The sterile powder anadrol dosage and sterile diluent for suspension for intramuscular injection of long-acting. The powder of white or nearly white to light yellow-brown color, with no visible foreign matter; easily suspended in a solvent without the formation of agglomerates. Solvent : clear, colorless liquid. The recovered slurry from white to white with a slightly yellowish-brown tint; It must pass through the needle (included in the kit) with little resistance and without resistance. There must be no exit without a solvent slurry.
Naltrexone is an opioid receptor antagonist with the greatest affinity for the mu opioid receptor.
In addition to the blockade of opioid receptors, the drug has no other pharmacological activity. Use of the drug for unknown reasons, can cause constriction of the pupil. Application Vivitrola not cause addiction or drug dependence. Patients with physical opioid dependence, administration of the drug causes symptoms “cancel.”
Neurobiological mechanisms responsible for the reduction in alcohol consumption observed in the treating naltrexone patients with alcohol dependence are clear not fully, but it is assumed that the mechanism of action involves the endogenous opioid system.
Naltrexone blocks the effects of opioids, competitively binding to opioid receptors. The blockade of the action can be eliminated naltrexone administration of high doses of opioids which can lead to an increase of histamine release with the characteristic clinical picture. The binding to opioid receptors can block the effects of endogenous opioid peptides.
Vivitrol is not a means of aversive therapy and does not cause disulfiramopodobnyh reaction when taking opiates or alcohol.
Pharmacokinetics Absorption Vivitrol is a long-acting formulation intended for intramuscular injection every four weeks or one time per month. After intramuscular change naltrexone plasma concentration is characterized by an initial peak with a peak after about 2 hours after administration and a second peak in 2-3 days. From about the 14th day after administration, the concentration is gradually reduced in the plasma, but measurable concentration is more than 1 month. The maximum concentration (C max ) and area under the curve “concentration-time” naltrexone and its major metabolite – 6-beta -naltreksola – plasma Vivitrola administered dose proportional. Total naltrexone exposure after a single administration of 380 mg Vivitrola 3-4 times higher than its ingestion of 50 mg for 28 days. After the first injection, the equilibrium concentration achieved by the end of dosing interval. After repeated administration Minimal accumulation Vivitrola observed (less than 15%) of naltrexone and 6-beta naltrexol. DistributionNaltrexone weakly bound to plasma proteins in vitro (21%). Metabolism Naltrexone subjected active metabolized in the body. The main metabolite – 6-beta-naltrexol – formed cytosolic enzyme digidrodioldegidrogenazoy. Cytochrome P450 enzymes are not involved in the metabolism of naltrexone. Other metabolites include 2-hydroxy-3-methoxy-6-beta-naltrexol and 2-hydroxy-3-methoxy-naltrexone.Naltrexone and its metabolites to form conjugates with glucuronide. When injecting Vivitrola compared with oral forms significantly fewer 6-beta-naltrexol, which is caused by reduced first-pass metabolism in the liver. Excretion of naltrexone and its metabolites are excreted mainly in urine, and intact the form displays a minimal amount of drug. The half-life of naltrexone is about 5-10 days, depending on the degree of polymer degradation. The half-life of 6-beta-naltrexol is 5-10 days. Pharmacokinetics in patients with renal and hepatic impairment Hepatic insufficiency The pharmacokinetics of Vivitrola not altered in patients with mild to moderate hepatic impairment (classes A and B according to Child-Pugh). Such patients dose adjustment is required. In patients with severe liver function Vivitrola pharmacokinetics has not been studied. Renal insufficiency results of pharmacokinetic analyzes indicate that mild renal insufficiency (creatinine clearance 50-80 ml / min) has practically no effect on the pharmacokinetics of Vivitrola and the need for a dose of the drug is not correct. In patients with moderate and severe renal insufficiency pharmacokinetics Vivitrola has not been studied. The influence of gender study conducted in healthy patients of both sexes (18 women and 18 men) found that half of patients did not affect the pharmacokinetics of Vivitrola. Influence of age and race Pharmacokinetics Vivitrola I have not been studied in elderly patients, children, and members of different races.
- The drug is indicated for the treatment of alcohol dependence in patients who are able to abstain from drinking alcohol before starting treatment. Patients should not consume alcohol active at the beginning of treatment Vivitrolom.
- The drug is indicated for the prevention of relapse of opioid dependence following opioid detoxification.
Opioidzavisimye patients, including patients who receive treatment for alcohol dependence, opioids should not take at the beginning of drug treatment. Treatment of drug should be part of an appropriate program to eliminate dependence, including psychosocial support. Children and elderly patients Data on the safety and efficacy of the drug in children are absent. Insufficient number of patients over 65 years were included in the clinical trial Vivitrola to compare the effect of treatment in the elderly and in younger patients.
Vivitrol is contraindicated in:
- Patients receiving narcotic analgesics;
- When receiving opioids on a background of drug treatment;
- Patients in a state of acute opioid withdrawal (opioid withdrawal syndrome);
- Patients who have not been provocative sample naloxone or having a positive test for the presence of opioids in the urine;
- Patients with a hypersensitivity to the active ingredient preparation or to any of its components, fillers and a solvent;
- In severe hepatic dysfunction (including acute hepatitis and liver failure);
- При беременности и лактации;
- Children under 18 years old.
Precautions Use in hepatic insufficiency Patients with mild to moderate hepatic impairment (classes A and B according to Child-Pugh) dose adjustment is required. In patients with severe hepatic impairment has not been studied pharmacokinetics Vivitrola function. Such patients Vivitrol, like all other intramuscular injections, should be used with caution because of the risk associated with intramuscular injection (eg, in the presence of thrombocytopenia and coagulation disorders). Use in renal failure patients with mild renal insufficiency (creatinine clearance 50-80 ml / min) a dose adjustment is required. In patients with moderate and severe renal insufficiency Vivitrola pharmacokinetics has not been studied. Because naltrexone and its primary metabolite are excreted primarily in the urine, it is recommended with caution Vivitrol patients with moderate or severe renal insufficiency.
Warnings and Precautions
To prevent the development of acute syndrome “cancel” in patients with opioid dependence and the prevention of exacerbation of pre-existing patients should stop taking opioids for at least 7-10 days before treatment Vivitrolom.
Since the absence of opioids in the urine often is not enough to confirm the absence of opioids in the body, if there is the risk of the syndrome “cancel” before applying Vivitrola should conduct a provocative test with naloxone. Eliminating Vivitrola blockade in case of emergency in the case of patients treated Vivitrolom, prospective way to relieve pain is regional analgesia or use of non-narcotic analgesics. in if patients require the use of narcotic analgesics for anesthesia or analgesia, such patients should be long-term medical monitoring. Therapy narcotic analgesics should be carried out by specially trained personnel in order to avoid problems with the breath, capable of carrying out mechanical ventilation in case of complications. Regardless of the means, selected for elimination action of naltrexone, the patient should be under constant supervision of qualified medical personnel in a specially equipped resuscitation department. depression and suicidal behavior should closely monitor for signs of depression or suicidal thoughts in patients with alcoholic and / or opioid dependence, including patients, treated Vivitrolom. Family members and caregivers of patients people should be warned about the need to monitor closely the emergence of symptoms of depression or suicidal behavior, and immediately report the occurrence of such symptoms your doctor. Alcohol dependence During controlled clinical trials Vivitrola suicidality (suicidal ideation, suicide attempt, suicide) observed infrequently, however, occurred in the group of patients treated Vivitrolom more frequently than in patients receiving placebo (1% versus 0). In some cases, suicidal thoughts and behavior have been recorded in the patient after completion of the study, but were a consequence of depression develop during treatment with the drug. There was a two committed suicide, in both cases, the patients were treated Vivitrolom. Stopping the drug associated with the manifestation of depression, often occurred in patients taking Vivitrol (1%) than in the placebo group (0). In the 24-week, placebo-controlled study, adverse events associated with depression were observed in 10% of patients receiving treatment Vivitrolom at a dose of 380 mg, and in the group of patients receiving placebo injections -. 5% of opioid dependence during safety studies Vivitrol drug side effects of suicidal ideation (depressed mood , suicidal ideation, suicide attempts) were reported in 5% of patients with opioid dependence who received Vivitrol and 10% of patients treated with oral naltrexone. during the 24-week placebo-controlled study of such adverse events as depressed mood, or suicidal thoughts are not identified any group of patients receiving treatment Vivitrolom at a dose of 380 mg, either in a group of patients receiving the placebo injection. Reactions at the injection site injection Vivitrola may be accompanied by pain, tenderness, induration, swelling, erythema and pruritus. However, in some cases injection site reactions may be very strong. During clinical studies, one patient was formed seal that 4 weeks after injection continued to increase with subsequent development of necrosis, which is required for removal surgery. During postmarketing observations were noted other cases of injection site reactions, including induration, cellulitis, hematoma, abscess, sterile abscess, and necrosis, to eliminate some of them required surgery. In some cases, mostly women, were formed at the site of the scars. Vivitrol for injection in the gluteal muscle, accidental subcutaneous administration of the drug can increase the risk of serious adverse reactions at the injection site. The needle for injection, which is part of the package, designed specifically for the introduction of the drug Vivitrol and in any case should not be replaced by any other needle. In some cases, due to the features of a constitution needle length may not be sufficient for intramuscular injection. Therefore, a doctor, before an injection is to make sure that the needle is suitable to the patient. If the needle is not suitable to assign different treatment. Patients should be warned of the need to inform the physician of the occurrence of any reaction at the site of the injection. In case of an abscess symptoms, inflammation of the subcutaneous tissue, necrosis or significant swelling, should decide whether surgery. Alcohol Cancel Application Vivitrola not only does not exclude, but does not reduce the manifestation of symptoms associated with the cancellation of the admission of alcohol. Occlusion of retinal occlusion retinal artery after the injection of another drug-containing copolymer of lactic and glycolic acid, a post-marketing study was very rare and has taken place in the presence of abnormal arteriovenous anastomosis. During clinical studies and post-marketing Vivitrola there was not a single case of obstruction of the retinal artery. Vivitrol should be entered only in the gluteal muscle, avoiding contact with the blood vessel.
Pregnancy and lactation
Exposure Vivitrola not been studied in pregnant women. Assign Vivitrol during pregnancy should only if the potential benefit to the mother of its use outweighs the potential risk to the fetus. Lactation When oral naltrexone was observed allocation of naltrexone and 6-beta naltrexol breast milk. Because of the potential carcinogenicity and the likelihood of infants serious side effects, discontinue treatment with Vivitrol during breast-feeding or to stop breastfeeding during treatment with the drug, depending on the degree of importance of the therapy for the mother.
Dosing and Administration
Vivitrol should be administered by qualified medical personnel only using the available components in the package. It is impossible to replace the components of the package. Vivitrola recommended dose is 380 mg / m once every four weeks or once a month. The drug should be administered in the gluteal muscle, alternating buttocks. Vivitrol should not be administered intravenously and subcutaneously!If the patient misses the introduction of the next dose, the next injection should be done as quickly as possible. Before applying Vivitrola not required oral naltrexone. The resumption of treatment after an interval of data to resume treatment after a break are missing. Translation alcohol-dependent patients with oral naltrexone on Vivitrol No systematic data on the transfer of patients with oral naltrexone on Vivitrol. Instructions for the preparation of a suspension for suspension only use the supplied solvent. Enter the drug should only be located in the needle set. All packaging components – the powder vial, a vial with a solvent for suspension needle and an injection needle with a protective cap – are necessary for administration. Included also is a spare needle for injection with a protective cap. Do not substitute components are included. To ensure accurate dosing should follow clear instructions on preparation and administration of the drug. Follow the rules of asepsis.
|The kit contains:
1 vial of powder,
1 vial of solvent,
1 disposable syringe,
1 short needle for suspension,
2 injection needles with protective cap,
instructions for medical use of the drug.
|1. Before using, remove the packaging with the product from the refrigerator and let it warm to room temperature (about 45 minutes).
2. To facilitate mixing tap bottomed bottle with a powder on a hard surface to loosen the powder.
3. Remove the aluminum caps from both vials. Do not use the medication if the vial cap is damaged or missing.
4. Wipe the necks of bottles with an alcohol swab.
5. Put the short needle for suspension in the syringe and Collect 3.4 ml of the solvent from the vial with the solvent. Vial some solvent remains.
|Use 3.4 ml of solvent into the vial with powder|
|Stir the solvent and the powder in the vial vigorously shaking for approximately 1 minute. Before proceeding, make sure that the suspension is homogeneous.Properly blended suspension should be milky white, without lumps and flow freely along the walls of the bottle.|
|Stir the solvent and the powder in the vial vigorously shaking for approximately 1 minute. Before proceeding, make sure that the suspension is homogeneous.Properly blended suspension should be milky white, without lumps and flow freely along the walls of the bottle.|
|1.Srazu after preparation Aspirate the syringe 4.2 ml of suspension using a needle to prepare a slurry.
2. Remove the needle and attach the syringe to the needle injection.
|Prior to injection, tap the syringe to release air bubbles, then gently push the plunger until the syringe is not left 4 ml of suspension.
The suspension is ready for immediate administration.
|1. The needle of the syringe injected deep into the gluteal muscle. Thereafter, suction motion of the piston is checked whether the needle into the vessel hit (if hit, is thrown into the syringe the blood). When the blood is necessary to repeat the procedure after replacing a spare needle.
2. The drug is administered smooth movement deep in the buttock. The suspension is introduced alternately in different buttocks.
3. Vivitrol should not be administered intravenously and subcutaneously.
|After administration of the drug, close the needle protective cap by pressing it with one hand to a solid surface, and keeping away from you. The use of protective cap prevents splashing of fluid that may remain on the needle after injection. Throw away used and unused packaging components.|
In clinical studies of up to 6 months duration 9% of patients with alcohol dependence, who were treated Vivitrolom, discontinued treatment because of side effects. In the group of patients treated with a placebo treatment because of adverse events 7% of patients discontinued. The most frequent reasons for not treating Vivitrolom were injection site reactions (3%), nausea (2%), pregnancy (1%), headache (1%) and suicidal behavior (0.3%). In the group of patients receiving a placebo injection, the treatment stopped only 1% of patients on the cause of the reactions at the injection site.
In clinical studies lasting up to 6 months 2% of patients with opioid dependence who were treated Vivitrolom, discontinued treatment because of side effects. In the group of patients treated with a placebo treatment because of side effects stopped 2% of patients.
The following listed side effects in patients with alcohol dependence encountered in clinical studies in more than 5% of the (frequent), the severity of these adverse effects characterized as mild to moderate.on the part of the gastrointestinal tract: Nausea, vomiting, diarrhea, frequent urge to defecation, gastrointestinal upset, loose stools, abdominal pain, stomach discomfort, dry mouth, anorexia, decreased appetite, violation of appetite. The respiratory system: upper respiratory tract infection, laryngitis, sinusitis, pharyngitis (including strep), nasopharyngitis. General disorders and reactions at the injection site:pain, tenderness, induration, swelling, itching, bleeding, fatigue, lethargy , lethargy. On the part of the musculoskeletal system: arthritis, joint pain, joint stiffness, back pain, pain in limbs, muscle spasms, muscle twitching, muscle stiffness. skin and subcutaneous tissue disorders: rash, papular rash, prickly heat. From the nervous system : headache, migraine, dizziness, fainting, drowsiness, anxiety, sedative state.
Side effects in opioid-dependent patients were essentially the same as that of the alcohol-dependent patients.
Below are adverse effects in opioid-dependent patients, occurring during clinical trials in over 2% of the (frequent), the severity of those side phenomena characterized as mild to moderate. Laboratory findings: Increased alanine aminotransferase activity, aspartate aminotransferase and gamma-glutamyl transferase. The respiratory system: . nasopharyngitis, influenza From the nervous system: insomnia, headache. On the part of the cardiovascular system: Increased blood pressure. General disorders and administration site reactions: pain. On the part of the gastrointestinal tract: Toothache.
Adverse reactions identified during the pre-registration research preparation: From the gastrointestinal tract : Perversion of taste, increased appetite, reflux esophagitis, constipation, flatulence, hemorrhoids, colitis, gastrointestinal bleeding, paralytic ileus, pararectal abscess, gastroenteritis, abscess tooth, abdominal discomfort, acute pancreatitis. General disorders and reactions at the injection site : Rising temperatures, lethargy, chest pain, chest tightness, increase or decrease in body weight, tremors, chills, face edema. Psychiatric disorders : Irritability, sleep disturbances , a syndrome of “cancellation” of alcohol, agitation, euphoria, delirium tremens. From the nervous system : Violation of attention, migraine, decreased mental activity, seizures, ischemic stroke, aneurysm of cerebral arteries, paresthesia.From the senses: Blurred vision, conjunctivitis. From the musculoskeletal system: pain in the extremities, muscle spasm, stiffness in the joints, myalgia. skin and subcutaneous tissue disorders: sweating, including at night, itching. The respiratory system : sore throat, shortness of breath, nasal congestion, obstructive bronchitis, bronchitis, pneumonia, laryngitis, sinusitis, upper respiratory tract infection. On the part of metabolism: Heat stroke, dehydration, hypercholesterolemia. cardio-vascular system : “Tides”, deep vein thrombosis, pulmonary thrombosis, heart palpitations, atrial fibrillation , myocardial infarction, angina, unstable angina, chronic heart failure, atherosclerosis of the coronary arteries. From the blood and lymphatic system: lymphadenopathy, including inflammation of the lymph nodes, increase in blood leukocytes. immune system : Seasonal allergies, hypersensitivity reactions , including angioedema and urticaria, pogressirovanie HIV infection in HIV-infected patients. With the genitourinary system: Spontaneous abortion, decreased libido, urinary tract infection. On the part of the hepatobiliary system : Cholelithiasis, increased activity of alanine aminotransferase and aspartate aminotransferase, acute cholecystitis.
Data on overdose is very limited. Single doses of 784 mg were administered to healthy volunteers 5. They had been no serious adverse events. The most common adverse events were injection site reactions, nausea, abdominal pain, drowsiness and dizziness. Significant increase in the amount of liver enzymes were noted.
Should be appropriate supportive treatment in case of overdose.
Interaction with other drugs
Vivitrola interaction with other drugs has not been studied.
Naltrexone is an antagonist of opioid-containing medicines (eg, drugs for coughs, colds, antidiarrheal preparations and opioid analgesics).
Because naltrexone is not a substrate enzyme system cytochrome, inducers or inhibitors of these enzymes are unlikely to affect Vivitrola clearance. Studies to evaluate the clinical significance of the effect of other drugs on metabolism was not Vivitrola done, so be careful and evaluate the potential risk and the potential benefit in the appointment Vivitrola in conjunction with other medications.
The safety record Vivitrola application together with antidepressants or without the same.
Reception excessive doses of naltrexone can cause hepatocellular disorders.
Naltrexone is contraindicated in acute hepatitis and liver failure. Appointment Vivitrola patients with active liver disease must be carefully considered and justified, taking into account the risk of liver dysfunction. The relationship between a safe dose of naltrexone and the dose causing hepatic disorders, <5.
When used in recommended doses Vivitrol is not hepatotoxic.
Patients should be warned of the risk of liver disorders and advised to seek medical help in case of hepatitis symptoms. In the event of such symptoms Vivitrolom treatment should be discontinued.Eosinophilic pneumonia in clinical trials and one case of a suspected case of eosinophilic pneumonia was diagnosed. In both cases, patients required hospitalization, were treated with antibiotics and corticosteroids. It is necessary to consider the possibility of eosinophilic pneumonia in patients receiving Vivitrol, and advise patients with symptoms such as, progressive dyspnea and hypoxia, immediately seek medical care. Physicians should take into account possibility of eosinophilic pneumonia in patients who are resistant to antibiotics. hypersensitivity reactions When receiving Vivitrol drug may develop side effects such as urticaria, angioedema, anaphylaxis. Patients should be warned that in case of hypersensitivity reactions should seek medical advice immediately and cease any further treatment with the drug. An overdose of opioids after trying to overcome their blockade after opioid detoxification patients are usually reduced tolerance to opioids. Vivitrol blocks the effects of exogenous opioids for 28 days, but there are cases of fatal overdose of opioids in patients who were taking opioids before introducing new dose Vivitrola or in the case of missing the next injection Vivitrola. Patients who have undergone treatment Vivitrolom, may be sensitive to lower doses of opioids than before treatment. It can cause potentially life-threatening opioid intoxication (respiratory failure or respiratory failure, collapse, etc.).Patients should be warned about the fact that after stopping treatment Vivitrolom they may be more sensitive to lower doses of opioids. It is important to remember to reduce opioid tolerance at the end of the dosing interval, that is, about a month after the injection and in the case of missing the next injection. Patients and their families should be warned about an increased sensitivity to opioids and the risk of opioid overdose. Despite the fact that Vivitrol is a potent antagonist of the opioid receptor with prolonged pharmacological effect caused by the blockade of them can be overcome. Patients trying to overcome the blockade of the introduction of large doses of exogenous opioids, at risk of a lethal dose of opioids and expose his life to danger. The concentration of opioid in the plasma as soon as they receive may be sufficient to overcome the competitive blockade of opioid receptors, and as a result the patient can quickly develop a life-threatening opioid intoxication, manifested by respiratory depression, collapse.Patients should be aware of the seriousness of the consequences of attempts to overcome the blockade of opioid receptors. The effect of the drug on the duration of labor and childbirth Effect on the duration of labor and delivery is unknown. The effect of the drug on laboratory parameters of blood in patients receiving treatment Vivitrolom, it noted elevated levels of eosinophils in the blood, however, after several months of treatment eosinophils normalized. in patients receiving high-dose, there was a decrease in platelet count on average 17.8 x 10 3 l. However, randomized controlled trials of the effect of the increase in bleeding Vivitrola not proved. In patients with opioid dependence treated with the drug for 24 weeks, there was a reduction in platelet count by an average of 62.8 x 10 3 l. Patients in the placebo group, the platelet count decreased by an average of 39.9 x 10 3 l. However, the effect of randomized controlled trials to increase bleeding Vivitrola not shown. Increased activity of AST in the blood during treatment Vivitrolom was the same as in the treatment and oral naltrexone was 1.5% compared with 0.9% in the group of patients receiving placebo. In clinical studies lasting up to 6 months in patients with opioid dependence, 89% of patients were diagnosed with hepatitis C, 41% of patients – HIV infection. The study is often observed increased activity of “liver” enzymes (alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transferase). These side effects were more common in patients treated with Vivitrolom 380 mg than in patients receiving placebo. Patients with alanine aminotransferase or aspartate aminotransferase activity exceeding ULN more than three times, not included in the study. Patients treated Vivitrolom, increased transaminases more than 3 times compared to the upper limit of normal, and requires immediate treatment, were observed more frequently than in patients receiving placebo. This increase in enzyme activity was observed in 20% of patients treated Vivitrolom, compared with 13% of patients in the placebo group. Increased aspartate aminotransferase activity in more than three times the upper limit of normal as often observed in patients treated with Vivitrolom (14%) compared with patients in the placebo group (11%). In patients with opioid dependence treated Vivitrolom , alanine aminotransferase activity increased an average of 61 IU / l in patients in the placebo group -. an average of 48 IU / l in patients with opioid dependence treated Vivitrolom, aspartate aminotransferase activity increased an average of 40 IU / l in patients placebo -. an average of 31 IU / l in clinical trials in patients receiving Vivitrol observed increase of creatine phosphokinase activity, as a rule, 1 – 2 times as compared with the upper limit of normal. A similar increase in creatine kinase activity is also observed in the treatment of oral naltrexone. However, there are cases of 4-fold and even 35-fold increase in the activity of this enzyme in the group of patients treated with oral naltrexone and Vivitrol, respectively. In 39% of patients with opioid dependence treated Vivitrolom observed increased activity of creatine kinase above normal values in the group of patients placebo increase creatine phosphokinase activity was observed in 32% of patients. in some cases, patients treated with placebo, creatine phosphokinase activity was increased 41.8 times compared with the upper limit of normal; in the group of patients treated Vivitrolom, cases increase creatine phosphokinase activity of 22.1 times compared with the upper limit of normal. In carrying out some of the immunoassays of urine may cause false-positive results on a number of drugs, especially opioids. For more information, to conduct analyzes of specific instructions.
Effects on ability to drive and operate machinery.
During treatment with Vivitrol dizziness may occur. In the event of dizziness should refrain from driving a vehicle, as well as working with machinery.
Powder for suspension for intramuscular injection of long-acting 380 mg. Powder : The amount of powder containing 430 mg of naltrexone (12.9% excess) was placed in a glass vial with 5 ml capacity, a sealed with a rubber stopper and an aluminum cap with a break in the plastic cover, facilitates opening. solvent : 4 mL of solvent was placed in a glass bottle with capacity of 5 ml, a sealed rubber septum and run-aluminum cap with a plastic cap to facilitate opening. one vial of powder, one vial of 4 ml of solvent, a 5-mL syringe, one short needle for preparing suspension, two needles for injection with a protective cap, in a pack carton along with instructions for medical use. steroiden kaufen
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