Appendix I Template - Product Monograph Template - Schedule D

[Title Page]

PRODUCT MONOGRAPH

<Scheduling Symbol>  <BRAND NAME>

<Proper name>

<Dosage Form(s) and Strength(s)>

<Therapeutic Classification>

<Sponsor Name>
<Sponsor Address>

Date of Preparation:
<MON DD, YYYY>
or
Date of Revision:
<MON DD, YYYY>

Submission Control No: <control number> [optional]

Table of Contents

[To update, right-click anywhere in the Table of Contents and select "Update Field", "Update entire table", click OK.]

• Part I: Health professional information
  • Summary product information
  • Indications and clinical use
  • Contraindications
  • Warnings and precautions
  • Adverse reactions
  • Drug interactions
  • Dosage and administration
  • Overdosage
  • Action and clinical pharmacology
  • Storage and stability
  • Special handling instructions
  • Dosage forms, composition and packaging
    
• Part II: Scientific information
  • Pharmaceutical Information
  • Clinical Trials
  • Detailed Pharmacology
  • Toxicology
  • References
    
• Part III: Consumer Information

<PROPRIETARY OR BRAND NAME>

< Proper name >

Part I: Health Professional Information

Summary product information

Description

Physical Characteristics
<text>

External Radiation
<text>

Indications and clinical use

<Brand Name (proper name)> is indicated for:

• treatment of <text>
• prevention of <text>
• diagnosis of <text>

[Brief discussion of any promising clinical information - if applicable]

[Distribution restrictions - if applicable]

[When the product is not recommended - if applicable]

Geriatrics (> x years of age):
<text>

Pediatrics (x - y years of age) or (< years of age):
<text>

Contraindications

• Patients who are hypersensitive to this drug or to any ingredient in the formulation or component of the container. For a complete listing, see the Dosage Forms, Composition and Packaging section of the product monograph. [if applicable]
• <text>
• <text>

Warnings and precautions

[headings to be included as applicable]

General
The product should be administered under the supervision of a health professional who is experienced in the use of radiopharmaceuticals.  Appropriate management of therapy and complications is only possible when adequate diagnostic and treatment facilities are readily available.

The radiopharmaceutical product may be received, used and administered only by authorized persons in designated clinical settings. Its receipt, storage, use, transfer and disposal are subject to the regulations and/or appropriate licenses of local competent official organizations.

As in the use of any other radioactive material, care should be taken to minimize radiation exposure to patients consistent with proper patient management, and to minimize radiation exposure to occupational workers.
<text>
<text>

Carcinogenesis and Mutagenesis
<text>

Cardiovascular
<text>

Contamination
<text>

Dependence/Tolerance
<text>

Ear/Nose/Throat
<text>

Endocrine and Metabolism
<text>

Gastrointestinal
<text>

Genitourinary
<text>

Hematologic
<text>

Hepatic/Biliary/Pancreatic
<text>

Immune
<text>

Neurologic
<text>

Ophthalmologic
<text>

Peri-Operative Considerations
<text>

Psychiatric
<text>

Renal
<text>

Respiratory
<text>

Sensitivity/Resistance
<text>

Sexual Function/Reproduction
<text>

Skin
<text>

Special Populations

Pregnant Women: [Ideally examinations using radiopharmaceuticals, especially those elective in nature of women of childbearing capability should be performed during the first ten days following the onset of menses.]

[The extent of exposure in pregnancy during clinical trials should be included:
Wide: > 1000 pregnancies
Limited: < 1000 pregnancies
Very Limited: individual cases only
No experience ]

Nursing Women: <text>

Pediatrics (x - y years of age) or (< years of age): <text>

Geriatrics (> x years of age): <text>

Monitoring and Laboratory Tests
<text>

Adverse reactions

Adverse Drug Reaction Overview
[An overview of the ADR information that may affect prescribing decisions. It should contain: serious and important ADRs; the most frequent ADRs; and ADRs that most commonly result in clinical intervention.]

Clinical Trial Adverse Drug Reactions

Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.

[Include description of data sources]

[Narrative to follow table to explain or supplement the information provided in the table]

Less Common Clinical Trial Adverse Drug Reactions (<1%)
[Presented as a list and categorized by body system]
Cardiovascular: <text>
Digestive: <text>
Gastrointestinal: <text>

Abnormal Hematologic and Clinical Chemistry Findings
<table>

Post-Market Adverse Drug Reactions
<narrative>

Drug interactions

Overview
<narrative>
[should include the following information: interactions suspected based on the pharmacokinetic or pharmacologic profile of the drug (e.g., cytochrome P450 interactions); drug class statements if the interaction has not yet been documented, but would be clinically significant; potential interaction with alcohol]

Drug-Drug Interactions

Legend: C = Case Study, CT = Clinical Trial, T = Theoretical

Drug-Food Interactions
<narrative>

Drug-Herb Interactions
<narrative>

Drug-Laboratory Interactions
<narrative>

Drug-Lifestyle Interactions
<narrative>

Dosage and administration

Dosing Considerations
<text>

Dosage
<text>

Administration
The patient dose should be measured by a suitable radioactivity calibration system prior to administration.
<narrative>

Image Acquisition and Interpretation
<text>

Instructions for Preparation and Use
<text>

Directions for Quality Control
<text>

Radiation Dosimetry

Example of Acceptable Presentation of Dose Estimate Data:

Effective Dose Equivalent (mSv/MBq) (rem/mCi)
Effective Dose (mSv/MBq) (rem/mCi)

Overdosage

<narrative>

Action and clinical pharmacology

Mechanism of Action
<narrative>

Pharmacodynamics
<narrative>

Pharmacokinetics

Absorption:  <text>

Distribution:  <text>

Metabolism:  <text>

Excretion:  <text>

Special Populations and Conditions

Pediatrics: <text>

Geriatrics:  <text>

Gender:  <text>

Race:  <text>

Hepatic Insufficiency:  <text>

Renal Insufficiency:  <text>

Genetic Polymorphism: <text>

Storage and stability

<narrative>

Special handling instructions

As in the use of any other radioactive material, care should be taken to minimize radiation exposure to patients consistent with proper patient management, and to minimize radiation exposure to occupational workers.
<narrative>

Dosage forms, composition and packaging

<narrative>

Part II: Scientific information

Pharmaceutical Information

Drug Substance

• Proper name: <text>
• Chemical name: <text>
• Molecular formula and molecular mass: <text>
• Structural formula: <image>
• Physicochemical properties: <text>

Product Characteristics
<narrative>

Clinical Trials

Study demographics and trial design

[Provide a brief narrative describing the demographic characteristics of the study population].

Study results

Detailed Pharmacology

<narrative>

Toxicology

[table format wherever possible]

References

[numbered list]

Part III: Consumer Information

<Brand name>
<Proper Name>

This leaflet is part III of a three-part  "Product Monograph" published when  <brand name> was approved for sale in Canada and is designed specifically for Consumers. This leaflet is a summary and will not tell you everything about <brand name>.  Contact your doctor or pharmacist if you have any questions about the drug.

ABOUT THIS  MEDICATION

What the medication is used for:
<narrative> and/or

• <text>
• <text>

What it does:
<text>

When it should not be used:
<text>

What the medicinal ingredient is:
<proper name>

What the important nonmedicinal ingredients are:
<alphabetical listing>
For a full listing of nonmedicinal ingredients see Part 1 of the product monograph.

WARNINGS AND PRECAUTIONS

BEFORE you receive <brand name> talk to your doctor or pharmacist if:

• <Current conditions  (Contraindications, Warnings and Precautions)>
• <Past diseases (Contraindications, Warnings and Precautions)>
• <Reproductive issues (Contraindications, Warnings and Precautions)>
• <Anticipated medical procedures (Warnings and Precautions)>
• <Any allergies to this drug or its ingredients or components of the container (Contraindications)>
• <Contamination (Warnings and Precautions) >

INTERACTIONS WITH THIS MEDICATION

Drugs that may interact with <brand name> include: <text> .

PROPER USE OF THIS MEDICATION

This product (<brand name>) will be administered under the supervision of a health professional who is experienced in the use of radiopharmaceuticals.>

SIDE EFFECTS AND WHAT TO DO ABOUT THEM

<text>

This is not a complete list of side effects.  If you have any unexpected effects after receiving <Brand Name>, contact your doctor or pharmacist.

MORE INFORMATION

This document plus the full product monograph, prepared for health professionals can be found at:
http://www.website.document
or by contacting the sponsor, <Sponsor Name>,
at: 1-800-XXX-XXXX

The HPFB (BGTD and TPD) website address is to be included in this section.  The sponsor also has the option of including their company website address.

This leaflet was prepared by <Sponsor Name>

Last revised:  <MON DD, YYYY>.