Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism of Action Emergency contraceptive pills are not effective if a woman is already pregnant. Next Choice™ is believed to act as an emergency contraceptive principally by preventing ovulation or fertilization (by altering tubal transport of sperm and/or ova). In addition, they may inhibit implantation (by altering the endometrium). It is not effective once the process of implantation has begun. Pharmacokinetics Absorption No specific investigation of the absolute bioavailability of levonorgestrel tablets in humans has been conducted. However, literature indicates that levonorgestrel is rapidly and completely absorbed after oral administration (bioavailability about 100%) and is not subject to first pass metabolism. After a single dose of levonorgestrel tablets (0.75 mg) administered to 16 women under fasting conditions, the mean maximum serum concentration of levonorgestrel was 14.1 ng/mL at an average of 1.6 hours. See Table 2. Table 2: Pharmacokinetic Parameter Values Following Single Dose Administration of Levonorgestrel Tablets 0.75 mg to Healthy Female Volunteers under Fasting Conditions Mean (± SD) Cmax (ng/mL) Tmax (h)* CL (L/h) Vd (L) t½ (n) AUCinf (ng·hr/mL) Levonorgestrel 14.1 (7.7) 1.6 (0.7) 7.7 (2.7) 260.0 24.4 (5.3) 123.1 (50.1) Cmax = maximum concentration Tmax = time to maximum concentration CL = clearance Vd = volume of distribution t½ = elimination half life AUCinf= area under the drug concentration curve from time 0 to infinity Effect of Food: The effect of food on the rate and the extent of levonorgestrel absorption following single oral administration of levonorgestrel has not been evaluated. Distribution The apparent volume of distribution of levonorgestrel is reported to be approximately 1.8 L/kg. It is about 97.5 to 99% protein-bound, principally to sex hormone binding globulin (SHBG) and, to a lesser extent, serum albumin. Metabolism Following absorption, levonorgestrel is conjugated at the 17β-0H position to form sulfate conjugates and, to a lesser extent, glucuronide conjugates in plasma. Significant amounts of conjugated and unconjugated 3α, 5β-tetrahydro levonorgestrel are also present in plasma, along with much smaller amounts of 3α, 5α-tetrahydro levonorgestrel and 16β hydroxy levonorgestrel. Levonorgestrel and its phase I metabolites are excreted primarily as glucuronide conjugates. Metabolic clearance rates may differ among individuals by several-fold, and this may account in part for the wide variation observed in levonorgestrel concentrations among users. Excretion About 45% of levonorgestrel and its metabolites are excreted in the urine and about 32% are excreted in feces, mostly as glucuronide conjugates. Specific Populations Pediatric: This product is not intended for use in the premenarcheal population, and pharmacokinetic data are not available for this population. Geriatric: This product is not intended for use in postmenopausal women and pharmacokinetic data are not available for this population. Race: No formal studies have evaluated the effect of race on pharmacokinetics of levonorgestrel tablets. However, clinical trials demonstrated a higher pregnancy rate in Chinese women with both levonorgestrel tablets and the Yuzpe regimen (another form of emergency contraception). The reason for this apparent increase in the pregnancy rate with emergency contraceptives in Chinese women is unknown [see Use In Specific Populations]. Hepatic Impairment: No formal studies were conducted to evaluate the effect of hepatic disease on the disposition of levonorgestrel tablets. Renal Impairment: No formal studies were conducted to evaluate the effect of renal disease on the disposition of levonorgestrel tablets. Drug-Drug Interactions No formal drug-drug interaction studies were conducted with levonorgestrel tablets [see DRUG INTERACTIONS]. Clinical Studies A double-blind, randomized, multinational controlled clinical trial in 1,955 evaluable women (mean age 27) compared the efficacy and safety of levonorgestrel tablets (one 0.75 mg tablet of levonorgestrel taken within 72 hours of unprotected intercourse, and one tablet taken 12 hours later) to the Yuzpe regimen (two tablets each containing 0.25 mg levonorgestrel and 0.05 mg ethinyl estradiol, taken within 72 hours of intercourse, and two additional tablets taken 12 hours later). After a single act of intercourse occurring anytime during the menstrual cycle, the expected pregnancy rate of 8% (with no contraceptive use) was reduced to approximately 1% with levonorgestrel tablets. Emergency contraceptives are not as effective as routine hormonal contraception since their failure rate, while low based on a single use, would accumulate over time with repeated use [see INDICATIONS]. At the time of expected menses, approximately 74% of women using levonorgestrel tablets had vaginal bleeding similar to their normal menses, 14% bled more than usual, and 12% bled less than usual. The majority of women (87%) had their next menstrual period at the expected time or within + 7 days, while 13% had a delay of more than 7 days beyond the anticipated onset of menses.

Next Choice™ (levonorgestrel) Tablets, 0.75 mg, for oral use DESCRIPTION Each Next Choice™ tablet contains 0.75 mg of a single active steroid ingredient, levonorgestrel [18,19-Dinorpregn-4-en-20-yn-3-one-13-ethyl-17-hydroxy-, (17α)-(-)-], a totally synthetic progestogen. The inactive ingredients present are colloidal silicon dioxide, corn starch, FD&C Yellow #6, magnesium stearate, povidone, and lactose monohydrate. Levonorgestrel has a molecular weight of 312.45, and the following structural and molecular formulas:

INDICATIONS Next Choice™ is a progestin-only emergency contraceptive indicated for prevention of pregnancy following unprotected intercourse or a known or suspected contraceptive failure. To obtain optimal efficacy, the first tablet should be taken as soon as possible within 72 hours of intercourse. The second tablet should be taken 12 hours later. Next Choice™ is available only by prescription for women younger than age 17 years, and available over the counter for women 17 years and older. Next Choice™ is not indicated for routine use as a contraceptive. DOSAGE AND ADMINISTRATION Take one levonorgestrel tablet orally as soon as possible within 72 hours after unprotected intercourse or a known or suspected contraceptive failure. Efficacy is better if the tablet is taken as soon as possible after unprotected intercourse. The second tablet should be taken 12 hours after the first dose. Next Choice™ can be used at any time during the menstrual cycle. If vomiting occurs within two hours of taking either dose of medication, consideration should be given to repeating the dose. HOW SUPPLIED Dosage Forms and Strengths Each Next Choice™ tablet is supplied as a peach, round, bevel edged, flat faced tablet containing 0.75 mg of levonorgestrel and is embossed with "475" on one side and "WATSON" on the other side. Next Choice™ (levonorgestrel) tablets, 0.75 mg, are available for a single course of treatment in PVC/aluminum foil blister packages of two tablets each. Each tablet is peach, round, bevel edged, and flat faced and embossed with "475" on one side and "WATSON" on the other side. Available as: Unit-of-use NDC 52544-275-36 Store Next Choice™ tablets at 20° to 25°C (68° to 77°F) [see USP controlled room temperature]. Manufactured by: Watson Laboratories, Inc. Corona, CA 92880 USA. Distributed by: Watson Pharma, Inc. Corona, CA 92880 USA. Phone: 1-866-9WATSON (1-866-992-8766) www.mynextchoice.com. Issued: August 2009

PATIENT INFORMATION Next Choice™ (Levonorgestrel) Tablets 0.75 mg Emergency Contraceptive Contains FD&C yellow #6 as a color additive. Next Choice™Emergency Contraceptive. Important Information About Next Choice™, Birth Control & Sexually Transmitted Diseases. For additional information intended for healthcare professionals, please see enclosed Product Information for Next Choice™. What is Next Choice™? Next Choice™ is emergency contraception that helps prevent pregnancy after birth control failure or unprotected sex. It is a backup method of preventing pregnancy and is not to be used routinely. Next Choice™ can reduce your chance of pregnancy after unprotected sex (if your regular birth control was used incorrectly or fails, or if you have had sex without birth control). For example, if you were using a condom and it broke or slipped, if you did not use your regular birth control as you should have, or if you did not use any birth control, Next Choice™ may work for you. What Next Choice™ is not. Next Choice™ will not work if you are already pregnant and will not affect an existing pregnancy. Next Choice™should not be used as regular birth control. It is important to have another reliable source of birth control that is right for you. Next Choice™ will not protect you from HIV infection (the virus that causes AIDS) and other sexually transmitted diseases. When is the appropriate time to use Next Choice™? You can use Next Choice™ after you have had unprotected sex in the last 72 hours (3 days), and you do not want to become pregnant. Next Choice™ can be used as a backup or emergency method to regular birth control if, for example, Your regular birth control method was used incorrectly or failed (your partner's condom broke or slipped) You made a mistake with your regular method You did not use any birth control method When is it not appropriate to use Next Choice™? Next Choice™ should not be used as a regular birth control method. It does not work as well as most other forms of birth control when they are used consistently and correctly. Next Choice™ is a backup or emergency method of contraception. Next Choice™ should not be used if you are already pregnant because it will not work. Next Choice™ should not be used if you are allergic to levonorgestrel or any other ingredients in Next Choice™. Next Choice™ does not protect against HIV (the virus that causes AIDS) or other sexually transmitted diseases (STDs). The best ways to protect yourself against getting HIV or other STDs are to use a latex condom correctly with every sexual act or not to have sex at all. How does Next Choice™ work? Next Choice™is two pills with levonorgestrel, a hormone that has been used in many birth control pills for over 35 years. Next Choice™ contains a higher dose of levonorgestrel than birth control pills, but works in a similar way to prevent pregnancy. It works mainly by stopping the release of an egg from the ovary. It is possible that Next Choice™ may also work by preventing fertilization of an egg (the uniting of sperm with the egg) or by preventing attachment (implantation) to the uterus (womb). How can I get the best results from Next Choice™? You have only a few days to try to prevent pregnancy after unprotected sex. The sooner you take Next Choice™, the better it will work. Take the first Next Choice™ tablet as soon as possible within 72 hours (3 days) after unprotected sex. Take the second tablet 12 hours later. How effective is Next Choice™? The sooner you take Next Choice™, the better it will work. Take Next Choice™ as soon as possible after unprotected sex. If it is taken as soon as possible within 72 hours (3 days) after unprotected sex, it will significantly decrease the chance that you will get pregnant. Seven out of every 8 women who would have gotten pregnant will not become pregnant. How will I know if Next Choice™ worked? Most women will have their next menstrual period at the expected time or within a week of the expected time. If your menstrual period is delayed beyond 1 week, you may be pregnant. You should get a pregnancy test and follow up with your healthcare professional. What if I am already pregnant and use Next Choice™? There is no medical evidence that Next Choice™ would harm a developing baby. If you take Next Choice™ (accidentally) after you are already pregnant or it does not work and you become pregnant, it is not likely to cause any harm to you or your pregnancy. The pregnancy will continue. Next Choice™ will not work if you are already pregnant. What should I do if my menstrual period is delayed beyond 1 week and I have severe lower stomach (abdominal) pain? If you have severe lower stomach (abdominal) pain about 3 to 5 weeks after taking Next Choice™, you may have a pregnancy outside the uterus, which is called a tubal pregnancy. A tubal pregnancy requires immediate medical treatment, so you should see a healthcare professional right away. Can I use Next Choice™ for regular birth control? No. Next Choice™ should not be used for regular birth control. It is an emergency or backup method to be used if your regular birth control fails or is used incorrectly or if you have sex without birth control. You should protect yourself against STDs and pregnancy every time you have sex. If you have unprotected sex again after taking Next Choice™, it will not help protect you from getting pregnant. How often can I use Next Choice™? Next Choice™ is meant for emergency protection only, and is not designed to be used frequently. If you find that you need to use emergency contraception often, talk to your healthcare professional and learn about methods of birth control and STD prevention that are right for you. Will I experience any side effects from Next Choice™? When used as directed, Next Choice™ is safe for women. Some women will have mild, temporary side effects, such as menstrual changes, nausea, lower stomach (abdominal) pain, tiredness, headache, dizziness, breast pain and vomiting. These are similar to the side effects that some women have when taking regular birth control pills. Some women taking Next Choice™ will have menstrual changes such as spotting or bleeding before their next period. Some women may have a heavier or lighter next period, or a period that is early or late. If your period is more than a week late, you should get a pregnancy test. What warnings should I know about when using Next Choice™? Next Choice™ does not protect against the AIDS virus (HIV) or other sexually transmitted diseases (STDs). Do not use: If you are already pregnant (because it will not work) If you are allergic to levonorgestrel or any of the ingredients in Next Choice™ For regular birth control When using this product, you may have: Menstrual changes Nausea Lower stomach (abdominal) pain Tiredness Headache Dizziness Breast pain Vomiting Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center right away at 1-800-222-1222. What are the directions for using Next Choice™? Women 17 years of age and older: Take the first Next Choice™ tablet as soon as possible within 72 hours (3 days) after unprotected sex. Take the second tablet 12 hours after you take the first tablet. If you vomit within 2 hours of taking either dose of medication, call a healthcare professional to find out if you should repeat that dose. Prescription only for women younger than age 17. If you are younger than 17, see a healthcare professional. What should I do if I have questions about Next Choice™? If you have questions or need more information about this product, call our toll-free number, 1-866-9WATSON (1-866-992-8766), visit our web site at www.mynextChoice™.com, or ask a healthcare professional. Other information This package is sealed for your protection. Do not use if torn or broken. Store at 20° to 25°C (68° to 77°F) [see USP controlled room temperature]. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. Active ingredient: levonorgestrel 0.75 mg in each tablet Inactive ingredients: colloidal silicon dioxide, povidone, magnesium stearate, FD&C yellow #6, corn starch, lactose monohydrate Protect yourself in more ways than one! If you are sexually active, but you are not ready for a pregnancy, it is important to use regular pregnancy protection. There are many types of birth control. Whichever type you choose, it is important to use your regular birth control method as directed. This ensures that you have effective protection against pregnancy every time you have sex. But things do not always go as planned. For example, if you were using a condom and it broke or slipped, or if you did not use your regular birth control as you should have, or if you did not use any birth control, Next Choice™ may work for you. Next Choice™ is an emergency contraceptive that helps prevent pregnancy after unprotected sex or when your birth control fails or is not used correctly. Remember, Next Choice™ is only for emergency pregnancy prevention. There are many other products that work for regular birth control that are available by prescription or over-the-counter. There is also another form of protection to think about when you have sex: protection against sexually transmitted diseases (STDs). Some common STDs are HIV/AIDS, chlamydia, genital herpes, gonorrhea, hepatitis, human papilloma virus (HPV), genital warts, syphilis, and trichomonas. Some of these STDs can be very serious and can lead to infertility (inability to have a baby), problems during pregnancy, chronic illness, and even death. All sexually active women are at risk of catching STDs because they may not know that their partner has an STD (the partner himself may not know). If your partner uses a latex condom correctly each and every time you have sex with him, this will help reduce, but not eliminate, the chance that you will catch an STD. No other birth control methods will effectively protect you from STDs. The female condom may give you some STD protection, but it is not as effective as a male latex condom. For more information on STDs, call the Centers for Disease Control and Prevention (CDC) AIDS/STD Hotline. The CDC phone numbers are 1-800-342-AIDS (2437) for English, 1-800-344-7432 for Spanish, or 1-800-243-7889 for hearing impaired, TDD. Be sure to protect yourself against pregnancy and STDs by using some form of birth control plus a latex condom. Of course, not having sex is the most effective way to prevent pregnancy and stay free of STDs. Next Choice™ is used to prevent pregnancy after unprotected sex. Next Choice™ should not be used for regular birth control, if you are already pregnant (because it will not work), or if you are allergic to levonorgestrel or any of the ingredients in Next Choice™. The sooner you take Next Choice™, the better it will work. Next Choice™ does not protect against the AIDS virus (HIV) or other sexually transmitted diseases (STDs) Common side effects associated with the use of Next Choice™ include menstrual changes, nausea, lower stomach (abdominal) pain, tiredness, headache, dizziness, breast pain and vomiting.

OVERDOSE There are no data on overdosage of levonorgestrel tablets, although the common adverse event of nausea and associated vomiting may be anticipated. CONTRAINDICATIONS Next Choice™ is contraindicated for use in the case of known or suspected pregnancy.

SIDE EFFECTS 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. A double-blind, controlled clinical trial in 1,955 evaluable women compared the efficacy and safety of levonorgestrel tablets (one 0.75 mg tablet of levonorgestrel taken within 72 hours of unprotected intercourse, and one tablet taken 12 hours later) to the Yuzpe regimen (two tablets each containing 0.25 mg levonorgestrel and 0.05 mg ethinyl estradiol, taken within 72 hours of intercourse, and two tablets taken 12 hours later). The most common adverse events ( > 10%) in the clinical trial for women receiving levonorgestrel tablets included menstrual changes (26%), nausea (23%), abdominal pain (18%), fatigue (17%), headache (17%), dizziness (11%), and breast tenderness (11%). Table 1 lists those adverse events that were reported in ≥ 5% of levonorgestrel tablets users. Table 1: Adverse Events in ≥ 5% of Women, by % Frequency Most Common Adverse Events Levonorgestrel N=977 (%) Nausea 23.1 Abdominal Pain 17.6 Fatigue 16.9 Headache 16.8 Heavier Menstrual Bleeding 13.8 Lighter Menstrual Bleeding 12.5 Dizziness 11.2 Breast Tenderness 10.7 Other complaints 9.7 Vomiting 5.6 Diarrhea 5.0 Postmarketing Experience The following adverse reactions have been identified during post-approval use of Next Choice™. 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 Pain, Nausea, Vomiting General Disorders and Administration Site Conditions Fatigue Nervous System Disorders Dizziness, Headache Reproductive System and Breast Disorders Dysmenorrhea, Irregular Menstruation, Oligomenorrhea, Pelvic Pain DRUG INTERACTIONS Drugs or herbal products that induce enzymes, including CYP3A4, that metabolize progestins may decrease the plasma concentrations of progestins, and may decrease the effectiveness of progestin-only pills. Some drugs or herbal products that may decrease the effectiveness of progestin-only pills include: barbiturates bosentan carbamazepine felbamate griseofulvin oxcarbazepine phenytoin rifampin St. John's wort topiramate Significant changes (increase or decrease) in the plasma levels of the progestin have been noted in some cases of coadministration with HIV protease inhibitors or with non-nucleoside reverse transcriptase inhibitors. Consult the labeling of all concurrently used drugs to obtain further information about interactions with progestin-only pills or the potential for enzyme alterations. Drug Abuse And Dependence Levonorgestrel is not a controlled substance. There is no information about dependence associated with the use of Next Choice™.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Ectopic Pregnancy Ectopic pregnancies account for approximately 2% of all reported pregnancies. Up to 10% of pregnancies reported in clinical studies of routine use of progestin-only contraceptives are ectopic. A history of ectopic pregnancy is not a contraindication to use of this emergency contraceptive method. Healthcare providers, however, should consider the possibility of an ectopic pregnancy in women who become pregnant or complain of lower abdominal pain after taking Next Choice™. A follow-up physical or pelvic examination is recommended if there is any doubt concerning the general health or pregnancy status of any woman after taking Next Choice™. Existing Pregnancy Next Choice™ is not effective in terminating an existing pregnancy. Effects on Menses Some women may experience spotting a few days after taking Next Choice™. Menstrual bleeding patterns are often irregular among women using progestin-only oral contraceptives and women using levonorgestrel for postcoital and emergency contraception. If there is a delay in the onset of expected menses beyond 1 week, consider the possibility of pregnancy. STI/HIV Next Choice™ does not protect against HIV infection (AIDS) or other sexually transmitted infections (STIs). Physical Examination and Follow-up A physical examination is not required prior to prescribing Next Choice™. A follow-up physical or pelvic examination is recommended if there is any doubt concerning the general health or pregnancy status of any woman after taking Next Choice™. Fertility Following Discontinuation A rapid return of fertility is likely following treatment with Next Choice™ for emergency contraception; therefore, routine contraception should be continued or initiated as soon as possible following use of Next Choice™ to ensure ongoing prevention of pregnancy. Presence of FD&C Yellow #6 Next Choice™ contains FD&C Yellow #6 as a color additive. Patient Counseling Information Information for Patients Take Next Choice™ as soon as possible and not more than 72 hours after unprotected intercourse or a known or suspected contraceptive failure. If you vomit within two hours of taking either tablet, immediately contact your healthcare provider to discuss whether to take another tablet. Seek medical attention if you experience severe lower abdominal pain 3 to 5 weeks after taking Next Choice™, in order to be evaluated for an ectopic pregnancy. After taking Next Choice™, consider the possibility of pregnancy if your period is delayed more than one week beyond the date you expected your period. Do not use Next Choice™ as routine contraception. Next Choice™ is not effective in terminating an existing pregnancy. Next Choice™ does not protect against HIV-infection (AIDS) and other sexually transmitted diseases/infections. For women younger than age 17 years, Next Choice™ is available only by prescription. Next Choice™ contains FD&C Yellow #6 as a color additive. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity: There is no evidence of increased risk of cancer with short-term use of progestins. There was no increase in tumorgenicity following administration of levonorgestrel to rats for 2 years at approximately 5 µg/day, to dogs for 7 years at up to 0.125 mg/kg/day, or to rhesus monkeys for 10 years at up to 250 µg/kg/day. In another 7 year dog study, administration of levonorgestrel at 0.5 mg/kg/day did increase the number of mammary adenomas in treated dogs compared to controls. There were no malignancies. Genotoxicity: Levonorgestrel was not found to be mutagenic or genotoxic in the Ames Assay, in vitro mammalian culture assays utilizing mouse lymphoma cells and Chinese hamster ovary cells, and in an in vivo micronucleus assay in mice. Fertility: There are no irreversible effects on fertility following cessation of exposures to levonorgestrel or progestins in general. Use In Specific Populations Pregnancy Many studies have found no harmful effects on fetal development associated with long-term use of contraceptive doses of oral progestins. The few studies of infant growth and development that have been conducted with progestin-only pills have not demonstrated significant adverse effects. Nursing Mothers In general, no adverse effects of progestin-only pills have been found on breastfeeding performance or on the health, growth or development of the infant. However, isolated post-marketing cases of decreased milk production have been reported. Small amounts of progestins pass into the breast milk of nursing mothers taking progestin-only pills for long-term contraception, resulting in detectable steroid levels in infant plasma. Pediatric Use Safety and efficacy of progestin-only pills for long-term contraception have been established in women of reproductive age. Safety and efficacy are expected to be the same for postpubertal adolescents less than 17 years and for users 17 years and older. Use of Next Choice™ emergency contraception before menarche is not indicated. Geriatric Use This product is not intended for use in postmenopausal women. Race No formal studies have evaluated the effect of race. However, clinical trials demonstrated a higher pregnancy rate in Chinese women with both levonorgestrel tablets and the Yuzpe regimen (another form of emergency contraception). The reason for this apparent increase in the pregnancy rate with emergency contraceptives in Chinese women is unknown. Hepatic Impairment No formal studies were conducted to evaluate the effect of hepatic disease on the disposition of levonorgestrel tablets. Renal Impairment No formal studies were conducted to evaluate the effect of renal disease on the disposition of levonorgestrel tablets.