EMSAM^®
(SELEGILINE TRANSDERMAL SYSTEM)

Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of EMSAM or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised for the need for close observation and communication with the prescriber. EMSAM is not approved for use in pediatric patients. (See WARNINGS and PRECAUTIONS, Pediatric Use.)

Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with major depressive disorder (MDD), obsessive compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients receiving antidepressants was 4%, twice the placebo risk of 2%. No suicides occurred in these trials.

EMSAM^®(selegiline transdermal system) is a transdermally administered antidepressant. When applied to intact skin, EMSAM is designed to continuously deliver selegiline over a 24-hour period.

Selegiline base is a colorless to yellow liquid, chemically described as (-)-(N)-Methyl-N-[(1R)-1-methyl-2-phenylethyl]prop-2-yn-1-amine. It has an empirical formula of C₁₃H₁₇N and a molecular weight of 187.30. The structural formula is:

EMSAM systems are transdermal patches that contain 1 mg of selegiline per cm² and deliver approximately 0.3 mg of selegiline per cm² over 24 hours. EMSAM systems are available in three sizes: 20 mg/20 cm², 30 mg/30 cm², and 40 mg/40 cm² that deliver, on average, doses of 6 mg, 9 mg, or 12 mg, respectively, of selegiline over 24 hours.

EMSAM is a matrix-type transdermal system composed of three layers as illustrated in Figure 1 below. Layer 1 is the Backing Film that provides the matrix system with occlusivity and physical integrity and protects the adhesive/drug layer. Layer 2 is the Adhesive/Drug Layer. Layer 3 consists of side-by-side release liners that are peeled off and discarded by the patient prior to applying EMSAM. The inactive ingredients are acrylic adhesive, ethylene vinyl acetate/polyethylene, polyester, polyurethane, and silicon coated polyester.

Figure 1: Side view of EMSAM system. (Not to scale.)

Selegiline (the drug substance of EMSAM) is an irreversible inhibitor of monoamine oxidase (MAO), an intracellular enzyme associated with the outer membrane of mitochondria. MAO exists as two isoenzymes, referred to as MAO-A and MAO-B. Selegiline has a greater affinity for MAO-B, compared to MAO-A. However, at antidepressant doses, selegiline inhibits both isoenzymes (see below).

The mechanism of action of EMSAM as an antidepressant is not fully understood, but is presumed to be linked to potentiation of monoamine neurotransmitter activity in the central nervous system (CNS) resulting from its inhibition of MAO activity. In an in vivo animal model used to test for antidepressant activity (Forced Swim Test), selegiline administered by transdermal patch exhibited antidepressant properties only at doses that inhibited both MAO-A and MAO-B activity in the brain. In the CNS, MAO-A and MAO-B play important roles in the catabolism of neurotransmitter amines such as norepinephrine, dopamine, and serotonin, as well as neuromodulators such as phenylethylamine. Other molecular sites of action have also been explored and in this regard, a direct pharmacological interaction may also occur between selegiline and brain neuronal α_2B receptors. In in vitro receptor binding assays, selegiline has demonstrated affinity for the human recombinant adrenergic α_2B receptor (K_i = 284 µM). No affinity [K_i > 10 µM] was noted at dopamine receptors, adrenergic β₃, glutamate, muscarinic M₁-M₅, nicotinic, or rolipram receptor/sites.

The efficacy of EMSAM as a treatment for major depressive disorder was established in two placebo-controlled studies of 6 and 8 weeks duration in adult outpatients (ages 18 to 70 years) meeting DSM-IV criteria for major depressive disorder. In both studies, patients were randomized to double-blind treatment with EMSAM or placebo. The 6-week trial (N = 176) showed that EMSAM 6 mg/24 hours was significantly more effective than placebo on the 17-li Hamilton Depression Rating Scale (HAM-D). In an 8-week dose titration trial, depressed patients (N = 265), who received EMSAM or placebo at a starting dose of 6 mg/24 hours, with possible increases to 9 mg/24 hours or 12 mg/24 hours based on clinical response, showed significant improvement compared with placebo on the primary outcome measure, the 28-li HAM-D total score.

In another trial, 322 patients meeting DSM-IV criteria for major depressive disorder who had responded during an initial 10-week open-label treatment phase for about 25 days, on average, to EMSAM 6 mg/24 hours were randomized either to continuation of EMSAM at the same dose (N = 159) or to placebo (N = 163) under double-blind conditions for observation of relapse. About 52% of the EMSAM-treated patients, as well as about 52% of the placebo-treated patients, had discontinued treatment by week 12 of the double-blind phase. Response during the open-label phase was defined as 17-li HAM-D score < 10 at either week 8 or 9 and at week 10 of the open-label phase. Relapse during the double-blind phase was defined as follows: (1) a 17-li HAM-D score ≥ 14, (2) a CGI-S score of ≥ 3 (with at least a 2-point increase from double-blind baseline), and (3) meeting DSM-IV criteria for major depressive disorder on two consecutive visits ≥ 11 days apart. In the double-blind phase, patients receiving continued EMSAM experienced a significantly longer time to relapse.

An examination of population subgroups did not reveal any clear evidence of differential responsiveness on the basis of age, gender, or race.

EMSAM (selegiline transdermal system) is indicated for the treatment of major depressive disorder.

The efficacy of EMSAM in the treatment of major depressive disorder was established in 6- and 8-week placebo-controlled trials of outpatients with diagnoses of DSM-IV category of major depressive disorder (see Clinical Efficacy Trials).

A major depressive episode (DSM-IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least five of the following nine symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and suicide attempt or suicidal ideation.

The benefit of maintaining patients with major depressive disorder on therapy with EMSAM after achieving a responder status for an average duration of about 25 days was demonstrated in a controlled trial (see Clinical Efficacy Trials under CLINICAL PHARMACOLOGY). The physician who elects to use EMSAM for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient (see DOSAGE AND ADMINISTRATION).

The antidepressant action of EMSAM in hospitalized depressed patients has not been studied.

EMSAM (selegiline transdermal system) is contraindicated in patients with known hypersensitivity to selegiline or to any component of the transdermal system.

EMSAM (selegiline transdermal system) is contraindicated with selective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine, sertraline, and paroxetine); dual serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine and duloxetine); tricyclic antidepressants (TCAs, e.g., imipramine and amitriptyline); bupropion hydrochloride; meperidine and analgesic agents such as tramadol, methadone, and propoxyphene; the antitussive agent dextromethorphan; St. John's wort; mirtazapine; and cyclobenzaprine. EMSAM should not be used with oral selegiline or other MAO inhibitors (MAOIs e.g., isocarboxazid, phenelzine, and tranylcypromine) (see WARNINGS).

Carbamazepine and oxcarbazepine are contraindicated in patients taking selegiline (see PRECAUTIONS, Drug Interactions).

As with other MAOIs, EMSAM is contraindicated for use with sympathomimetic amines, including amphetamines as well as cold products and weight-reducing preparations that contain vasoconstrictors (e.g., pseudoephedrine, phenylephrine, phenylpropanolamine, and ephedrine).

As with other MAOIs, patients taking EMSAM should not undergo elective surgery requiring general anesthesia. Also, they should not be given cocaine or local anesthesia containing sympathomimetic vasoconstrictors. EMSAM should be discontinued at least 10 days prior to elective surgery. If surgery is necessary sooner, benzodiazepines, mivacurium, rapacuronium, fentanyl, morphine, and codeine may be used cautiously.

As with other MAOIs, EMSAM is contraindicated for use in patients with pheochromocytoma.

EMSAM is an irreversible MAO inhibitor. As a class, these compounds have been associated with hypertensive crises caused by the ingestion of foods containing high amounts of tyramine. In its entirety, the data for EMSAM 6 mg/24 hours support the recommendation that a modified diet is not required at this dose. Due to the more limited data available for EMSAM 9 mg/24 hours and 12 mg/24 hours, patients receiving these doses should follow Dietary Modifications Required for Patients Taking EMSAM 9 mg/24 hours and 12 mg/24 hours. (See WARNINGS and PRECAUTIONS, Drug Interactions, Tyramine.)

Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. There has been a long-standing concern that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients. Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders.

Pooled analyses of short-term placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with MDD, OCD, or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal behavior or thinking (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients receiving antidepressants was 4%, twice the placebo risk of 2%. There was considerable variation in risk among drugs, but a tendency toward an increase for almost all drugs studied. The risk of suicidality was most consistently observed in the MDD trials, but there were signals of risk arising from trials in other psychiatric indications (obsessive compulsive disorder and social anxiety disorder) as well. No suicides occurred in these trials. It is unknown whether the suicidality risk in pediatric patients extends to longer-term use, i.e., beyond several months. It is also unknown whether the suicidality risk extends to adults.

All pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Such observation would generally include at least weekly face-to-face contact with patients or their family members or caregivers during the first 4 weeks of treatment, then every other week visits for the next 4 weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks. Additional contact by telephone may be appropriate between face-to-face visits.

Adults with MDD or co-morbid depression in the setting of other psychiatric illness being treated with antidepressants should be observed similarly for clinical worsening and suicidality, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.

If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms.

Families and caregivers of pediatric patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for EMSAM should be written for the smallest quantity consistent with good patient management, in order to reduce the risk of overdose. Families and caregivers of adults being treated for depression should be similarly advised.

A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that EMSAM is not approved for use in treating bipolar depression.

EMSAM is an irreversible MAO inhibitor. MAO is important in the catabolism of dietary amines (e.g., tyramine). In this regard, significant inhibition of intestinal MAO-A activity can impose a cardiovascular safety risk following the ingestion of tyramine-rich foods. As a class, MAOIs have been associated with hypertensive crises caused by the ingestion of foods with a high concentration of tyramine.

Hypertensive crises, which in some cases may be fatal, are characterized by some or all of the following symptoms: occipital headache which may radiate frontally, palpitation, neck stiffness or soreness, nausea, vomiting, sweating (sometimes with fever and sometimes with cold, clammy skin), dilated pupils, and photophobia. Either tachycardia or bradycardia may be present and can be associated with constricting chest pain. Intracranial bleeding has been reported in association with the increase in blood pressure. Patients should be instructed as to the signs and symptoms of severe hypertension and advised to seek immediate medical attention if these signs or symptoms are present.

In 6 of the 7 clinical studies conducted with EMSAM at doses of 6 mg/24 hours - 12 mg/24 hours, patients were not limited to a modified diet typically associated with this class of compounds. Although no hypertensive crises were reported as part of the safety assessment, the likelihood of developing this reaction cannot be fully determined since the amount of tyramine typically consumed during the course of treatment is not known and blood pressure was not continuously monitored.

To further define the likelihood of hypertensive crises with use of EMSAM, several Phase I tyramine challenge studies were conducted both with and without food (see PRECAUTIONS, Drug Interactions, Tyramine). In its entirety, the data for EMSAM 6 mg/24 hours support the recommendation that a modified diet is not required at this dose. Due to the more limited data available for EMSAM 9 mg/24 hours, and the results from the Phase I tyramine challenge study in fed volunteers administered EMSAM 12 mg/24 hours (see PRECAUTIONS, Drug Interactions, Tyramine), patients receiving these doses should follow Dietary Modifications Required for Patients Taking EMSAM 9 mg/24 hours and 12 mg/24 hours.

If a hypertensive crisis occurs, EMSAM should be discontinued immediately and therapy to lower blood pressure should be instituted immediately. Phentolamine 5 mg or labetalol 20 mg administered slowly intravenously is recommended therapy to control hypertension. Alternately, nitroprusside delivered by continuous intravenous infusion may be used. Fever should be managed by means of external cooling. Patients must be closely monitored until symptoms have stabilized.

The following foods and beverages should be avoided beginning on the first day of EMSAM 9 mg/24 hours or 12 mg/24 hours treatment, and should continue to be avoided for 2 weeks after a dose reduction to EMSAM 6 mg/24 hours or following the discontinuation of EMSAM 9 mg/24 hours or 12 mg/24 hours.

Food and beverages to avoid and those which are acceptableAdapted from K. I. Shulman, S. E. Walker, Psychiatric Annals 2001; 31:378-384:

Serious, sometimes fatal, central nervous system (CNS) toxicity referred to as the "serotonin syndrome" has been reported with the combination of non-selective MAOIs with certain other drugs, including tricyclic or selective serotonin reuptake inhibitor antidepressants, amphetamines, meperidine, or pentazocine. Serotonin syndrome is characterized by signs and symptoms that may include hyperthermia, rigidity, myoclonus, autonomic instability with rapid fluctuations of the vital signs, and mental status changes that include extreme agitation progressing to delirium and coma. Similar less severe syndromes have been reported in a few patients receiving a combination of oral selegiline with one of these agents.

Therefore, EMSAM (selegiline transdermal system) should not be used in combination with selective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine, sertraline, paroxetine); dual serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine and duloxetine); tricyclic antidepressants (TCAs, e.g., imipramine and amitriptyline); oral selegiline or other MAOIs (e.g., isocarboxazid, phenelzine, and tranylcypromine); mirtazapine; bupropion hydrochloride; meperidine and analgesic agents such as tramadol, methadone, and propoxyphene; the antitussive agent dextromethorphan; or St. John's wort because of the risk of life-threatening adverse reactions. Also, EMSAM should not be used with sympathomimetic amines, including amphetamines as well as cold products and weight-reducing preparations that contain vasoconstrictors (e.g., pseudoephedrine, phenylephrine, phenylpropanolamine, and ephedrine). (See CONTRAINDICATIONS.)

Concomitant use of EMSAM with buspirone hydrochloride is not advised since several cases of elevated blood pressure have been reported in patients taking MAOIs who were then given buspirone HCl.

After stopping treatment with SSRIs; SNRIs; TCAs; MAOIs; meperidine and analgesics such as tramadol, methadone, and propoxyphene; dextromethorphan; St. John's wort; mirtazapine; bupropion HCl; or buspirone HCl, a time period equal to 4 - 5 half-lives (approximately 1 week) of the drug or any active metabolite should elapse before starting therapy with EMSAM. Because of the long half-life of fluoxetine and its active metabolite, at least 5 weeks should elapse between discontinuation of fluoxetine and initiation of treatment with EMSAM. At least 2 weeks should elapse after stopping EMSAM before starting therapy with buspirone HCl or a drug that is contraindicated with EMSAM.

Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with EMSAM and should counsel them in its appropriate use. A patient Medication Guide About Using Antidepressants in Children and Teenagers is available for EMSAM. The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its spans. Patients should be given the opportunity to discuss the spans of the Medication Guide and to obtain answers to any questions they may have. The complete div of the Medication Guide is reprinted at the end of this document.

Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking EMSAM.

Patients, their families and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment or when the dose is adjusted up or down. Families and caregivers of patients should be advised to observe for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly change in the medication.

Patients should be advised not to use oral selegiline while on EMSAM therapy.

Patients should be advised not to use carbamazepine or oxcarbazepine while on EMSAM therapy.

Patients should be advised not to use meperidine and analgesic agents such as tramadol, methadone, and propoxyphene.

Patients should be advised not to use sympathomimetic agents while on EMSAM therapy.

Patients should be advised not to use selective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine, sertraline, paroxetine, and St. John's wort), dual serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine and duloxetine), tricyclic antidepressants (TCAs, e.g., imipramine and amitriptyline), mirtazapine, oral selegiline or other MAOIs (e.g., isocarboxazid, phenelzine, and tranylcypromine), bupropion hydrochloride or buspirone hydrochloride while on EMSAM therapy.

EMSAM (selegiline transdermal system) has not been shown to impair psychomotor performance; however, any psychoactive drug may potentially impair judgment, thinking, or motor skills. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that EMSAM therapy does not impair their ability to engage in such activities.

Patients should be told that, although EMSAM has not been shown to increase the impairment of mental and motor skills caused by alcohol, the concomitant use of EMSAM and alcohol in depressed patients is not recommended.

Patients should be advised to notify their physician if they are taking, or plan to take, any prescription or over-the-counter drugs, including herbals, because of the potential for drug interactions. Patients should also be advised to avoid tyramine-containing nutritional supplements and any cough medicine containing dextromethorphan.

Patients should be advised to use EMSAM exactly as prescribed. The need for dietary modifications at higher doses should be explained, and a brief description of hypertensive crisis provided. Rare hypertensive reactions with oral selegiline at doses recommended for Parkinson's disease and associated with dietary influences have been reported. The clinical relevance to EMSAM is unknown.

Patients should be advised that certain tyramine-rich foods and beverages should be avoided while on EMSAM 9 mg/24 hours or EMSAM 12 mg/24 hours, and for 2 weeks following discontinuation of EMSAM at these doses (see CONTRAINDICATIONS and WARNINGS).

Patients should be instructed to immediately report the occurrence of the following acute symptoms: severe headache, neck stiffness, heart racing or palpitations, or other sudden or unusual symptoms.

Patients should be advised to avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight since heat may result in an increase in the amount of selegiline absorbed from the EMSAM patch and produce elevated serum levels of selegiline.

Patients should be advised to change position gradually if lightheaded, faint, or dizzy while on EMSAM therapy.

Patients should be advised to notify their physician if they become pregnant or intend to become pregnant during EMSAM therapy.

Patients should be advised to notify their physician if they are breast-feeding an infant.

While patients may notice improvement with EMSAM therapy in 1 to several weeks, they should be advised of the importance of continuing drug treatment as directed.

Patients should be advised not to cut the EMSAM system into smaller portions.

For instructions on how to use EMSAM, see DOSAGE AND ADMINISTRATION, How to Use EMSAM.

The potential for drug interactions between EMSAM and a variety of drugs was examined in several human studies. Drug interaction studies described below were conducted with EMSAM 6 mg/24 hours. Although no differences are expected, drug interaction studies have not been conducted at higher doses (see In vitro Metabolism). In all of the studies described below, no drug-related adverse events were noted that required discontinuation of any subjects. Further, the incidence and nature of the adverse events were consistent with those known for selegiline or the test agent.

The effect of EMSAM on labor and delivery in humans is unknown.

In a prenatal and postnatal study of transdermal selegiline in rats, selegiline and metabolites were excreted into the milk of lactating rats. The levels of selegiline and metabolites in milk were approximately 15 and 5 times, respectively, steady-state levels of selegiline and metabolites in maternal plasma. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised administering EMSAM to a nursing mother.

Safety and effectiveness in the pediatric population have not been established (see BOX WARNING and WARNINGS, Clinical Worsening and Suicide Risk).

Anyone considering the use of EMSAM (selegiline transdermal system) in a child or adolescent must balance the potential risks with the clinical need.

One hundred ninety-eight (198) elderly (≥ 65 years of age) patients participated in clinical studies with EMSAM 6 mg/24 hours to 12 mg/24 hours. There were no overall differences in effectiveness between elderly and younger patients. In short-term, placebo-controlled depression trials, patients age 50 and older appeared to be at higher risk for rash (4.4% EMSAM vs. 0% placebo) than younger patients (3.4% EMSAM vs. 2.4% placebo).

The premarketing development program for EMSAM included selegiline exposures in patients and/or normal subjects from two different groups of studies: 702 healthy subjects in clinical pharmacology/pharmacokinetics studies and 2036 exposures from patients in controlled and uncontrolled major depressive disorder clinical trials. The conditions and duration of treatment with EMSAM varied and included double-blind, open-label, fixed-dose, and dose titration studies of short-term and longer-term exposures. Safety was assessed by monitoring adverse events, physical examinations, vital signs, body weights, laboratory analyses, and ECGs.

Adverse events during exposure were obtained primarily by general inquiry and recorded by clinical investigators. In the tables and tabulations that follow, standard COSTART terminology has been used to classify reported adverse events. The stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse event of the type uled. An event was considered treatment-emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation.

During the premarketing assessment in major depressive disorder, EMSAM was administered to 2036 patients in Phase III studies. The conditions and duration of exposure to EMSAM, varied and included double-blind and open-label studies.

In the tabulations that follow, reported adverse events were classified using a standard COSTART-based dictionary terminology. All reported adverse events are included except those already uled in Table 1 or elsewhere in labeling, and those events occurring in only one patient. It is important to emphasize that although the events occurred during treatment with EMSAM, they were not necessarily caused by it.

Events are further categorized by body system and uled in order of decreasing frequency according to the following definitions: frequent adverse events are those occurring on one or more occasions in at least 1/100 patients; infrequent adverse events are those occurring in less than 1/100 patients but at least 1/1000 patients; rare events are those occurring in fewer than 1/1000 patients.

Body as a Whole: Frequent: Chest pain, neck pain. Infrequent: Bacterial infection, fever, cyst, fungal infection, chills, viral infection, suicide attempt, neck rigidity, pelvic pain, photosensitivity reaction, face edema, flank pain, hernia, intentional injury, neoplasm, generalized edema, overdose. Rare: Body odor, halitosis, heat stroke, parasitic infection, malaise, moniliasis.

Cardiovascular System: Frequent: Hypertension. Infrequent: Vasodilatation, tachycardia, migraine, syncope, atrial fibrillation, peripheral vascular disorder. Rare: Myocardial infarct.

Digestive System: Frequent: Constipation, flatulence, anorexia, gastroenteritis, vomiting. Infrequent: Increased appetite, thirst, periodontal abscess, eructation, gastritis, colitis, dysphagia, tongue edema, glossitis, increased salivation, abnormal liver function tests, melena, tongue disorder, tooth caries. Rare: GI neoplasia, rectal hemorrhage.

Hemic and Lymphatic System: Frequent: Ecchymosis. Infrequent: Anemia, lymphadenopathy. Rare: Leukocytosis, leukopenia, petechia.

Metabolic and Nutritional: Frequent: Peripheral edema. Infrequent: Hyperglycemia, increased SGPT, edema, hypercholesteremia, increased SGOT, dehydration, alcohol intolerance, hyponatremia, increased lactic dehydrogenase. Rare: Increased alkaline phosphatase, bilirubinemia, hypoglycemic reaction.

Musculoskeletal System: Frequent: Myalgia, pathological fracture. Infrequent: Arthralgia, generalized spasm, arthritis, myasthenia, arthrosis, tenosynovitis. Rare: Osteoporosis.

Nervous System: Frequent: Agitation, paresthesia, thinking abnormal, amnesia. Infrequent: Leg cramps, tremor, vertigo, hypertonia, twitching, emotional lability, confusion, manic reaction, depersonalization, hyperkinesias, hostility, myoclonus, circumoral paresthesia, hyperesthesia, increased libido, euphoria, neurosis, paranoid reaction. Rare: Ataxia.

Respiratory System: Frequent: Cough increased, bronchitis. Infrequent: Dyspnea, asthma, pneumonia, laryngismus. Rare: Epistaxis, laryngitis, yawn.

Skin and Appendages: Frequent: Pruritus, sweating, acne. Infrequent: Dry skin, maculopapular rash, contact dermatitis, urticaria, herpes simplex, alopecia, vesiculobullous rash, herpes zoster, skin hypertrophy, fungal dermatitis, skin benign neoplasm. Rare: Eczema.

Special Senses: Frequent: Taste perversion, tinnitus. Infrequent: Dry eyes, conjunctivitis, ear pain, eye pain, otitis media, parosmia. Rare: Mydriasis, otitis external, visual field defect.

Urogenital System: Frequent: Urinary tract infection, urinary frequency, dysmenorrhea, metrorrhagia. Infrequent: Urinary tract infection (male), vaginitis, cystitis (female), hematuria (female), unintended pregnancy, dysuria (female), urinary urgency (male and female), vaginal moniliasis, menorrhagia, urination impaired (male), breast neoplasm (female), kidney calculus (female), vaginal hemorrhage, amenorrhea, breast pain, polyuria (female).

EMSAM (selegiline transdermal system) is not a controlled substance.

Several animal studies have assessed potential for abuse and/or dependence with chronic selegiline administration. None of these studies demonstrated a potential for selegiline abuse or dependence.

EMSAM has not been systematically studied in humans for its potential for abuse, tolerance, or physical dependence. While the clinical trials did not reveal any tendency for any drug-seeking behavior, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, patients should be evaluated carefully for a history of drug abuse, and such patients should be observed closely for signs of EMSAM misuse or abuse (e.g., development of tolerance, increases in dose, or drug-seeking behavior).

There are no specific antidotes for EMSAM. If symptoms of overdosage occur, immediately remove the EMSAM system and institute appropriate supportive therapy. For contemporary consultation on the management of poisoning or overdosage, contact the National Poison Control Center at 1-800-222-1222.

EMSAM is considered to be an irreversible MAOI at therapeutic doses and, in overdosage, is likely to cause excessive MAO-A inhibition, and may result in the signs and symptoms resembling overdosage with other non-selective, oral MAOI antidepressants [e.g., tranylcypromine (Parnate^®), phenelzine (Nardil^®), or isocarboxazide (Marplan^®)].

NOTE: The following is provided for reference only; it does not describe events that have actually been observed with selegiline in overdosage. No information regarding overdose by ingestion of EMSAM is available.

Typical signs and symptoms associated with overdosage of non-selective MAOI antidepressants may not appear immediately. Delays of up to 12 hours between ingestion of drug and the appearance of signs may occur, and peak effects may not be observed for 24 - 48 hours. Since death has been reported following overdosage with MAOI agents, hospitalization with close monitoring during this period is essential.

Overdosage with MAOI agents is typically associated with CNS and cardiovascular toxicity. Signs and symptoms of overdosage may include, alone or in combination, any of the following: drowsiness, dizziness, faintness, irritability, hyperactivity, agitation, severe headache, hallucinations, trismus, opisthotonos, convulsions, coma, rapid and irregular pulse, hypertension, hypotension and vascular collapse, precordial pain, respiratory depression and failure, hyperpyrexia, diaphoresis, and cool, clammy skin. Type and intensity of symptoms may be related to extent of the overdosage.

Treatment should include supportive measures, with pharmacological intervention as appropriate. Symptoms may persist after drug washout because of the irreversible inhibitory effects of these agents on systemic MAO activity. With overdosage, in order to avoid the occurrence of hypertensive crisis ("cheese reaction"), dietary tyramine should be restricted for several weeks beyond recovery to permit regeneration of the peripheral MAO-A isoenzyme.

EMSAM should be applied to dry, intact skin on the upper torso (below the neck and above the waist), upper thigh or the outer surface of the upper arm once every 24 hours. The recommended starting dose and target dose for EMSAM is 6 mg/24 hours. EMSAM has been systematically evaluated and shown to be effective in a dose range of 6 mg/24 hours to 12 mg/24 hours. However, the trials were not designed to assess if higher doses are more effective than the lowest effective dose of 6 mg/24 hours. Based on clinical judgment, if dose increases are indicated for individual patients, they should occur in dose increments of 3 mg/24 hours (up to a maximum dose of 12 mg/24 hours) at intervals of no less than 2 weeks. As with all antidepressant drugs, full antidepressant effect may be delayed.

Patients should be informed that tyramine-rich foods and beverages should be avoided beginning on the first day of EMSAM 9 mg/24 hours or 12 mg/24 hours treatment and should continue to be avoided for 2 weeks after a dose reduction to EMSAM 6 mg/24 hours or following the discontinuation of EMSAM 9 mg/24 hours or 12 mg/24 hours (see WARNINGS).

No dosage adjustment is required for patients with mild to moderate renal or hepatic impairment. The recommended dose for elderly patients (≥ 65 years) is EMSAM 6 mg/24 hours daily. Dose increases, in the elderly, should be made with caution and patients should be closely observed for postural changes in blood pressure throughout treatment.

1. EMSAM should be applied to dry, intact skin on the upper torso (below the neck and above the waist), upper thigh or the outer surface of the upper arm. A new application site should be selected with each new patch to avoid re-application to the same site on consecutive days. Patches should be applied at approximately the same time each day.

2. Apply the patch to an area of skin that is not hairy, oily, irritated, broken, scarred or calloused. Do not place the patch where your clothing is tight, which could cause the patch to rub off.

3. After you have selected the site for your patch, wash the area gently and thoroughly with soap and warm water. Rinse until all soap is removed. Dry the area with a clean dry towel.

4. Just before you apply the patch, remove it from the pouch. Remove half of the protective backing and throw it away. Try not to touch the exposed side (sticky side) of the patch, because the medicine could come off on your fingers.

5. Press the sticky side of the patch firmly against the skin site that was just washed and dried. Remove the second half of the protective liner and press the remaining sticky side firmly against your skin. Make sure that the patch is flat against the skin (there should be no bumps or folds in the patch) and is sticking securely. Be sure the edges are stuck to the skin surface.

6. After you have applied the patch, wash your hands thoroughly with soap and water to remove any medicine that may have gotten on them. Do not touch your eyes until after you have washed your hands.

7. After 24 hours, remove the patch. Do not touch the sticky side. As soon as you have removed the patch, fold it so that the sticky side sticks to itself.

8. Throw away the folded patch so that children and/or pets cannot reach it.

9. Wash your hands with soap and water.

10. If your patch falls off, apply a new patch to a new site and resume your previous schedule.

11. Only one EMSAM patch should be worn at a time.

12. Avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight.

It is generally agreed that episodes of depression require several months or longer of sustained pharmacologic therapy. The benefit of maintaining depressed patients on therapy with EMSAM at a dose of 6 mg/24 hours after achieving a responder status for an average duration of about 25 days was demonstrated in a controlled trial (see Clinical Efficacy Trials and INDICATIONS AND USAGE). The physician who elects to use EMSAM for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient.

EMSAM (selegiline transdermal system) is supplied as 6 mg/24 hours (20 mg/20 cm²), 9 mg/24 hours (30 mg/30 cm²) and 12 mg/24 hours (40 mg/40 cm²) transdermal systems.

They are available as:

NDC 39506-033-30: 6 mg/24 hours (20 mg/20 cm²) box of 30 transdermal systems.
NDC 39506-044-30: 9 mg/24 hours (30 mg/30 cm²) box of 30 transdermal systems.
NDC 39506-055-30: 12 mg/24 hours (40 mg/40 cm²) box of 30 transdermal systems.

Store at 20° to 25° C (68° to 77° F). [See USP Controlled Room Temperature.] Do not store outside of the sealed pouch. Apply immediately upon removal from the protective pouch. Discard used EMSAM in household trash in a manner that prevents accidental application or ingestion by children, pets or others.

EMSAM^® [EM sam]

Generic Name: selegiline transdermal system

Rx only

Read this Medication Guide carefully before you start using EMSAM and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about EMSAM, ask your doctor or pharmacist.

IMPORTANT: Be sure to read the section of this Medication Guide beginning with "What is the most important information I should know about EMSAM?" It contains important information about certain changes in diet that might be needed, other medications to avoid, and other important information about this medication. It immediately follows the next section called "About Using Antidepressants in Children and Teenagers."

ABOUT USING ANTIDEPRESSANTS IN CHILDREN AND TEENAGERS

What is the most important information I should know if my child is being prescribed an antidepressant?

Parents or guardians need to think about 4 important things when their child is prescribed an antidepressant:

• There is a risk of suicidal thoughts or actions
• How to try to prevent suicidal thoughts or actions in your child
• You should watch for certain signs if your child is taking an antidepressant
• There are benefits and risks when using antidepressants

1. There is a Risk of Suicidal Thoughts or Actions

Children and teenagers sometimes think about suicide, and many report trying to kill themselves.

Antidepressants increase suicidal thoughts and actions in some children and teenagers. But suicidal thoughts and actions can also be caused by depression, a serious medical condition that is commonly treated with antidepressants. Thinking about killing yourself or trying to kill yourself is called suicidality or being suicidal.

A large study combined the results of 24 different studies of children and teenagers with depression or other illnesses. In these studies, patients took either a placebo (sugar pill) or an antidepressant for 1 to 4 months. No one committed suicide in these studies, but some patients became suicidal. On sugar pills, 2 out of every 100 became suicidal. On the antidepressants, 4 out of every 100 patients became suicidal.

For some children and teenagers, the risks of suicidal actions may be especially high. These include patients with:

• Bipolar illness (sometimes called manic-depressive illness)
• A family history of bipolar illness
• A personal or family history of attempting suicide

If any of these are present, make sure you tell your healthcare provider before your child takes an

antidepressant.

2. How to Try to Prevent Suicidal Thoughts and Actions

To try to prevent suicidal thoughts and actions in your child, pay close attention to changes in her or his moods or actions, especially if the changes occur suddenly. Other important people in your child's life can help by paying attention as well (e.g., your child's brothers and sisters, teachers, and other important people). The changes to look out for are uled in Section 3, on what to watch for.

Whenever an antidepressant is started or its dose is changed, pay close attention to your child.

After starting an antidepressant, your child should generally see her or his healthcare provider:

• Once a week for the first 4 weeks
• Every 2 weeks for the next 4 weeks
• After taking the antidepressant for 12 weeks
• After 12 weeks, follow your healthcare provider's advice about how often to come back
• More often if problems or questions arise (see Section 3)

You should call your child's healthcare provider between visits if needed.

3. You Should Watch for Certain Signs If Your Child is Taking an Antidepressant

Contact your child's healthcare provider right away if your child exhibits any of the following signs for the first time, or if they seem worse, or worry you, your child, or your child's teacher:

• Thoughts about suicide or dying
• Attempts to commit suicide
• New or worse depression
• New or worse anxiety
• Feeling very agitated or restless
• Panic attacks
• Difficulty sleeping (insomnia)
• New or worse irritability
• Acting aggressive, being angry, or violent
• Acting on dangerous impulses
• An extreme increase in activity and talking
• Other unusual changes in behavior or mood

Never let your child stop taking an antidepressant without first talking to her or his healthcare

provider. Stopping an antidepressant suddenly can cause other symptoms.

4. There are Benefits and Risks When Using Antidepressants

Antidepressants are used to treat depression and other illnesses. Depression and other illnesses can lead to suicide. In some children and teenagers, treatment with an antidepressant increases suicidal thinking or actions. It is important to discuss all the risks of treating depression and also the risks of not treating it. You and your child should discuss all treatment choices with your healthcare provider, not just the use of antidepressants.

Other side effects can occur with antidepressants (see section below).

Of all the antidepressants, only fluoxetine (Prozac^®) has been FDA approved to treat pediatric depression.

For obsessive compulsive disorder in children and teenagers, the FDA has approved only fluoxetine (Prozac^®), sertraline (Zoloft^®), fluvoxamine (Luvox^®), and clomipramine (Anafranil^®).

Your healthcare provider may suggest other antidepressants based on the past experience of your child or other family members.

Is this all I need to know if my child is being prescribed an antidepressant?

No. This is a warning about the risk for suicidality. Other side effects can occur with antidepressants.

Be sure to ask your healthcare provider to explain all the side effects of the particular drug he or she is prescribing. Also ask about drugs to avoid when taking an antidepressant. Ask your healthcare provider or pharmacist where to find more information.

What is the most important information I should know about EMSAM?

• 1. EMSAM (selegiline transdermal system) contains a medicine called a monoamine oxidase inhibitor, also called a MAOI. MAOI medicines, including EMSAM, can cause a sudden, large increase in blood pressure (hypertensive crisis) if you eat foods and drinks that contain high amounts of tyramine. A hypertensive crisis can be a life-threatening condition. See "What are the possible side effects of EMSAM?" for signs and symptoms of a hypertensive crisis.
  • EMSAM comes in three different doses and patch sizes:
    • a 6 mg/24 hours patch
    • a 9 mg/24 hours patch
    • a 12 mg/24 hours patch
  • You must avoid (not eat or drink) certain foods and drinks while using EMSAM 9 mg/24 hours and EMSAM 12 mg/24 hours patches and for 2 weeks after stopping EMSAM 9 mg/24 hours and EMSAM 12 mg/24 hours patches. (The table below uls these foods and drinks.) The table also uls foods and drinks that are okay to eat and drink while using EMSAM 9 mg/24 hours and EMSAM 12 mg/24 hours patches.
  • You do not have to make any diet changes with the EMSAM 6 mg/24 hours patch.

•  
  • All foods you eat must be fresh or properly frozen.
  • Avoid foods when you do not know their storage conditions.

• 2. EMSAM can cause serious and potentially life-threatening reactions if used with certain other medicines. Do not take the following medicines while using EMSAM, and for 2 weeks after stopping EMSAM:
  • other medicines to treat depression (antidepressants) including other MAOI medicines
  • medicine which contains selegiline (such as Eldepryl^®)
  • St. John's wort (a herbal supplement)
  • Demerol^® (meperidine), or medicines that contain meperidine (a narcotic pain medicine) or the pain medicines tramadol, methadone, or propoxyphene
  • Tegretol^® (carbamazepine), or other medicines that contain carbamazepine (a seizure medicine)
  • Trileptal^® (oxcarbazepine), or other medicines that contain oxcarbazepine (a seizure medicine)
  • Cold or cough preparations that contain dextromethorphan
  • Flexeril^® or other medicines that contain cyclobenzaprine (a medicine used to treat muscle spasms)
  • decongestant medicines, found in many products to treat cold symptoms
  • over-the-counter diet pills or herbal weight-loss products
  • any herbal or dietary supplement that contains tyramine
  • medicines called amphetamines, also called stimulants or "uppers"
  • BuSpar^® (buspirone HCl), an anxiety medicine

Some of these medicines will have to be stopped for at least a week before you can start using EMSAM.

What is EMSAM?

EMSAM is a skin patch (transdermal system) used to treat major depression. The skin patch delivers the medicine through your skin and into your bloodstream.

EMSAM has not been studied for the treatment of depression in children under 18 years of age.

Who should not use EMSAM?

Do not use EMSAM (selegiline transdermal system) if you are:

• taking certain other medicines. See "What is the most important information I should know about EMSAM?"
• allergic to anything in EMSAM. See the end of this Medication Guide for a complete ul of ingredients in EMSAM.

What should I tell my doctor before starting EMSAM?

Tell your doctor about all your medical conditions, including if you:

• have any heart problems
• have or had manic episodes (a mental condition that causes "high" moods)
• have or had seizures (convulsions or "fits")
• tend to get dizzy or faint
• are pregnant or planning to become pregnant. It is not known if EMSAM can harm your unborn baby.
• are breastfeeding. It is not known if EMSAM passes into your milk or if it can harm your baby.

Tell your doctor about all the medicines you take including prescription and non-prescription medicines, vitamins, and herbal supplements. EMSAM can cause a serious and life-threatening reaction if used with certain other medicines. See "What is the most important information I should know about EMSAM?"

Know the medicines you take. Keep a ul of them with you to show your doctor and pharmacist. Do not take any new medicine while using EMSAM, and for 2 weeks after you stop using it, before talking with your doctor.

How should I use EMSAM?

See the end of this Medication Guide for "How to Use and Apply an EMSAM Patch".

• Use EMSAM exactly as prescribed by your doctor. Use only one patch at a time. Change the patch once a day (every 24 hours). Choose a time of day that works best for you.
• Your doctor will prescribe a dose of EMSAM (selegiline transdermal system) based on your condition. Your doctor may change your dose if needed.
• Talk to your doctor often about your condition. You may notice an improvement in your condition with EMSAM therapy after several weeks. Do not stop or change your treatment with EMSAM without talking to your doctor.
• Make sure you do not eat foods or drink beverages that contain high amounts of tyramine while using EMSAM 9 mg/24 hours or EMSAM 12 mg/24 hours patches, and for 2 weeks after you stop using them.
• If you use more than one EMSAM patch at a time, remove EMSAM patches right away and call your doctor or local Poison Control Center.
• Avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight.
• Tell your doctor if you plan to have surgery. Also, tell your surgeon that you take EMSAM. EMSAM should be stopped 10 days before you have elective surgery.

What should I avoid while using EMSAM?

• You must not eat foods or drink beverages that contain high amounts of tyramine while using EMSAM 9 mg/24 hours and 12 mg/24 hours patches. You do not have to make any diet changes with the EMSAM 6 mg/24 hours patch. See "What is the most important information I should know about EMSAM?"
• Do not take other medicines while using EMSAM or for 2 weeks after you stop using it unless your doctor has told you it is okay. See "What is the most important information I should know about EMSAM?"
• Do not drive or operate dangerous machinery until you know how EMSAM affects you. EMSAM may reduce your judgment, ability to think, or coordination.
• Drinking alcoholic beverages is not recommended while using EMSAM.

What are the possible side effects of EMSAM?

EMSAM:

• can cause a sudden, large increase in blood pressure (''hypertensive crisis'') if you eat certain foods and drinks during treatment. See "What is the most important information I should know about EMSAM?" A hypertensive crisis can lead to stroke and death. Symptoms of a hypertensive crisis include the sudden onset of severe headache, nausea, stiff neck, a fast heartbeat or a change in the way your heart beats (palpitations), a lot of sweating, and confusion. If you suddenly have these symptoms, get medical care right away.
• can cause serious and potentially life-threatening reactions if used with certain other medicines. See "What is the most important information I should know about EMSAM?"
• may worsen your depression, give you suicidal thoughts, or cause unusual changes in behavior. Call your doctor right away if you feel worse with EMSAM.
• may cause a mental condition called mania or hypomania (mental condition which causes high moods) in people who have a history of mania.
• can cause low blood pressure. Lie down if you feel dizzy, faint, or lightheaded. Change your position slowly if low blood pressure is a problem for you. Tell your doctor if you have these symptoms. You may need a lower dose of EMSAM.

The most common side effect of EMSAM is a skin reaction where the patch is placed. You may see mild redness at the site when a patch is removed. This redness should go away within several hours after removing the patch. If irritation or itching continues, tell your doctor.

These are not all the side effects of EMSAM. For more information, ask your doctor or pharmacist.

How do I store EMSAM?

• Store EMSAM at 20° to 25° C (68° to 77° F).
• Store EMSAM in its sealed pouch until use.
• Keep EMSAM and all medicines out of the reach of children and away from pets.

General information about EMSAM

Medicines are sometimes prescribed for conditions that are not mentioned in Medication Guides. Do not give EMSAM to other people, even if they have the same symptoms you have. It may harm them.

This Medication Guide summarizes the most important information about EMSAM. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about EMSAM that is written for health professionals.

For more information, call 1-800-321-1335 or visit www.EMSAM.com

What are the ingredients in EMSAM?

Active Ingredient: Selegiline

Inactive Ingredients: acrylic adhesive, ethylene vinyl acetate, polyethylene, polyester, polyurethane, and silicon coated polyester

How to Use and Apply an EMSAM Patch

Read these instructions carefully before you apply EMSAM (selegiline transdermal system). Ask your doctor or pharmacist about anything you do not understand.

• Apply a new EMSAM patch every day (24 hours).
• Wear only one EMSAM patch at a time. Wear one EMSAM patch all the time until it is time to apply a new one.
• Remove a used patch before applying a new one.
• Change the patch at the same time each day.
• Apply an EMSAM patch to dry, smooth skin on your (A) upper chest or back (below the neck and above the waist), (B) upper thigh, or (C) to the outer surface of the upper arm. Choose a new site each time you change your patch. Do not use the same site 2 days in a row. (See Picture 1 for skin sites that may be used.)

Picture 1. Skin sites for EMSAM patch. (Do not use more than one patch at a time.)

• Apply an EMSAM patch to an area of skin that is not hairy, oily, irritated, broken, scarred, or calloused. Do not place the patch where your clothing is tight, which could cause the patch to rub off.
• After you have selected the site for your patch, wash the area gently and well with soap and warm water. Rinse until all soap is removed. Dry the area with a clean dry towel.
• Just before you apply the patch, remove it from its sealed pouch. Do not keep or store the patch outside of the sealed pouch. Never cut an EMSAM patch into smaller pieces to use.
• Remove half of the protective backing and throw it away. (See Picture 2.) Try not to touch the exposed side (sticky side) of the patch, because the medicine could come off on your fingers. With your fingertips, press the sticky side of the patch firmly against the skin site that was just washed and dried. Remove the second half of the protective liner and press the remaining sticky side firmly against your skin. Make sure that the patch is flat against the skin (there should be no bumps or folds in the patch) and is sticking securely. Be sure the edges are stuck to the skin surface. (See Picture 3.)

Picture 2. Removing the protective backing from an EMSAM patch.

Picture 3. Applying an EMSAM patch.

• After you have applied the patch, wash your hands well with soap and water to remove any medicine that may have gotten on them. Do not touch your eyes until after you have washed your hands.
• After 24 hours, remove the patch slowly and carefully to avoid damaging the skin. Do not touch the sticky side. As soon as you have removed the patch, fold it so that the sticky side sticks to itself.
• Throw away the folded patch so that children and pets cannot reach it. This patch still contains some medicine and could harm a child or pet.
• Gently wash the old application site with warm water and a mild soap to remove any sticky material (adhesive) that stays on your skin after removing the patch. A small amount of baby oil may also be used to remove any adhesive. You may need to use a medical adhesive removal pad that you can get from your pharmacist. Alcohol or other dissolving liquids such as nail polish remover may cause skin irritation and should not be used.
• Wash your hands with soap and water.
• If the patch becomes loose, press it back in place. If your EMSAM (selegiline transdermal system) patch falls off, apply a new EMSAM patch to a new site and resume your normal schedule for changing patches.
• If you forget to change your patch after 24 hours, remove the old patch, put on a new patch in a different area and continue to follow your original schedule.

This Medication Guide has been approved by the US Food and Drug Administration.