Paragard 313.4 Mg Drug Implant

     

Paragard should only be inserted by a healthcare provider trained in Paragard’s insertion procedures, because insertion for Paragard is different from that used for other intrauterine systems. Healthcare providers should become thoroughly familiar with the product, product educational materials, product insertion instructions, and prescribing information before attempting insertion of Paragard.
Insert one Paragard at the fundus of the uterine cavity [see Dosage and Administration ( 2.4 )].
Remove Paragard on or before 10 years from the date of insertion [see Dosage and Administration ( 2.6 )].
May replace Paragard at the time of removal with a new Paragard if continued contraceptive protection is desired.
Before considering use of Paragard, make sure that the female is an appropriate candidate for Paragard. Exclude pregnancy (consider the possibility of ovulation and conception) prior to use [see Contraindications ( 4 ) and Warnings and Precautions ( 5.2 )].

     

Refer to Table 1 for recommended timing of Paragard insertion.

Clinical   Situation	Recommended   Timing   of   Paragard   Insertion
1. Start Paragard in females not currently using contraception	At any time during the menstrual cycle.
2. Switch to Paragard from an oral, transdermal, or vaginal form of hormonal contraception or an injectable progestin contraceptive	At any time during the menstrual cycle; discontinue the previous method.
3. Switch to Paragard from a contraceptive implant or other intrauterine system	Same day the implant or IUS is removed (insert at any time during the menstrual cycle).
4. Insert Paragard after abortion or miscarriage	Immediately after abortion, although immediate placement has a slightly higher risk of expulsion than placement at other times. Insertion after second trimester abortion is associated with a higher risk of expulsion than insertion after a first trimester abortion.
5. Insert Paragard after Childbirth	May insert immediately postpartum. Insertion before uterine involution is complete, which may not occur until the second postpartum month, has been associated with increased risk of expulsion [see Warnings and Precautions ( 5.6 , 5.7 )]. There appears to be an increased risk of perforation in lactating women [see   Warnings   and   Precautions   ( 5.6 )].

Note: The inserter provided with Paragard (see Figure 1) and the Insertion Procedure described in subsection 2.4 are not applicable for immediate insertion after childbirth. For immediate insertion post childbirth, remove the inserter and Paragard from the tray, move the button forward and then completely back to release the Paragard unit from the inserter and insert Paragard.

     

Read the Preparation Instructions and Insertion Procedure before initiating Paragard insertion .  

Before insertion: 

Do NOT remove the inserter from the tray before the arms are loaded into the insertion tube. The tray will be used to fold the Paragard arms down and load the IUS into the inserter.
Use strict aseptic techniques throughout preparation [see Warnings and Precautions (5.4)].
Prepare placement tools (e.g., speculum, cotton swab, tenaculum, uterine sound, scissors, and forceps).
Consider use of an analgesic.
Establish the size and position of the uterus by performing a bi-manual examination.
Insert a speculum and, using a cotton swab, cleanse the cervix and vagina with an antiseptic solution.
Apply a tenaculum to the cervix and use gentle traction to align the cervical canal with the uterine cavity.
Gently insert a sterile uterine sound to measure the depth of the uterine cavity. The uterus should sound to a depth of 6 to 9 cm except when inserting Paragard immediately postabortion or immediately postpartum. Insertion of Paragard may be associated with pain and/or bleeding, vasovagal reactions (e.g. syncope, bradycardia), or seizure, especially in patients with a predisposition to these conditions.
Insertion into a uterine cavity measuring less than 6 cm may increase the incidence of expulsion, bleeding, pain, and perforation.
If cervical stenosis is encountered, avoid undue force. Dilators and analgesia/local anesthesia may be helpful in this situation.

     

Follow the i nsertion i nstructions exactly as described to ensure proper placement and avoid early release of Paragard from the inserter.

Use strict aseptic techniques throughout the insertion procedure [see Warnings and Precautions ( 5.4 )].

Step 1: Opening the Sterile Paragard Package

Place the package containing Paragard (face-up) on a flat sterile field (see Figure 1). Open the pouch from the handle end where the arrow on the Placement Guide says “OPEN”.

Figure 1: Inserter

Figure 2 : Paragard Intrauterine System (IUS)

Remove the clear cover from the tray (not shown).
Confirm that the top of the button is located at the starting line on the handle prior to loading Paragard.
The inserter should remain in the tray until Paragard T-Arms are loaded.

Do not slide the button on the handle before folding the arms in the tray.

Do not repeatedly slide the button forward and back as this may cause slack in the threads and may result in a n   uns uccessful placement .

Step 2:  Loading Paragard into the Inserter

Using sterile gloves, place one hand on the distal end of the tray and the other on the inserter handle. Slide the handle completely forward so that the Paragard advances into the Loading Tip folding the T-Arms of Paragard against the stem (see Figure 3).

            Figure 3 : Folding Tips of T-Arms of Paragard using Loading Tip

Once the T-Arms are folded against the stem, slide the button on the handle completely forward to advance the insertion tube over the tips of the T-Arms (see Figure 4). Only the tips of the T-Arms should be in the insertion tube. Do not advance beyond the copper collars.

IMPORTANT:   Do   not   leave   the   T-Arms   of   Paragard   bent   for   more   than   5   minutes, as the arms may not open properly .

        Figure   4 :   Inserting   Tips   of   T-Arms   into   Insertion   Tube

Step 3:  Adjusting the Flange

Once the above steps are completed and Paragard is in the insertion tube, adjust the blue flange. The tray is marked with centimeters and can be used to set the flange to the correct depth (see Figure 5).
Adjust the flange so the distance from the top of Paragard (where it protrudes from the inserter) to the top of the flange is equal to the pre-measured uterine depth.

     

      Figure   5 :   Adjusting   the   Blue   Flange   to   sound   depth

     

Step 4:  Removing Inserter from Tray

Ensure the button remains in the forward position.
To remove the inserter from the tray, gently lift the handle out of the tray, then gently slide the inserter back and lift out of the tray. (see Figure 6).
Upon removal from the tray, verify and rotate the blue flange as needed so that the horizontal arms of Paragard and the long axis of the blue flange and handle lie in the same horizontal plane to ensure the arms open in the proper direction.
Confirm that both T-Arms are captured within the insertion tube.

     

      Figure   6 :   Removal   of   Inserter   from   Tray

     

     

     

Step 5:  Inserting Paragard to the Fundus

To orient the uterus in an axial position, apply gentle traction to the tenaculum. While holding the button forward, pass the loaded inserter through the cervical canal until the Paragard reaches the fundus of the uterus. This will ensure placement of Paragard at the highest possible position within the uterus.
The blue flange should be at the cervix in the horizontal plane. The button should remain in the forward position (see Figure 7).

         Figure   7 :   Inserter   with   Paragard   at   Uter ine     Fundus

Step 6:  Releasing Paragard and Withdrawing Inserter

Release the arms of Paragard by holding the handle steady and sliding the button all the way down (and you may feel a click). Do not stop at the starting line as it is not used for deployment.
This releases the threads and the T-Arms of Paragard high in the uterine fundus (see Figure 8).

      Figure   8 :   Release   T-Arms   of   Paragard   at   Uter ine Fundus

Gently and slowly withdraw the inserter from the uterus and cervical canal.
Only the threads should be visibly protruding from the cervix (see Figure 9). Trim the threads so that 3 to 4 cm protrude into the vagina.
Measure and note the length of threads, date of placement and Paragard lot number.
Discard the used inserter – do not attempt to re-use the inserter because it is a single use device.
If you suspect that Paragard is not in the correct position, check placement (with ultrasound, if necessary). If Paragard is not positioned completely within the uterus, remove it and replace it with a new Paragard. Do not reinsert an expelled or partially expelled Paragard.

Figure   9 :   Appropriate   Paragard   Placement   in   Uterus

     

Following placement:

Examine the female after her first menses to confirm that Paragard is still in place. You should be able to visualize or feel only the threads. The length of the visible threads may change with time. However, no action is needed unless you suspect partial expulsion, perforation, pregnancy, or breakage.
If you cannot find the threads in the vagina, check that Paragard is still in the uterus. The threads can retract into the uterus or break, or Paragard can break, perforate the uterus, or be expelled. Gentle probing of the cavity, x-ray, or sonography may be required to locate Paragard.
Remove Paragard if it has been partially expelled or perforated the uterus [see Warnings and Precautions ( 5.6 , 5.7 )].

Do   not   reinsert   a   used Paragard.

     

Timing   of Removal

Paragard can be removed at any time prior to 10 years after insertion.
Remove Paragard no later than 10 years after insertion. A new Paragard can be inserted at the time of removal if continued contraceptive protection is desired.

Removal   Instructions

Use a speculum and visualize the cervix.
Remove Paragard with forceps, pulling gently on the exposed threads. The arms of Paragard will fold upwards as it is withdrawn from the uterus.
If removal cannot be accomplished by gentle pulling, consider checking Paragard location and assess for embedment and perforation (with imaging, if necessary).
Breakage or embedment of Paragard in the myometrium can make removal difficult [see Warnings and Precautions, ( 5.5 )]. IUS breakage may be associated with removal. Analgesia, paracervical anesthesia, cervical dilation, alligator forceps or other grasping instrument, or hysteroscopy may assist in removing an embedded Paragard. 
Make sure Paragard is intact upon removal.
Removal may be associated with some pain and/or bleeding, vasovagal reactions (e.g. syncope, bradycardia), or seizure, especially in patients with a predisposition to these conditions.

     

Evaluate for possible ectopic pregnancy in any female who becomes pregnant while using Paragard because a pregnancy that occurs with Paragard in place is more likely to be ectopic than a pregnancy in the general population. However, because Paragard prevents most pregnancies, females who use Paragard have a lower risk of an ectopic pregnancy than sexually active females who do not use any contraception.

The incidence of ectopic pregnancy in the clinical trials with Paragard (which excluded females with a previous history of ectopic pregnancy) was approximately 0.06%. Ectopic pregnancy may require surgery and may result in loss of fertility.

     

If intrauterine pregnancy occurs with Paragard in place and the strings are visible or can be retrieved from the cervical canal, remove Paragard because leaving it in place may increase the risk of spontaneous abortion and preterm labor. Removal of Paragard may also result in spontaneous abortion. In the event of an intrauterine pregnancy with Paragard, consider the following:

Septic Abortion

In females becoming pregnant with an intrauterine system (IUS), including Paragard in place, septic abortion, with septicemia, septic shock, and death, may occur [see   Warnings   and   Precautions   ( 5.3 )]. Septic abortion typically requires hospitalization and treatment with intravenous antibiotics. Septic abortion may result in spontaneous abortion or a medical indication for pregnancy termination. A hysterectomy may be required if severe infection of the uterus occurs, which will result in permanent infertility.

Continuation   of Pregnancy

If a female becomes pregnant with Paragard in place and if Paragard cannot be removed or the female chooses not to have it removed, warn her that failure to remove Paragard increases the risk of miscarriage, sepsis, premature labor, and premature delivery. Prenatal care should include counseling about these risks and that she should report immediately any flu-like symptoms, fever, chills, cramping, pain, bleeding, vaginal discharge or leakage of fluid, or any other symptom that suggests complications of the pregnancy.

     

Severe infection or sepsis, including Group A streptococcal sepsis (GAS), have been reported following insertion of IUSs, including Paragard. In some cases, severe pain occurred within hours of insertion followed by sepsis within days. Because death from GAS is more likely if treatment is delayed, it is important to be aware of these rare but serious infections. Aseptic technique during insertion of Paragard is essential in order to minimize serious infections such as GAS [see Dosage and   Administration ( 2.3 )].

     

Insertion of Paragard is contraindicated in the presence of known or suspected Pelvic Inflammatory Disease (PID) or endometritis [see Contraindications ( 4 )]. IUSs, including Paragard, have been associated with an increased risk of PID, most likely due to organisms being introduced into the uterus during insertion. In the clinical trials with Paragard, the incidence of PID that resulted in the removal of Paragard was approximately 0.1% [see Clinical Studies ( 14 )].

Counsel women who receive Paragard to notify a healthcare provider if they have complaints of lower abdominal or pelvic pain, odorous discharge, unexplained bleeding, fever, or genital lesions or sores. In such circumstances, perform a pelvic examination promptly to evaluate for possible pelvic infection.

Remove Paragard in cases of recurrent PID or endometritis, or if an acute pelvic infection is severe or does not respond to treatment.

PID can have serious consequences, such as tubal damage (leading to ectopic pregnancy or infertility), hysterectomy, sepsis, and death.

Females   at   Increased   Risk   for   PID

PID or endometritis are often associated with a sexually transmitted infection (STI) and Paragard does not protect against STIs. The risk of PID or endometritis is greater for females who have multiple sexual partners, and also for females whose sexual partner(s) have multiple sexual partners. Females who have had PID or endometritis are at increased risk for a recurrence or re-infection. In particular, ascertain whether a female is at increased risk of infection (for example, leukemia, acquired immune deficiency syndrome (AIDS), intravenous drug abuse).

Asymptomatic   PID

PID or endometritis may be asymptomatic but still result in tubal damage and its sequelae.

Treatment of PID or Endometritis in Patients Using Paragard

Remove Paragard in cases of recurrent endometritis or PID, or if an acute pelvic infection is severe or does not respond to treatment. Prophylactic antibiotics administered at the time of insertion do not appear to lower the incidence of PID.

Promptly assess and treat any female who develops signs or symptoms of PID. Perform appropriate testing for sexually transmitted infection and initiate antibiotic therapy promptly. Paragard does not need to be removed immediately. Reassess the patient in 48-72 hours. If no clinical improvement occurs, continue antibiotics and consider removal of Paragard. If the decision is to remove Paragard, start antibiotics prior to removal to avoid the potential risk for bacterial spread resulting from the removal procedure.

Actinomycosis

Actinomycosis has been associated with IUS use, including Paragard. Symptomatic women with known actinomycosis infection should have Paragard removed and receive antibiotics. Actinomycetes can be found in the genital tract cultures in healthy women without IUSs. The significance of actinomyces-like organisms on a Papanicolaou (PAP) smear in an asymptomatic IUS user is unknown, and this finding alone does not always require IUS removal and treatment. When possible, confirm a PAP smear diagnosis with cultures.

     

Partial penetration or embedment of Paragard in the myometrium can make removal difficult. In some cases, surgical removal may be necessary. Breakage of an embedded Paragard during non-surgical removal has been reported [see Dosage and Administration ( 2.6 )].

     

Partial or total perforation of the uterine wall or cervix may occur during insertions, although the perforation may not be detected until sometime later. Perforation may reduce contraceptive efficacy and result in pregnancy. The incidence of perforation during or following Paragard insertion in clinical trials was 0.2% (13 out of 5344).

Delayed detection or removal of Paragard in cases of perforation may result in migration outside the uterine cavity, adhesions, peritonitis, intestinal penetration, intestinal obstruction, abscesses and/or damage to adjacent organs.

A postmarketing safety study conducted in Europe (EURAS IUD) with IUSs, including copper IUSs, demonstrated an increased risk of perforation in lactating women. The risk of perforation may be increased if an IUS, such as Paragard, is inserted when the uterus is fixed, retroverted or not completely involuted during the postpartum period.

If perforation does occur, locate and remove Paragard promptly. Surgery may be required. Preoperative imaging followed by laparoscopy or laparotomy is often required to remove Paragard from the peritoneal cavity.

     

Partial or complete expulsion of Paragard has been reported, resulting in the loss of contraceptive protection. The incidence of expulsion in the clinical trials with Paragard was approximately 2.3%. Consider further diagnostic imaging, such as x-ray, to confirm expulsion if the IUS is not found in the uterus.

Paragard has been placed immediately after delivery, although the risk of expulsion may be increased when the uterus is not completely involuted at the time of insertion. Remove a partially expelled Paragard.

     

Paragard may exacerbate Wilson’s disease, a rare genetic disease affecting copper excretion; therefore, the use of Paragard is contraindicated in females of reproductive potential with Wilson’s disease [see Contraindications ( 4 )].

     

Paragard can alter the bleeding pattern and result in heavier and longer menstrual cycles with intermenstrual spotting.

In two clinical trials with Paragard, there were reports of oligomenorrhea and amenorrhea; however, a causal relationship between Paragard and these events could not be established. Menstrual changes were the most common medical reason for discontinuation of Paragard. Discontinuation rates for pain and bleeding combined were highest in the first year of use and diminished thereafter. The percentage of females who discontinued Paragard because of bleeding problems or pain during these studies ranged from 12% in the first year to 2% in Year 9. Females complaining of heavy vaginal bleeding should be evaluated and treated, and may need to discontinue Paragard [see Adverse Reactions ( 6.1 )].

     

Non-clinical testing has demonstrated that Paragard is MR Conditional. A patient with Paragard can be safely scanned in an MR system meeting the following conditions:

Static magnetic field of 3.0 T or 1.5T
Maximum spatial field gradient of 4,000 gauss/cm (40 T/m)
Maximum MR system reported, whole body averaged specific absorption rate (SAR) of 2 W/kg (Normal Operating Mode)

Under the scan conditions defined above, Paragard is expected to produce a maximum temperature rise of less than 0.5º C after 15 minutes of continuous scanning.

In non-clinical testing, the image artifact caused by the system extended less than 5 mm from the implant when imaged with a gradient echo pulse sequence and a 3.0 T MRI system.

     

Medical equipment that contain high levels of Radiofrequency (RF) energy such as diathermy may cause health effects (by heating tissue) in females with a metal-containing IUD including Paragard. Avoid using high medical RF transmitter devices in females with Paragard.

     

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

The data described below reflect exposure in two trials [see   Clinical   Studies ( 14 )].

The WHO Study 79914 was a randomized, multicenter, multinational study of copper T IUSs, including Paragard in 1,396 women outside the U.S. In the WHO Study, 100% were parous and the mean age at enrollment was 29 years old.
The U.S. Composite Study was a meta-analysis that evaluated randomized, double-blind, comparative studies of copper T IUSs, including Paragard in 3,536 women in the U.S. In the U.S. Composite Study, 64% were nulliparous, 49% were nulligravida, 68% were under age 25 at the time of enrollment (median age 23 years old).

Table 2 shows discontinuation rates from the two clinical studies by adverse reaction and year.

	Year
	1	2	3	4	5	6	7	8	9	10
Number of Women   at   Start of Year	4,932	3,149	2,018	1,121	872	621	563	483	423	325
Expulsion	5.7	2.5	1.6	1.2	0.3	0.0	0.6	1.7	0.2	0.4
Bleeding/Pain	11.9	9.8	7.0	3.5	3.7	2.7	3.0	2.5	2.2	3.7
Other   Medical Event	2.5	2.1	1.6	1.7	0.1	0.3	1.0	0.4	0.7	0.3

*Rates were calculated by weighting the annual rates by the number of subjects starting each year for each of the U.S. Composite Study (3536 subjects) and the World Health Organization (1396 subjects) trials.

The following adverse reactions have also been observed: anemia, backache, dysmenorrhea, dyspareunia, complete or partial expulsion, prolonged menstrual flow, menstrual spotting, pain and cramping, and vaginitis.

Study CSIPD-001

The Paragard inserter that enables single-hand insertion was evaluated in Study CSIPD-001. A total of 117 females of reproductive potential aged 18 to 49 years, underwent Paragard insertion and were followed for up to 12 weeks of Paragard use. Subjects were predominantly white (76%), 45% were parous, and 35% were obese. Successful placement of Paragard with first attempt occurred in 91% of the subjects and 99% with two insertion attempts. Adverse reactions of special interest occurring during the study were IUS expulsion (2.6%), vasovagal reaction (2.6%), IUS malposition (1.7%), partial uterine perforation (0.9%), and IUS embedment (0.9%).

     

The following adverse reactions have been identified during post-approval use of Paragard. 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.

Gastrointestinal   Disorders:  abdominal distension, nausea

General   Disorders   and   Administration   Site   Conditions:  device breakage, pyrexia; copper wire breakage

Immune System Disorders: allergy to metals, hypersensitivity

Infections and Infestations: endometritis/uterine infection

Musculoskeletal   and   Connective   Tissue   Disorders:  muscle spasms

Nervous System Disorders: dizziness

Reproductive   System   and   Breast   Disorders:  amenorrhea

Skin   and   Subcutaneous   Tissue   Disorders:  Stevens-Johnson syndrome

     

Risk   Summary

Use of Paragard is contraindicated for use in pregnant females because there is no need for pregnancy prevention in a female who is already pregnant and Paragard may cause adverse pregnancy outcomes. If a female becomes pregnant with Paragard in place, there is an increased risk of miscarriage, sepsis, premature labor, and premature delivery [see Contraindications ( 4 )  and Warnings and Precautions ( 5.1 , 5.2 ) ]. Advise the female of the potential risks if pregnancy occurs with Paragard in place.

Published studies on pregnancy outcomes exposed to copper IUSs report up to 27% miscarriage when the IUS was removed compared to 77% miscarriage when the IUS remained in the uterus. Studies on Paragard and birth defects have not been conducted.

     

Risk   Summary

No difference has been detected in concentration of copper in human milk before and after insertion of copper IUSs, including Paragard. There is no information on the effect of copper in a breastfed child or the effect on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Paragard and any potential adverse effects on the breastfed child from Paragard.

     

The safety and effectiveness of Paragard have been established in females of reproductive potential. Efficacy is expected to be the same for postmenarcheal females regardless of age.

Paragard is not indicated in females before menarche.

     

Paragard has not been studied in women over 65 years of age and is not indicated in this population.

     

Paragard (intrauterine copper contraceptive) is a T-shaped intrauterine system (IUS), measuring 32 mm horizontally and 36 mm vertically, with a 3 mm diameter bulb at the tip of the vertical stem. (See Figure 10) [see Dosage and Administration (2.3)]. A monofilament polyethylene thread is tied through the tip, resulting in two white threads, each approximately 36.5 cm in length, to aid in detection and removal of the intrauterine system. The T-frame is made of polyethylene with barium sulfate to aid in detecting the intrauterine system under x-ray. Paragard also contains copper (approximately 176 mg of wire wrapped around the vertical stem and an approximately 68.7 mg collar placed on each side of the horizontal arm). The total exposed copper surface area is 380 ± 23 mm². One Paragard weighs less than one (1) gram.

Figure 10 – Paragard IUS

Paragard, its components, and the packaging are not made with natural rubber latex.

     

Paragard is packaged with a sterile pre-assembled inserter as a single-use, disposable device in a tray and in a Tyvek^® polyethylene pouch. A moveable blue flange on the insertion tube aids in gauging the depth of insertion through the cervical canal and into the uterine cavity (See Figure 11) [see Dosage and Administration ( 2.3 )].

      Figure 11 –   Paragard with Inserter

     

     

Copper continuously released into the uterine cavity contributes to the contraceptive effectiveness of Paragard. Mechanism(s) by which copper enhances contraceptive efficacy include interference with sperm transport and fertilization of an egg, and possibly prevention of implantation.

     

Adequate long-term studies in animals to assess the carcinogenic potential of a copper-containing IUS have not been performed.

The genotoxic potential of a copper-containing IUS has not been evaluated.