ethinyl estradiol/levonorgestrel transdermal (Rx)

Brand and Other Names:Twirla
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

ethinyl estradiol/levonorgestrel

transdermal patch

  • (30mcg/120mcg)/day

Contraception

Indicated for contraception in females of reproductive potential with a BMI <30 kg/m2 for whom a combined hormonal contraceptive is appropriate

28-day (4-week) cycle

  • 1 new transdermal system (TDS) is applied and worn for 7 days for 3 consecutive weeks (Weeks 1, 2, and 3); no TDS is worn during Week 4 when withdrawal bleeding is expected
  • Every new TDS should be applied on the same day of the week
  • On the day after Week 4 ends, a new 28-day cycle is started by applying a new TDS
  • Under no circumstances should there be >7-day TDS-free interval between dosing cycles
  • If there are >7 TDS-free days, women may not be protected from pregnancy and nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) must be used for 7 days
  • See Administration for how to initiate dosing if no contraception is currently used or if switching from another form of contraception

Dosing Considerations

Before prescribing, consider the drug’s reduced effectiveness in women with a BMI ≥25 to <30 kg/m2

Dosage Forms & Strengths

ethinyl estradiol/levonorgestrel

transdermal patch

  • (30mcg/120mcg)/day

Contraception

Indicated for contraception in females of reproductive potential with a BMI <30 kg/m2 for whom a combined hormonal contraceptive is appropriate

28-day (4-week) cycle

  • 1 new transdermal system (TDS) is applied and worn for 7 days for 3 consecutive weeks (Weeks 1, 2, and 3); no TDS is worn during Week 4 when withdrawal bleeding is expected
  • Every new TDS should be applied on the same day of the week
  • On the day after Week 4 ends, a new 28-day cycle is started by applying a new TDS
  • Under no circumstances should there be >7-day TDS-free interval between dosing cycles
  • If there are >7 TDS-free days, females may not be protected from pregnancy and nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) must be used for 7 days
  • See Administration for how to initiate dosing if no contraception is currently used or if switching from another form of contraception

Dosing Considerations

Efficacy is expected to be the same in postmenarcheal females regardless of age

Before prescribing, consider the drug’s reduced effectiveness in women with a BMI ≥25 to <30 kg/m2

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Interactions

Interaction Checker

and ethinyl estradiol/levonorgestrel transdermal

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            Adverse Effects

            1-10%

            Application site disorder (6.2%)

            Nausea (4.1%)

            Headache (3.6%)

            Dysmenorrhea (2.3%)

            Increased weight (2%)

            <1%

            Cholelithiasis

            Cholecystitis

            Major depression

            Suicidal ideation

            Appendicitis

            Ectopic pregnancy

            Pneumonia

            Gastroenteritis

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            Warnings

            Black Box Warnings

            Cigarette smoking and serious cardiovascular events

            • Cigarette smoking increases risk of serious cardiovascular events from combined hormonal comtraceptive (CHC) use
            • This risk increases with age, particularly in women aged ≥35 yr, and with the number of cigarettes smoked
            • For this reason, CHCs are contraindicated in women aged ≥35 yr of age who smoke

            Contraindicated with BMI 30 kg/m2 or greater

            • Contraindicated in women with BMI ≥30 kg/m2
            • Compared with lower BMI, women with a BMI ≥30 kg/m2 had reduced effectiveness and may have a higher risk for venous thromboembolism events (VTEs)

            Contraindications

            Have headaches with focal neurological symptoms, migraine headaches with aura

            Women aged >35 yr with any migraine headache

            BMI ≥30 kg/m2; reduced effectiveness and may have higher risk for VTEs compared with women with lower BMI

            Liver tumors (benign or malignant), acute viral hepatitis, severe (decompensated) cirrhosis, or liver disease

            Undiagnosed abnormal uterine bleeding

            Pregnancy, given there is no reason to use CHCs during pregnancy

            Breast cancer or other estrogen- or progestin-sensitive cancer, now or in the past

            Hypersensitivity to any components; observed reactions include itching and irritation at application site

            Use of hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, owing to potential for elevated ALT

            High risk for arterial or VTEs

            • Examples include women who
              • Smoke, if over aged ≥35 yr
              • Have current or history of DVT or PE
              • Have cerebrovascular disease
              • Have coronary artery disease
              • Have thrombogenic valvular or thrombogenic rhythm heart diseases (eg, SBE with valvular disease, atrial fibrillation)
              • Have inherited or acquired hypercoagulopathies
              • Have uncontrolled hypertension or hypertension with vascular disease
              • Have diabetes mellitus and are aged ≥35 yr, diabetes mellitus with hypertension, or vascular disease or other end-organ damage, or diabetes mellitus of >20 years' duration

            Cautions

            Contraindicated with benign or malignant liver tumors, acute viral hepatitis, or severe cirrhosis; discontinue if jaundice occurs

            Increased ALT observed in women taking ethinyl estradiol-containing medications with certain hepatitis C drug regimens (ie, ombitasvir/paritaprevir/ritonavir, with or without dasabuvir)

            Contraindicated with uncontrolled hypertension or hypertension with vascular disease; if administered to women with well-controlled hypertension, monitor blood pressure; discontinue immediately if blood pressure increases significantly

            Consider age-related risk factors for CV disease (eg, hypertension, diabetes, dyslipidemia, obesity)

            Increase risk of gall bladder disease among CHC users

            Contraindicated in diabetic women aged ≥35 yr, or women who have diabetes with hypertension, nephropathy, retinopathy, or neuropathy, other vascular disease, or women with diabetes >20 yr duration

            Contraindicated in women who have headaches with focal neurological symptoms or have migraine headaches with aura, and women aged ≥35 yr who have migraine headaches with or without aura

            Carefully observe women with history of depression; discontinue if depression recurs to a serious degree

            Some studies suggest that CHCs are associated with increased risk of cervical cancer or intraepithelial neoplasia; controversial whether these findings are caused by CHCs or sexual behavior and other factors

            Estrogen may raise serum concentrations of thyroxine-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin; dose of replacement thyroid hormone or cortisol therapy may need to be increased

            Exogenous estrogens may induce or exacerbate symptoms of angioedema

            Chloasma may occur, especially in women with a history of chloasma gravidarum; avoid sun exposure or ultraviolet radiation

            Thromboembolic disorders and other vascular conditions

            • Women are at increased risk for VTE when using CHCs
            • VTE risk may be greater with BMI ≥30 kg/m2 compared with lower BMI and CHCs are contraindicated in obese patients
            • Additional information
              • Discontinue if an arterial or VTE occurs
              • Discontinue if unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions occurs; evaluate for retinal vein thrombosis immediately
              • Discontinue during prolonged immobilization and resume treatment based on clinical judgement; if feasible, stop at least 4 weeks before and through 2 weeks after major surgery or other surgeries known to have an elevated risk of thromboembolism
              • Start no earlier than 4 weeks after delivery in women who are not breastfeeding; risk of postpartum thromboembolism decreases after the third postpartum week, whereas the likelihood of ovulation increases after the third postpartum week
              • Before initiating, evaluate any medical history or family history of thromboembolism or thromboembolic disorders; consider whether the history suggests an inherited or acquired hypercoagulopathy
              • Contraindicated in women with high risk of arterial or VTE, including women aged ≥35 yr who smoke

            Bleeding irregularities and amenorrhea

            • Bleeding and spotting
              • Women may experience unscheduled (breakthrough or intracyclic) bleeding and spotting, especially during the first 3 months of use
              • Bleeding irregularities may resolve over time or by changing to a different contraceptive product
              • If bleeding persists or occurs after previously regular cycles, evaluate for causes (eg, pregnancy, malignancy)
            • Amenorrhea and oligomenorrhea
              • Women may experience absence of scheduled (withdrawal) bleeding, even if they are not pregnant
              • If scheduled bleeding does not occur, consider the possibility of pregnancy
              • Evaluate adherence and rule out pregnancy

            Drug interaction overview

            • Drugs that decrease systemic exposure of hormonal contraceptives
              • Enzyme inducers: May decrease plasma concentrations of estrogen and/or progestin component of CHCs
              • Colesevelam: Coadministration significantly decreases systemic exposure of ethinyl estradiol
              • HIV protease inhibitors (eg, nelfinavir, ritonavir, darunavir/ritonavir, fosamprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir) and some non-nucleoside reverse transcriptase inhibitors (eg, nevirapine)
            • Drugs that increase systemic exposure of hormonal contraceptives
              • HIV protease inhibitors (eg, indinavir, atazanavir/ritonavir) and with other non-nucleoside reverse transcriptase inhibitors (eg, etravirine)
              • Atorvastatin or rosuvastatin increase systemic exposure of ethinyl estradiol by ~20-25%
              • Ascorbic acid and acetaminophen may increase systemic exposure of ethinyl estradiol, possibly by inhibition of conjugation
              • CYP3A4 inhibitors (eg, itraconazole, voriconazole, fluconazole, grapefruit juice, ketoconazole) may increase systemic exposure of estrogen and/or progestin
            • CHC effect on other drugs
              • Lamotrigine systemic exposure may be significantly decreased owing to induction of lamotrigine glucuronidation; lamotrigine dose adjustment may be required
              • Thyroid hormone: CHCs may increase systemic exposure of thyroid-binding globulin; thyroid hormone dose may need to be increased
              • Corticosteroids: CHCs may increase systemic exposure of cortisol-binding globulin; corticosteroid dose may need to be increased
              • CHCs may decrease systemic exposure of acetaminophen, morphine, salicylic acid, and temazepam
              • CHCs may increase systemic exposure of cyclosporine, prednisolone, theophylline, tizanidine, and voriconazole
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            Pregnancy & Lactation

            Pregnancy

            Contraindicated

            Discontinue if pregnancy occurs

            Epidemiologic studies and meta-analyses have not found an increased risk of genital or nongenital birth defects (including cardiac anomalies and limb-reduction defects) following exposure to CHCs before conception or during early pregnancy

            Lactation

            Contraceptive hormones and/or metabolites are present in human milk

            CHCs can reduce milk production in breastfeeding women, but this is less likely to occur once breastfeeding is well established

            Advise breastfeeding women to use another method of contraception until breastfeeding discontinued

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Combination hormonal contraceptives lower the risk of becoming pregnant primarily by suppressing ovulation

            Ethinyl estradiol: Reduces LHRH release from hypothalamus and reduces gonadotropin release from pituitary; increases synthesis of DNA, RNA, and various proteins in target tissues; other possible mechanisms include changes in cervical mucus that cause inhibition of sperm penetration and endometrial changes that reduce likelihood of implantation

            Levonorgestrel transdermal: Synthetic progestin; ovulation is inhibited from a negative feedback mechanism on hypothalamus, leading to reduced secretion of FSH and LH

            Absorption

            Concentration at steady-state

            • Cycle 1
              • Average steady-state concentration, levonorgestrel: 842 pg/mL (week 1); 2009 pg/mL (week 3)
              • Average steady-state concentration, ethinyl estradiol: 31.9 pg/mL (week 1); 34.8 pg/mL (week 3)
              • AUC levonorgestrel: 120 ng⋅h/mL (week 1); 339 ng⋅h/mL (week 3)
              • AUC ethinyl estradiol: 5040 pg⋅h/mL (week 1); 6210 pg⋅h/mL (week 3)
            • Cycle 2
              • Average steady-state concentration, levonorgestrel: 1389 pg/mL (week 1); 2209 pg/mL (week 3)
              • Average steady-state concentration, ethinyl estradiol: 38.6 pg/mL (week 1); 40.3 pg/mL (week 3)
              • AUC levonorgestrel: 207 ng⋅h/mL (week 1); 378 ng⋅h/mL (week 3)
              • AUC ethinyl estradiol: 6060 pg⋅h/mL (week 1); 7120 pg⋅h/mL (week 3)

            Distribution

            Protein bound

            • Levonorgestrel: Primarily bound to sex hormone-binding globulin (SHBG)
            • Ethinyl estradiol: 97% bound to plasma albumin; does not bind to SHBG, but induces SHBG synthesis

            Metabolism

            Since it is applied transdermally, first-pass metabolism (via GI tract and/or liver) of levonorgestrel and ethinyl estradiol that would be expected with PO administration does not occur

            Levonorgestrel

            • The most important hepatic metabolic pathways are reduction of the delta-4-3-oxo group and hydroxylation at positions 2-alpha, 1-beta, and 16-beta, followed by conjugation
            • Most circulating metabolites are sulfates of 3-alpha, 5-beta-tetrahydro-levonorgestrel, while excretion is mostly in the form of glucuronides

            Ethinyl estradiol

            • CYP3A4 metabolism in the liver is responsible for 2-hydroxylation that is the major oxidative reaction
            • 2-Hydroxy metabolite is further transformed by methylation and glucuronidation before urinary and fecal excretion

            Elimination

            Half-life

            • Elimination half-life
              • Levonorgestrel: 38.2 hr (cycle 1, week 3); 40.5 hr (cycle 2, week 3)
              • Ethinyl estradiol: 19.7 hr (cycle 1, week 3); 20.5 hr (cycle 2, week 3)
            • Mean terminal half-life
              • Levonorgestrel: 41 hr
              • Ethinyl estradiol: 21 hr

            Excretion

            • Levonorgestrel: 40-68% urine; 16-48% feces
            • Ethinyl estradiol: Excreted in urine and feces and glucuronide and sulfate conjugates; undergoes enterohepatic recirculation
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            Administration

            Transdermal Administration

            Application

            • For transdermal use only
            • To achieve maximum contraceptive effectiveness, transdermal system (TDS) must be used exactly as directed; failure rate may increase when TDS application is delayed/missed or when TDS is applied incorrectly
            • Apply TDS to clean, dry, and intact skin on abdomen, buttock, or upper torso (excluding breasts)
            • When applying a new TDS, do not apply the new TDS directly over the previous TDS site
            • Do not apply to skin that has been exposed to powder, oil, moisturizer, or lotion
            • Advise women not to routinely use large amounts of body lotions or oils at application sites
            • Prolonged exposure to water may interfere with TDS adherence
            • Do not cut or alter TDS in any way; apply whole TDS; if TDS is cut or damaged or altered in size, contraceptive efficacy may be impaired
            • Discard by folding used TDS so that the adhesive side sticks to itself and safely discard in the trash
            • Used TDS still contains some active hormones; should not be flushed down the toilet

            TDS edge lifts up

            • Press down firmly on TDS with the palm of the hand for 10 seconds, making sure that the whole TDS is adhered to skin
            • Then run fingers over the entire surface area to smooth out any wrinkles around the edges of the TDS
            • If lifted edge of TDS does not stick completely after attempted readhesion, remove TDS and replace with new TDS
            • Do not tape or wrap TDS to skin or reapply a TDS that is partially adhered to clothing

            TDS has been off or partially off

            • <1 day
              • Try to reapply TDS; if TDS does not adhere completely, apply new TDS immediately
              • No back-up contraception is needed and the Patch Change Day will stay the same
            • >1 day or unsure of timeframe
              • Woman may not be protected from pregnancy
              • Reduce pregnancy risk by applying new TDS and start a new 4-week cycle
              • The woman will now have a new Patch Change Day and MUST use nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) for the first 7 days of the new cycle

            Starting in women with no current hormonal contraceptive

            • Day 1 start
              • Apply first TDS during the first 24 hr of menstruation
              • Apply a new TDS each week for 3 weeks (21 total days) on the same day each week
              • No TDS is worn during Week 4
              • If a TDS is applied after the first 24 hr of menstruation, use nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) concurrently for first 7 days of first cycle only

            Switching from an oral combination hormonal contraceptive

            • Complete the current pill cycle and apply the first TDS on the day the next pill cycle would normally start
            • If menses does not occur within a week after taking the last active pill, instruct the woman to consult with a healthcare professional to be sure that pregnancy has not occurred
            • If no pregnancy has occurred, TDS may be started for contraception
            • If initiated >1 week after taking the last active pill, use nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) concurrently for first 7 days

            Switching from a transdermal hormonal contraceptive

            • Complete current TDS cycle and apply the first Twirla TDS on the day the next TDS cycle would normally start
            • If menses does not occur within a week after removing the last TDS, consult with a healthcare professional to ensure pregnancy has not occurred
            • If no pregnancy has occurred, Twirla TDS may be started for contraception
            • If Twirla TDS is applied >1 week after removal of the last TDS, use nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) concurrently for first 7 days

            Switching from vaginal ring

            • Complete vaginal ring cycle and apply the first TDS on the day the next vaginal ring would normally start
            • If menses does not occur within a week after removing vaginal ring, consult with a healthcare professional to ensure pregnancy has not occurred
            • If no pregnancy has occurred, TDS may be started for contraception
            • If TDS is applied >1 week after vaginal ring removal, use nonhormonal back-up contraception (eg, condoms and spermicide, or diaphragm and spermicide) concurrently for first 7 days

            Injection, intrauterine system, implant, or progestin-only pill

            • Injection: Apply first TDS on the day the next injection would normally occur
            • Intrauterine system or implant: Apply first TDS on the day of intrauterine system/implant removal
            • Progestin-only pill: Apply first TDS on the day the next progestin-only pill cycle would normally start

            Starting after abortion or miscarriage

            • First trimester abortion or miscarriage
              • May be started immediately within the first 5 days following a complete first trimester abortion or miscarriage without additional back-up contraception
              • If >5 days have elapsed from the first trimester abortion or miscarriage, use nonhormonal contraception (eg, condoms and spermicide, diaphragm and spermicide) and follow instructions for starting TDS for the first time
              • Ovulation may occur within 10 days of an abortion or miscarriage
            • Second trimester abortion or miscarriage
              • Do not start earlier than 4 weeks after a second trimester abortion or miscarriage owing to increased risk of thromboembolism

            Starting after childbirth

            • For women who elect not to breastfeed, do not start sooner than 4 weeks after childbirth owing to increased risk of thromboembolism
            • If a woman begins using TDS postpartum and has not yet had a period, consider possibility of ovulation and pregnancy; obtain pregnancy test to guide action
            • If not pregnant, use nonhormonal back-up contraception (eg, condoms and spermicide, diaphragm and spermicide) for the first 7 days of TDS use

            Missed doses

            • Forgetting to change TDS
              • At the start of any TDS cycle (Week 1/Day 1): May not be protected from pregnancy; apply the first TDS as soon as possible (this now starts a new 4-week cycle and is now the new Patch Change Day); use nonhormonal back-up contraception for 7 days
              • In the middle of TDS cycle (Week 2/Day 8 or Week 3/Day 15), for up to 48 hr: Apply new TDS immediately; apply next TDS on the usual Patch Change Day; no back-up contraception needed
              • ≥48 hr: May not be protected from pregnancy; stop current TDS cycle and start a new 4-week cycle immediately by applying a new TDS (this is now a new Patch Change Day); use nonhormonal back-up contraception for 7 days
              • At end of TDS cycle Week 3 (Day 22): If the woman forgets to remove her TDS, she should take it off as soon as she remembers; start next cycle on the usual Patch Change Day, which is the day after Day 28; no back-up contraception needed

            Storage

            Store in original pouch until application time

            Store at room temperature 20-25ºC (68-77ºF); excursions permitted to 15-30ºC (59-86ºF)

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
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            NC NOT COVERED – Drugs that are not covered by the plan.
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