne

  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.

BOXED WARNING

(What is this?)

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

Norgestimate and Ethinyl Estradiol Tablets USP are indicated for use by females of reproductive potential to prevent pregnancy [see Clinical Studies (14)].

1.2 Acne

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) are 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. Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) should be used for the treatment of acne only if the patient desires an oral contraceptive for birth control [see Clinical Studies (14)].

2 DOSAGE AND ADMINISTRATION

2.1 How to Start Norgestimate and Ethinyl Estradiol Tablets USP

Norgestimate and Ethinyl Estradiol Tablets USP are dispensed in a blister pack [see How Supplied/Storage and Handling (16)]. Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP

Table 1: Instructions for Administration of Norgestimate and Ethinyl Estradiol Tablets USP

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: Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) active tablets are dark blue (Day 1 to Day 21). Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) active tablets are light blue (Day 1 to Day 7), medium blue (Day 8 to Day 15) and dark blue (Day 16 to Day 21). Norgestimate and Ethinyl Estradiol Tablets USP both have white 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 white 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 Norgestimate and Ethinyl Estradiol Tablets USP. Take subsequent active tablets once daily at the same time each day for a total of 21 days. Take one white 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP	Start Norgestimate and Ethinyl Estradiol Tablets USP:
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 Norgestimate and Ethinyl Estradiol Tablets USP after Abortion or Miscarriage

First-trimester

• After a first-trimester abortion or miscarriage, Norgestimate and Ethinyl Estradiol Tablets USP may be started immediately. An additional method of contraception is not needed if Norgestimate and Ethinyl Estradiol Tablets USP are started immediately.
• If Norgestimate and Ethinyl Estradiol Tablets USP are 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 Norgestimate and Ethinyl Estradiol Tablets USP.

Second-trimester

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

Starting Norgestimate and Ethinyl Estradiol Tablets USP after Childbirth

• Do not start until 4 weeks after delivery, due to the increased risk of thromboembolic disease. Start contraceptive therapy with Norgestimate and Ethinyl Estradiol Tablets USP following the instructions in Table 1 for women not currently using hormonal contraception.
• Norgestimate and Ethinyl Estradiol Tablets USP are not recommended for use in lactating women [see Use in Specific Populations (8.3)].
• If the woman has not yet had a period postpartum, consider the possibility of ovulation and conception occurring prior to use of Norgestimate and Ethinyl Estradiol Tablets USP. [See Contraindications (4), Warnings and Precautions (5.1), Use in Specific Populations (8.1 and 8.3), and FDA-Approved Patient Labeling].

BEFORE YOU START TAKING YOUR PILLS, SET THE DAY:

• Day 1 Start:
  
  • Pick the day label strip that starts with the first day of your period (this is the day you start bleeding or spotting, even it is almost midnight when the bleeding begins).
  • Place this day label strip on the tablet blister card over the area that has the days of the week (starting with Sunday) printed on the blister.
  • Take the tablets in the direction of the arrows in the picture (from left to right) each week.
  • For Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg), take the first light blue “active” tablet during the first 24 hours of your period that corresponds with the day of the week the first tablet will be taken.
  • For Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg), take the first dark blue “active” tablet during the first 24 hours of your period that corresponds with the day of the week the first tablet will be taken.
• Sunday Start:
  • Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) - the first light blue “active” tablet should be taken on the first Sunday after the patient's menstrual period begins. If your period begins on Sunday, start the pack that same day.
  • Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) - the first dark blue “active” tablet should be taken on the first Sunday after the patient's menstrual period begins. If your period begins on Sunday, start the pack that same day.

2.3 Missed 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].

2.5 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) Use for Acne

The timing of initiation of dosing with Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) for acne should follow the guidelines for use of Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) as an oral contraceptive. Consult the DOSAGE AND ADMINISTRATION section (2.1) for instructions.

3 DOSAGE FORMS AND STRENGTHS

Norgestimate and Ethinyl Estradiol Tablets USP. (0.25 mg/0.035 mg):

Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg) are available in blister cards. Each blister card contains 28 tablets in the following order:

• 21 dark blue unscored round tablets debossed with on one side with “14”; the tablet contains 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 white round unscored tablets (non-hormonal placebo) debossed on one side with “11”; the tablet contains inert ingredients

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg):

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) are available in blister cards. Each blister card contains 28 tablets in the following order:

• 7 light blue unscored round tablets debossed on one side with “12”; the tablet contains 0.18 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 medium blue unscored round tablets debossed on one side with “13”; the tablet contains 0.215 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 dark blue unscored round tablet debossed on one side with “14”; the tablet contains 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 white unscored round tablets (non-hormonal placebo) debossed on one side with “11”; the tablet contains inert ingredients

4 CONTRAINDICATIONS

Do not prescribe Norgestimate and Ethinyl Estradiol Tablets USP to women who are known to have the following conditions:

• A high risk of arterial or venous thrombotic diseases. Examples include women who are known to:
  • Smoke, if over age 35 [see Boxed Warning and Warnings and Precautions (5.1)]
  • Have deep vein thrombosis or pulmonary embolism, now or in the past [see Warnings and Precautions (5.1)]
  • Have inherited or acquired hypercoagulopathies [see Warnings and Precautions (5.1)]
  • Have cerebrovascular disease [see Warnings and Precautions (5.1)]
  • Have coronary artery disease [see Warnings and Precautions (5.1)]
  • Have thrombogenic valvular or thrombogenic rhythm diseases of the heart (for example, subacute bacterial endocarditis with valvular disease, or atrial fibrillation) [see Warnings and Precautions (5.1)]
  • Have uncontrolled hypertension [see Warnings and Precautions (5.4)]
  • Have diabetes mellitus with vascular disease [see Warnings and Precautions (5.6)]
  • Have headaches with focal neurological symptoms or migraine headaches with aura [see Warnings and Precautions (5.7)]
    • Women over age 35 with any migraine headaches [see Warnings and Precautions (5.7)]
• Liver tumors, benign or malignant, or liver disease [see Warnings and Precautions (5.2)]
• Undiagnosed abnormal uterine bleeding [see Warnings and Precautions (5.8)]
• Pregnancy, because there is no reason to use COCs during pregnancy [see Warnings and Precautions (5.9) and Use in Specific Populations (8.1)]
• Breast cancer or other estrogen- or progestin-sensitive cancer, now or in the past [see Warnings and Precautions (5.11)]
• Use of Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to the potential for ALT elevations [see Warnings and Precautions (5.3)]

5 WARNINGS AND PRECAUTIONS

5.1 Thromboembolic Disorders and Other Vascular Problems

• Stop Norgestimate and Ethinyl Estradiol Tablets USP if an arterial thrombotic event or venous thromboembolic (VTE) event occurs.
• Stop Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP if jaundice develops.

Liver Tumors

Norgestimate and Ethinyl Estradiol Tablets USP are 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 Norgestimate and Ethinyl Estradiol Tablets USP prior to starting therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir [see Contraindications (4)]. Norgestimate and Ethinyl Estradiol Tablets USP can be restarted approximately 2 weeks following completion of treatment with the Hepatitis C combination drug regimen.

5.4 High Blood Pressure

Norgestimate and Ethinyl Estradiol Tablets USP are 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP. 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 Norgestimate and Ethinyl Estradiol Tablets USP develops new headaches that are recurrent, persistent, or severe, evaluate the cause and discontinue Norgestimate and Ethinyl Estradiol Tablets USP if indicated.

Consider discontinuation of Norgestimate and Ethinyl Estradiol Tablets USP in the case of increased frequency or severity of migraines 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 Norgestimate and Ethinyl Estradiol Tablets USP, the frequency and duration of breakthrough bleeding and/or spotting was assessed in 1,647 patients (21,275 evaluable cycles) and 4,826 patients (35,546 evaluable cycles), respectively. A total of 100 (7.5%) women discontinued Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) and 231 (4.8%) women discontinued Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg), at least in part, due to bleeding or spotting. Based on data from the clinical trials, 14-34% of women using Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) experienced unscheduled bleeding per cycle in the first year; for Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg), the respective numbers were 13-38%. The percent of women who experienced breakthrough/unscheduled bleeding tended to decrease over time.

Amenorrhea and Oligomenorrhea

Women who use Norgestimate and Ethinyl Estradiol Tablets USP 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 insofar as cardiac anomalies and limb reduction defects are concerned, when oral contraceptives are taken inadvertently during early pregnancy. Discontinue Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP if depression recurs to a serious degree.

5.11 Carcinoma of Breast and Cervix

• Norgestimate and Ethinyl Estradiol Tablets USP are con traindicated 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 Norgestimate and Ethinyl Estradiol Tablets USP.

6 ADVERSE REACTIONS

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

• Serious cardiovascular events and stroke [see Boxed Warning and Warnings and Precautions (5.1)]
• Vascular events [see Warnings and Precautions (5.1)]
• Liver disease [see Warnings and Precautions (5.2)]

Adverse reactions commonly reported by COC users are:

• Irregular uterine bleeding
• Nausea
• Breast tenderness
• Headache

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.

Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg)

The safety of Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) was evaluated in 1,647 healthy women of child-bearing potential who participated in 3 clinical trials and received at least 1 dose of Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) 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 and 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).

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg. 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

The safety of Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) was evaluated in 4,826 healthy women of child-bearing potential who participated in 6 clinical trials and received at least 1 dose of Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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 and 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).

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 (Inch 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 Norgestimate and Ethinyl Estradiol Tablets USP.

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, rufmamide, aprepitant, and products containing St. John's wort. Interactions between hormonal contraceptives and other drugs may lead to breakthrough bleeding and/or contraceptive Mure. 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 20-25%. 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., nelfmavir, 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP have been established in women of reproductive age. Efficacy is expected to be the same for postpubertal 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 Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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.

8.5 Geriatric Use

Norgestimate and Ethinyl Estradiol Tablets USP have not been studied in postmenopausal women and are not indicated in this population.

8.6 Hepatic Impairment

The pharmacokinetics of Norgestimate and Ethinyl Estradiol Tablets USP have 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 Norgestimate and Ethinyl Estradiol Tablets USP have 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

Each of the following products 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,l,3,5(10)-trien-20-yne-3,17-diol).

Norgestimate and Ethinvl Estradiol Tablets USP, (0.25 mg/0.035 mg)

• Each active dark blue tablet contains 0.25 mg of norgestimate and 0.035 mg of ethinyl estradiol. Inactive ingredients include colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.
• Each white placebo tablet containing only inert ingredients, as follows: lactose, magnesium stearate, microcrystalline cellulose and pregelatinized corn starch.

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

• Each active light blue tablet contains 0.18 mg of norgestimate and 0.035 mg of ethinyl estradiol. Inactive ingredients include colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.
• Each active medium blue tablet contains 0.215 mg of norgestimate and 0.035 mg of ethinyl estradiol. Inactive ingredients include colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.
• Each active dark blue tablet contains 0.25 mg of norgestimate and 0.035 mg of ethinyl estradiol. Inactive ingredients include colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.
• Each white placebo tablet contains only inert ingredients, as follows: lactose, magnesium stearate, microcrystalline cellulose and pregelatinized corn starch.
  

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.
• 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.

12.2 Pharmacodynamics

No specific pharmacodynamic studies were conducted with Norgestimate and Ethinyl Estradiol Tablets USP.

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 Norgestimate and Ethinyl Estradiol Tablets USP. 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 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) During a Three-Cycle Study
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 (1.5)	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)
Mean (SD) Pharmacokinetic Parameters of Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) 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)	15.0 (2.36)

Food Effect

The effect of food on the pharmacokinetics of Norgestimate and Ethinyl Estradiol Tablets USP 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% (45-49%) and 37% (16-49%) 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 (5.2, 5.11) and Use in Specific Populations (8.1).]

14 CLINICAL STUDIES

14.1 Contraception

In three US clinical trials with Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg), 1,651 women aged 18 to 38 years were studied for up to 24 cycles, providing a total of 24,272 cycles of exposure. The racial demographic was about 73-86% Caucasian, 8-13% African-American, 6-14% Hispanic with the remainder Asian or Other (≤1%). There were no exclusions on the basis of weight; the weight range for women treated was 82-303 lbs, with a mean weight of about 135 lbs. The pregnancy rate was approximately 1 pregnancy per 100 women-years.

In four clinical trials with Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.25 mg/0.035 mg and 0.25 mg/0.035 mg), 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 87-90% Caucasian, 6-10% African-American, with the remainder Asian (≤1%) or Other (2-5%). There were no exclusions on the basis of weight; the weight range for women treated was 80-310 lbs, with a mean weight of about 132 lbs. The pregnancy rate was approximately 1 pregnancy per 100 women-years.

14.2 Acne

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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 Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) 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
Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) (N=221)			Placebo; (N=234)	Difference in Counts between Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.025 mg) and Placebo at 6 Months
# of Lesions	Counts	%; Reduction	Counts	%; Reduction
INFLAMMATORY; LESIONS
Baseline Mean	19		19
Sixth Month Mean; NON-INFLAMMATORY LESIONS	10	48%	13	30%	3 (95% CI:-1.2, 5.1)
Baseline Mean	36		35
Sixth-Month Mean; TOTAL LESIONS	22	34%	25	21%	3 (95% CI: -0.2, 7.8)
Baseline Mean	55		54
Sixth Month Mean	31	42%	38	27%	7 (95% CI: 2.0, 11.9)

16 HOW SUPPLIED/STORAGE AND HANDLING

16.1 How Supplied

Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg)

Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) are available in a blister card: (NDC: 17478-260-28).

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

• 21 dark blue unscored round tablets debossed with on one side with “14”; the tablet contains 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 white round unscored tablets (non-hormonal placebo) debossed on one side with “11”; the tablet contains inert ingredients

Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) are packaged in a carton (NDC: 17478-260-06) containing 6 blister cards.

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) are available in a blister card (NDC: 17478-261-28).

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

• 7 light blue unscored round tablets debossed on one side with “12”; the tablet contains 0.18 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 medium blue unscored round tablets debossed on one side with “13”; the tablet contains 0.215 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 dark blue unscored round tablet debossed on one side with “14”; the tablet contains 0.25 mg norgestimate and 0.035 mg ethinyl estradiol
• 7 white unscored round tablets (non-hormonal placebo) debossed on one side with “11”; the tablet contains inert ingredients

Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) are packaged in a carton containing 6 blister cards: (NDC: 17478-261-06).

16.2 Storage Conditions

• Store at 20° to 25°C (68° to77°F); excursions permitted to 15° to 30°C (59° to 86°F).
• 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:

• 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)].
• Norgestimate and Ethinyl Estradiol Tablets USP do not protect against HIV infection (AIDS) and other sexually transmitted infections.
• Norgestimate and Ethinyl Estradiol Tablets USP are not to be used during pregnancy; if pregnancy occurs during use of Norgestimate and Ethinyl Estradiol Tablets USP, instruct the patient to stop further use [see Warnings and Precautions (5.9)].
• 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 Norgestimate and Ethinyl Estradiol Tablets USP [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 (5.8)].

AKORN

Manufactured for: Akorn, Inc., Lake Forest, IL 60045; Product Made in Poland

NG00N Rev. 10/17

PATIENT PACKAGE INSERT

PATIENT INFORMATION

Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg)

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

What is the most important information I should know about Norgestimate and Ethinyl Estradiol Tablets USP?

Do not use Norgestimate and Ethinyl Estradiol Tablets USP 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 are Norgestimate and Ethinyl Estradiol Tablets USP?

Norgestimate and Ethinyl Estradiol Tablets USP are birth control pills (oral contraceptive) used by women to prevent pregnancy.

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) are 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"). Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) should only be used to treat acne in women who want to take birth control pills to prevent pregnancy.

How do Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP.

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 Norgestimate and Ethinyl Estradiol Tablets USP?

Do not take Norgestimate and Ethinyl Estradiol Tablets USP 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 heartbeat 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
• take any Hepatitis C drug combination containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir. This may increase levels of the liver enzyme “alanine aminotransferase” (ALT) in the blood.
• 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 Norgestimate and Ethinyl Estradiol Tablets USP, stop taking Norgestimate and Ethinyl Estradiol Tablets USP right away and talk to your healthcare provider. Use non-hormonal contraception when you stop taking Norgestimate and Ethinyl Estradiol Tablets USP.

What should I tell my healthcare provider before taking Norgestimate and Ethinyl Estradiol Tablets USP?

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. Norgestimate and Ethinyl Estradiol Tablets USP may decrease the amount of breast milk you make. A small amount of the hormones in Norgestimate and Ethinyl Estradiol Tablets USP 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.

Norgestimate and Ethinyl Estradiol Tablets USP may affect the way other medicines work, and other medicines may affect how well Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP?

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

What are the possible serious side effects of Norgestimate and Ethinyl Estradiol Tablets USP?

• Like pregnancy, Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP.
• 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 if 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 Norgestimate and Ethinyl Estradiol Tablets USP. Use sunscreen if you have to be in the sunlight.

What are the most common side effects of Norgestimate and Ethinyl Estradiol Tablets USP?

• 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 Norgestimate and Ethinyl Estradiol Tablets USP. 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 Norgestimate and Ethinyl Estradiol Tablets USP?

• If you are scheduled for any lab tests, tell your healthcare provider you are taking Norgestimate and Ethinyl Estradiol Tablets USP. Certain blood tests may be affected by Norgestimate and Ethinyl Estradiol Tablets USP.
• Norgestimate and Ethinyl Estradiol Tablets USP do not protect against HIV infection (AIDS) and other sexually transmitted infections.

How should I store Norgestimate and Ethinyl Estradiol Tablets USP?

• Store Norgestimate and Ethinyl Estradiol Tablets USP at room temperature between 68°F to 77°F (20°C to 25°C).
• Keep Norgestimate and Ethinyl Estradiol Tablets USP and all medicines out of the reach of children.
• Store away from light.

General information about the safe and effective use of Norgestimate and Ethinyl Estradiol Tablets USP.

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

This Patient Information summarizes the most important information about Norgestimate and Ethinyl Estradiol Tablets USP. You can ask your pharmacist or healthcare provider for information about Norgestimate and Ethinyl Estradiol Tablets USP that is written for health professionals.

For more information, call 1-800-932-5676.

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 Norgestimate and Ethinyl Estradiol Tablets USP?

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 Norgestimate and Ethinyl Estradiol Tablets USP, 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 Norgestimate and Ethinyl Estradiol Tablets USP?

Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg):

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

Inactive ingredients:

Dark blue pills: colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.

White pills: lactose, magnesium stearate, microcrystalline cellulose and pregelatinized corn starch.

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg):

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

Inactive ingredients:

Light blue pills: colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.

Medium blue pills: colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.

Dark blue pills: colloidal silicon dioxide, FD & C Blue No. 2 Aluminum Lake, lactose, magnesium stearate and pregelatinized corn starch.

White pills: lactose, magnesium stearate, microcrystalline cellulose and pregelatinized corn starch.

INSTRUCTIONS FOR USE

Instructions For Use

Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg)

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

Important Information about taking Norgestimate and Ethinyl Estradiol Tablets USP

• Take 1 pill every day at the same time. Take the pills in the order directed on your pill dispenser.
• 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 Norgestimate and Ethinyl Estradiol Tablets USP, talk to your healthcare provider. When you first start taking Norgestimate and Ethinyl Estradiol Tablets USP, 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 Norgestimate and Ethinyl Estradiol Tablets USP. 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP.
• If you have vomiting or diarrhea within 3-4 hours of taking your pill, take another pill of the same color from your extra pill blister pack. If you do not have an extra pill blister pack, take the next pill in your pill blister pack. Continue taking all your remaining pills in order. Start the first pill of your next pill blister pack the day after finishing your current pill 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 Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP:

• 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 pill dispenser.
• Have backup contraception (condoms and spermicide) available and, if possible, an extra full pack of pills as needed.

When should I start taking Norgestimate and Ethinyl Estradiol Tablets USP?

If you start taking Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP. You do not need back-up contraception if you use the Day 1 Start.

If you start taking Norgestimate and Ethinyl Estradiol Tablets USP and you are switching from another birth control pill:

• Start your new Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP and previously used a vaginal ring or transdermal patch:

• Start using Norgestimate and Ethinyl Estradiol Tablets USP on the day you would have reapplied the next ring or patch.

If you start taking Norgestimate and Ethinyl Estradiol Tablets USP and you are switching from a progestin-only method such as an implant or injection:

• Start taking Norgestimate and Ethinyl Estradiol Tablets USP on the day of removal of your implant or on the day when you would have had your next injection.

If you start taking Norgestimate and Ethinyl Estradiol Tablets USP and you are switching from an intrauterine device or system (IUD or IUS):

• Start taking Norgestimate and Ethinyl Estradiol Tablets USP 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 Norgestimate and Ethinyl Estradiol Tablets USP.

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 Norgestimate and Ethinyl Estradiol Tablets USP?" 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 Norgestimate and Ethinyl Estradiol Tablets USP.

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.

Norgestimate and Ethinyl Estradiol Tablets USP come in a blister pack. Read the instructions below for using the blister pack.

Instructions for using your blister pack:

Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg)

• Each blister pack has 28 pills.
  • Norgestimate and Ethinyl Estradiol Tablets USP (0.25 mg/0.035 mg)
    • 21 dark blue pills with hormones, for Days 1 to 21.
    • 7 white pills (without hormones), for Days 22 to 28.

Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)

• Norgestimate and Ethinyl Estradiol Tablets USP (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg)
  • 7 light blue pills with hormones, for Days 1 to 7
  • 7 medium blue pills with hormones, for Days 8 to 14
  • 7 dark blue pills with hormones, for Days 15 to 21
  • 7 white pills (without hormones), for Days 22 to 28.

Step 1. SET THE DAY TO START YOUR BLISTER PACK

Sunday Start:

• Norgestimate and Ethinyl Estradiol Tablets USP, (0.25 mg/0.035 mg) - the first dark blue “active” tablet should be taken on the first Sunday after the patient's menstrual period begins. If your period begins on Sunday, start the pack that same day.
• Norgestimate and Ethinyl Estradiol Tablets USP, (0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg) - the first light blue “active” tablet should be taken on the first Sunday after the patient's menstrual period begins. If your period begins on Sunday, start the pack that same day.

Day 1 Start:

• Pick the day label strip that starts with the first day of your period (this is the day you start bleeding or spotting, even it is almost midnight when the bleeding begins).
• Place this day label strip on the blister pack over the area that has the days of the week (starting with Sunday) printed on the blister. See Figure A.
  

  Figure A

Step 2. You are ready to take pill “1.” You should always begin your pill cycle with pill “1” located in the top row of the blister. See Figure B. Take pills in the direction of the arrows (from left to right) each week.

Figure B

Step 3. Remove pill "1" by pushing down on the pill. The pill will come out through the foil in the back of the blister.

Step 4. Swallow the pill. You will take 1 pill every day, at the same time each day.

Step 5. Wait 24 hours to take your next pill. To take pill "2," push down on the next pill in the blister following the direction of the arrows. Continue to take 1 pill each day until all the pills have been taken.

Step 6. Take your pill at the same time every day. It is important to take the correct pill each day and not miss any pills.

To help you remember, take your pill at the same time as another daily activity, like turning off your alarm clock or brushing your teeth.

Step 7. Start a new blister pack. You will start a new blister pack on the first day after pill "28."

Step 8. Remember to take your first pill in every blister pack on the same day of the week, no matter when your next period starts.

What should I do if I miss any Norgestimate and Ethinyl Estradiol Tablets USP?

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.

AKORN

Manufactured for:
Akorn, Inc.
Lake Forest, IL 60045

Product made in Poland
NGA0N Rev. 10/17

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

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Kit Carton Label

NDC: 17478-260-06

Norgestimate & Ethinyl

Estradiol Tablets USP

0.25 mg/0.035 mg

21 dark blue tablets containing 0.25 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 white tablets containing inert ingredients

Rx only

Contains: 6 blister cards of 28 tablets each

AKORN

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Carton Label

NDC: 17478-260-28

Norgestimate & Ethinyl

Estradiol Tablets USP

0.25 mg/0.035 mg

21 dark blue tablets containing 0.25 mg Norgestimate and
0.035 mg Ethinyl Estradiol

7 white tablets containing inert ingredients

Rx only

Contains: 1 blister card of 28 tablets

AKORN

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Blister Pack Label

Norgestimate and Ethinyl Estradiol Tablets USP 28 Tablets

0.25 mg/0.035 mg

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Kit Carton Label

NDC: 17478-261-06

Norgestimate & Ethinyl

Estradiol Tablets USP

0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg

7 light blue tablets containing 0.18 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 medium blue tablets containing 0.215 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 dark blue tablets containing 0.25 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 white tablets containing inert ingredients

Rx only

Contains: 6 blister cards of 28 tablets each

AKORN

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Carton Label

NDC: 17478-261-28

Norgestimate & Ethinyl

Estradiol Tablets USP

0.18 mg/0.035 mg, 0.215 mg/0.035 mg and 0.25 mg/0.035 mg

7 light blue tablets containing 0.18 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 medium blue tablets containing 0.215 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 dark blue tablets containing 0.25 mg Norgestimate and 0.035 mg Ethinyl Estradiol

7 white tablets containing inert ingredients

Rx only

Contains: 1 blister card of 28 tablets

AKORN

PRINCIPAL DISPLAY PANEL

Principal Display Panel - Blister Pack Label

Norgestimate and Ethinyl Estradiol Tablets USP 28 Tablets

0.18 mg/0.035 mg, 0.215 mg/0.035 mg, 0.25 mg/0.035 mg

INGREDIENTS AND APPEARANCE

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol kit

Product Information
Product Type	HUMAN PRESCRIPTION DRUG	Item Code (Source)	NDC: 17478-260

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1	NDC: 17478-260-06	6 in 1 CARTON	11/15/2016
1	NDC: 17478-260-28	1 in 1 CARTON
1		1 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Quantity of Parts
Part #	Package Quantity	Total Product Quantity
Part 1	1 BLISTER PACK	21
Part 2	1 BLISTER PACK	7

Part 1 of 2

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol tablet

Product Information
Route of Administration	ORAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
Norgestimate (UNII: C291HFX4DY) (Norgestimate - UNII:C291HFX4DY)	Norgestimate	0.25 mg
Ethinyl Estradiol (UNII: 423D2T571U) (Ethinyl Estradiol - UNII:423D2T571U)	Ethinyl Estradiol	0.035 mg

Inactive Ingredients
Ingredient Name	Strength
Silicon Dioxide (UNII: ETJ7Z6XBU4)
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)

Product Characteristics
Color	blue (blue)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	14
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		21 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200384	11/15/2016

Part 2 of 2

INERT 
inert tablet

Product Information
Route of Administration	ORAL

Inactive Ingredients
Ingredient Name	Strength
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)
Microcrystalline cellulose (UNII: OP1R32D61U)

Product Characteristics
Color	white (white)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	11
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		7 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200384	11/15/2016

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200384	11/15/2016

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol kit

Product Information
Product Type	HUMAN PRESCRIPTION DRUG	Item Code (Source)	NDC: 17478-261

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1	NDC: 17478-261-06	6 in 1 CARTON	11/15/2016
1	NDC: 17478-261-28	1 in 1 CARTON
1		1 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Quantity of Parts
Part #	Package Quantity	Total Product Quantity
Part 1	1 BLISTER PACK	7
Part 2	1 BLISTER PACK	7
Part 3	1 BLISTER PACK	7
Part 4	1 BLISTER PACK	7

Part 1 of 4

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol tablet

Product Information
Route of Administration	ORAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
Norgestimate (UNII: C291HFX4DY) (Norgestimate - UNII:C291HFX4DY)	Norgestimate	0.18 mg
Ethinyl Estradiol (UNII: 423D2T571U) (Ethinyl Estradiol - UNII:423D2T571U)	Ethinyl Estradiol	0.035 mg

Inactive Ingredients
Ingredient Name	Strength
Silicon Dioxide (UNII: ETJ7Z6XBU4)
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)

Product Characteristics
Color	BLUE (light blue)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	12
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		7 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200383	11/15/2016

Part 2 of 4

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol tablet

Product Information
Route of Administration	ORAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
Norgestimate (UNII: C291HFX4DY) (Norgestimate - UNII:C291HFX4DY)	Norgestimate	0.215 mg
Ethinyl Estradiol (UNII: 423D2T571U) (Ethinyl Estradiol - UNII:423D2T571U)	Ethinyl Estradiol	0.035 mg

Inactive Ingredients
Ingredient Name	Strength
Silicon Dioxide (UNII: ETJ7Z6XBU4)
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)

Product Characteristics
Color	BLUE (medium blue)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	13
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		7 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200383	11/15/2016

Part 3 of 4

NORGESTIMATE AND ETHINYL ESTRADIOL 
norgestimate and ethinyl estradiol tablet

Product Information
Route of Administration	ORAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
Norgestimate (UNII: C291HFX4DY) (Norgestimate - UNII:C291HFX4DY)	Norgestimate	0.25 mg
Ethinyl Estradiol (UNII: 423D2T571U) (Ethinyl Estradiol - UNII:423D2T571U)	Ethinyl Estradiol	0.035 mg

Inactive Ingredients
Ingredient Name	Strength
Silicon Dioxide (UNII: ETJ7Z6XBU4)
FD&C BLUE NO. 2 (UNII: L06K8R7DQK)
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)

Product Characteristics
Color	blue (blue)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	14
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		7 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200383	11/15/2016

Part 4 of 4

INERT 
inert tablet

Product Information
Route of Administration	ORAL

Inactive Ingredients
Ingredient Name	Strength
LACTOSE, UNSPECIFIED FORM (UNII: J2B2A4N98G)
Magnesium Stearate (UNII: 70097M6I30)
Starch, Corn (UNII: O8232NY3SJ)
Microcrystalline cellulose (UNII: OP1R32D61U)

Product Characteristics
Color	white (white)	Score	no score
Shape	ROUND (ROUND)	Size	6mm
Flavor		Imprint Code	11
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1		7 in 1 BLISTER PACK; Type 1: Convenience Kit of Co-Package

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200383	11/15/2016

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
ANDA	ANDA200383	11/15/2016

Labeler - Akorn, Inc. (062649876)