NeuroBloc

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ANNEX I 
 

SUMMARY OF PRODUCT CHARACTERISTICS 
 



2 
 
 

1. NAME OF THE MEDICINAL PRODUCT 
 
NeuroBloc 5000 U/ml solution for injection. 
 
2. QUALITATIVE AND QUANTITATIVE COMPOSITION 
 
Each ml contains 5000 U Botulinum Toxin Type B. 
Each 0.5 ml vial contains 2500 U Botulinum Toxin Type B. 
Each 1.0 ml vial contains 5000 U Botulinum Toxin Type B. 
Each 2.0 ml vial contains 10,000 U Botulinum Toxin Type B. 
Produced in Clostridium botulinum Serotype B (Bean Strain) cells. 
 
For the full list of excipients, see section 6.1. 
 
3. PHARMACEUTICAL FORM 
 
Solution for injection. 
Clear and colourless to light yellow solution. 
 
4. CLINICAL PARTICULARS 
 
4.1 Therapeutic indications 
 
NeuroBloc is indicated for the treatment of cervical dystonia (torticollis) in adults. 
 
4.2 Posology and method of administration 
 
NeuroBloc should only be administered by a physician who is familiar with and experience in the 
treatment of cervical dystonia and in the use of botulinum toxins. 
 
Restricted to hospital use only.  
 
Posology 
 
The initial dose is 10,000 U and should be divided between the two to four most affected muscles. 
Data from clinical studies suggest that efficacy is dose dependent, but these trials, because they were 
not powered for a comparison, do not show a significant difference between 5000 U and 10,000 U. 
Therefore an initial dose of 5000 U may also be considered, but a dose of 10,000 U may increase the 
likelihood of clinical benefit. 
 
Injections should be repeated as required to maintain good function and minimise pain. In long term 
clinical studies, the average dosing frequency was approximately every 12 weeks, however this may 
vary between subjects, and a proportion of patients maintained a significant improvement relative to 
baseline for 16 weeks or longer. The dosing frequency should therefore be adapted based on the 
clinical assessment/response of an individual patient.  
 
For patients with reduced muscle mass the dose should be adjusted according to individual patient 
need. 
 
The potency of this medicinal product is expressed in NeuroBloc 5000 U/ml. These units are not 
interchangeable with the units used to express the potency of other botulinum toxin preparations (see 
section 4.4). 
 
Special populations 
 
Elderly 
No dose adjustment is required in older people ≥ 65 years of age. 
 



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Renal and hepatic impairment 
Studies have not been carried out in patients with hepatic or renal impairment. However, the 
pharmacological characteristics do not indicate any need to adjust the dose. 
 
Paediatric population 
The safety and efficacy of NeuroBloc in children aged less than 18 years have not yet been 
established. No data are available. 
 
Method of administration 
 
NeuroBloc must only be administered by intramuscular injection. Particular caution should be paid to 
ensure that it is not injected into a blood vessel. 
 
The initial dose of 10,000 U should be divided between the two to four most affected muscles. 
 
To allow division of the total dose between several injections, NeuroBloc may be diluted with sodium 
chloride 9 mg/ml (0.9%) solution for injection and the solution used immediately. For instructions on 
dilution of the product before administration, see section 6.6. 
 
4.3 Contraindications 
 
Individuals with known neuromuscular diseases (e.g. amyotrophic lateral sclerosis or peripheral 
neuropathy) or known neuromuscular junctional disorders (e.g. myasthenia gravis or Lambert-Eaton 
syndrome) must not be given NeuroBloc. 
 
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 
 
4.4 Special warnings and precautions for use 
 
NeuroBloc is recommended for intramuscular administration only.  
 
The safety of NeuroBloc outside the approved indication has not been established. This warning 
includes use in children and in any other indication besides cervical dystonia. The risks, which can 
include death, may outweigh the potential benefits. 
 
Seroconversion 
As with many biological/biotechnology proteins used as therapeutic agents, repeated administration of 
NeuroBloc may be associated with development of antibodies to Botulinum Toxin Type B in some 
patients. Immunogenicity data from three long term clinical studies indicate that approximately one 
third of patients develop antibodies, as determined by the mouse neutralisation/mouse protection assay 
dependent on duration of exposure (see section 5.1).   
 
An investigation into the consequence of seroconversion showed that the presence of antibodies was 
not synonymous with a loss of clinical response, and did not have an impact on the overall safety 
profile. However, the clinical relevance of the presence of antibodies as determined by the mouse 
neutralisation / mouse protection assay is uncertain. 
 
Caution should be used in patients with bleeding disorders or receiving anticoagulant therapy. 
 
Spread of toxin effect 
Neuromuscular effects related to spread of toxin, distant from the site of administration have been 
reported (see section 4.8). These include dysphagia and breathing difficulties.  
 



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Pre-Existing neuromuscular disorders 
Patients treated with therapeutic doses may experience exaggerated muscle weakness. Patients with 
neuromuscular disorders may be at increased risk of clinically significant effects including severe 
dysphagia and respiratory compromise from typical doses of NeuroBloc (see section 4.3). 
 
There have been spontaneous reports of dysphagia, aspiration pneumonia and/or potentially fatal 
respiratory disease, after treatment with Botulinum Toxin Type A/B. 
 
Children (non approved use) and patients with underlying neuromuscular disorders including 
swallowing disorders are at increased risk of these adverse reactions. In patients with neuromuscular 
disorders or history of dysphagia and aspiration, botulinum toxins should only be used in an 
experimental setting under strict medical supervision. 
 
Following NeuroBloc treatment, all patients and caregivers should be advised to seek medical 
attention for respiratory difficulties, choking or any new or worsening dysphagia. 
 
Dysphagia has been reported following injection to sites other than the cervical musculature. 
 
Lack of interchangeability between botulinum toxin products 
The initial starting dose of 10,000 U (or 5000 U) is relevant only to NeuroBloc (Botulinum Toxin 
Type B). These dose units are specific to NeuroBloc only and are not relevant to preparations of 
Botulinum Toxin Type A. The unit dose recommendations for Botulinum Toxin Type A are 
significantly lower than those for NeuroBloc and administration of Botulinum Toxin Type A at the 
unit dose recommended for NeuroBloc may result in systemic toxicity and life-threatening clinical 
sequelae. 
 
4.5 Interaction with other medicinal products and other forms of interaction 
 
The effect of administering different botulinum neurotoxin serotypes concurrently is unknown. 
However, in clinical studies, NeuroBloc was administered 16 weeks after the injection of Botulinum 
Toxin Type A. 
 
Co-administration of NeuroBloc and aminoglycosides or agents interfering with neuromuscular 
transmission (e.g. curare-like compounds) should be considered with caution. 
 
4.6 Fertility, pregnancy and lactation 
 
Pregnancy 
Animal reproduction studies are insufficient with respect to effects on pregnancy and embryonal/foetal 
development. The potential risk for humans is unknown. NeuroBloc should not be used during 
pregnancy unless the clinical condition of the woman requires treatment with Botulinum Toxin 
Type B (see section 5.3). 
 
Breast-feeding 
It is unknown whether Botulinum Toxin Type B is excreted in human breast milk. The excretion of 
Botulinum Toxin Type B in milk has not been studied in animals. A decision must be made on 
whether to continue/discontinue breast-feeding or to continue/discontinue therapy with NeuroBloc 
taking into account the benefit of breast-feeding to the child and the benefit of NeuroBloc therapy to 
the woman. 
 
Fertility 
No fertility studies have been performed and it is not known whether NeuroBloc can affect 
reproduction capacity. 
 
 
 



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4.7 Effects on ability to drive and use machines 
 
No studies on the effects on the ability to drive and use machines have been performed. Neurobloc 
may impair the ability to drive or operate machinery in case of adverse reactions such as muscle 
weakness and eye disorders (blurred vision, eyelid ptosis). 
 
4.8 Undesirable effects 
 
Summary of the safety profile 
The most commonly reported adverse reactions associated with NeuroBloc treatment were dry mouth, 
dysphagia, dyspepsia, and injection site pain. 
 
Adverse reactions related to spread of toxin distant from the site of administration have been reported: 
exaggerated muscle weakness, dysphagia, dyspnoea, aspiration pneumonia with fatal outcome in some 
cases (see section 4.4). 
 
Tabulated list of adverse reactions 
Adverse reactions seen in all clinical studies are listed below according to MedDRA system organ 
class and in decreasing frequency which is defined as follows: Very Common (>1/10); 
Common (>1/100 to <1/10); Uncommon (>1/1000 to <1/100). 
 
 
System Organ Class Very Common Common 
Nervous system disorders dry mouth, headache torticollis (worsening from 

baseline), taste perversion 
Eye disorders  blurred vision 
Respiratory thoracic and 
mediastinal disorders 

 dysphonia 

Gastrointestinal disorders dysphagia dyspepsia 
Musculoskeletal connective 
tissue and bone disorders 

 myasthenia 

General disorders and 
administration site conditions 

injection site pain 
 

neck pain 
influenza like illness 

 
 
In common with Botulinum Toxin Type A, electrophysiological jitter, which is not associated with 
clinical weakness or other electrophysiological abnormalities, may be experienced in some distant 
muscles. 
 
Post marketing experience 
Side effects related to spread of toxin distant from the site of administration have been reported 
(exaggerated muscle weakness, dysphagia, dyspnoea, aspiration pneumonia with fatal outcome in 
some cases) (see section 4.4). 
 
The following effects have also been reported during post marketing use: abnormal accommodation, 
ptosis, vomiting, constipation, flu-like symptoms, asthenia, angioedema, rash, urticaria and pruritus. 
 
The available reports indicate that the product has been used in the paediatric population. Case reports 
are more likely to be serious in children (40%) compared to those in adults and older people (12%), 
possibly as a result of using an inappropriately high dosage for the child (see section 4.9). 
 



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Reporting of suspected adverse reactions 
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It 
allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare 
professionals are asked to report any suspected adverse reactions via the national reporting system 
listed in Appendix V. 
 
4.9 Overdose 
 
Cases of overdose (some with signs of systemic toxicity) have been reported. In the event of an 
overdose, general medical supportive measures should be instituted. Doses of up to 15,000 U have 
infrequently resulted in clinically significant systemic toxicity in adults. If botulism is clinically 
suspected, hospitalisation for the monitoring of respiratory function (incipient respiratory failure) may 
be required. 
 
In the event of an overdose or injection into a muscle that normally compensates for the cervical 
dystonia, it is conceivable that the dystonia may worsen. As with other botulinum toxins spontaneous 
recovery will occur over a period of time. 
 
Paediatric use (non approved): in children, clinically significant systemic toxicity has occurred at 
doses approved for the treatment of adult patients. The risk of spreading of effect is greater than in 
adults, and more frequently severe. This can be due to the high dosages usually used in this 
population. 
 
5. PHARMACOLOGICAL PROPERTIES 
 
5.1 Pharmacodynamic properties 
 
Pharmacotherapeutic group: muscle relaxant, peripherally acting agents, ATC code: M03AX 01. 
 
Mechanism of action 
NeuroBloc is a neuromuscular blocking agent. The mechanism of action of NeuroBloc in blocking 
neuromuscular conduction occurs by a three-step process: 
 
1. Extracellular binding of the toxin to specific acceptors on motor nerve terminals 
2. Internalisation and release of the toxin into the cytosol of the nerve terminals 
3. Inhibition of acetylcholine release from nerve terminals at the neuromuscular junction 
 
When injected directly into a muscle, NeuroBloc causes a localised paralysis that gradually reverses 
over time. The mechanism by which muscle paralysis is reversed over time remains unknown, but 
may be associated with the intraneuronal turnover of the affected protein and/or sprouting of the nerve 
ending. 
 
Clinical efficacy and safety 
A series of clinical studies have been conducted to evaluate the efficacy and safety of NeuroBloc in 
the treatment of cervical dystonia. These studies have demonstrated the activity of NeuroBloc in both 
treatment-naïve patients, and patients who have previously received treatment with Botulinum Toxin 
Type A, including those that were considered clinically resistant to Botulinum Toxin Type A. 
 
Two Phase III randomised, multicentre, double-blind, placebo-controlled studies were conducted in 
patients with cervical dystonia. Both studies enrolled adult patients (³ 18 years) who had a history of 
receiving Botulinum Toxin Type A. The first study enrolled patients who were clinically resistant to 
type A toxin (A-non responders), confirmed by a Frontalis Type A test. The second study enrolled 
patients who continued to respond to type A toxin (A-responders). In the first study, type A resistant 
patients (A-non responders) were randomised to receive placebo or 10,000 U of NeuroBloc and in the 
second, type A toxin responsive patients (A-responders) were randomised to receive placebo, 5000 U 
or 10,000 U of toxin. The medicinal product was injected on a single occasion into 2 to 4 of the 

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following muscles: splenius capitus, sternocleidomastoid, levator scapulae, trapezius, semispinalis 
capitus and scalene. The total dose was divided between the selected muscles and 1 to 5 injections per 
muscle were administered. There were 77 subjects enrolled into the first study and 109 subjects into 
the second. Patient evaluations continued for 16 weeks post injection. 
 
The primary efficacy outcome variable for both studies was the Toronto Western Spasmodic 
Torticollis Rating Scale (TWSTRS)-Total score (range of possible scores is 0-87) at Week 4. The 
secondary endpoints included Visual Analogue Scales (VAS) to quantify the Patient Global 
Assessment of change and the Physician Global Assessment of change, both from baseline to Week 4. 
On these scales, scores of 50 indicate no change, 0 much worse, and 100 much better. Results of 
comparisons of the primary and secondary efficacy variables are summarised in Table 1. Analysis of 
the TWSTRS sub scales revealed significant effects on the severity of cervical dystonia and its 
associated pain and disability. 
 
Table 1 Efficacy Results from Phase III NeuroBloc Studies 

 STUDY 1 
(A-Resistant Patients) 

STUDY 2 
(A-Responsive Patients) 

Assessments Placebo 10,000 U Placebo 5000 U 10,000 U 
 n = 38 n = 39 n = 36 n = 36 n = 37 
TWSTRS-Total      
Mean At Baseline 51.2 52.8 43.6 46.4 46.9 
Mean at Week 4 49.2 41.8 39.3 37.1 35.2 
Change from Baseline -2.0 -11.1 -4.3 -9.3 -11.7 
P-Value*  0.0001  0.0115 0.0004 
Patient Global      
Mean at Week 4 39.5 60.2 43.6 60.6 64.6 
P-Value*  0.0001  0.0010 0.0001 
Physician Global      
Mean at Week 4 47.9 60.6 52.0 65.3 64.2 
P-Value*  0.0001  0.0011 0.0038 
 * Analysis of covariance, two-tailed tests, a = 0.05 
 
A further randomised, multicentre, double-blind study was conducted to compare the efficacy of 
NeuroBloc (10,000 U) to Botulinum Toxin Type A (150 U) in patients with cervical dystonia who 
have never previously received a botulinum toxin product. The primary efficacy assessment was the 
TWSTRS Total score, and secondary efficacy assessments included VAS assessment of change 
evaluated by patient and investigator, conducted at 4, 8 and 12 weeks after treatment. The study met 
the pre-defined criteria for non-inferiority of NeuroBloc compared to Botulinum Toxin Type A, both 
in terms of mean TWSTRS total score at week 4 after first and second treatment sessions, and in terms 
of duration of effect. 
 
The non-inferiority of NeuroBloc compared to Botulinum Toxin Type A was further supported by a 
responder analysis where similar percentages of subjects showed improvement in the TWSTRS score 
at Week 4 of Session 1 (86% NeuroBloc and 85% Botox), and a similar proportion of subjects 
experienced at least a 20% decrease from baseline in the TWSTRS score at Week 4 of Session 1 (51% 
NeuroBloc, 47% Botox). 
 
Further clinical studies and open label follow-up have shown that subjects can continue to respond to 
NeuroBloc for prolonged periods of time, with some subjects receiving more than 14 treatment 
sessions over a period of more than 3.5 years. In addition to improved function as demonstrated by a 
reduction in TWSTRS-total score, treatment with NeuroBloc was associated with a significant 
reduction in TWSTRS-Pain and pain VAS scores at each treatment session at weeks 4, 8 and 12 
relative to baseline. In these studies, the average dosing frequency was approximately every 12 weeks. 
 



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The immunogenicity of NeuroBloc has been evaluated in two clinical studies and an open-label 
extension study. The presence of antibodies in these studies was assessed using the mouse protection 
assay (also known as the Mouse Neutralization Assay, MNA).   
 
Immunogenicity data from three long-term clinical studies indicate that approximately one third of 
patients develop antibodies, as determined by the mouse neutralisation/ mouse protection assay 
dependent on duration of exposure. Specifically, these studies showed approximately 19-25% 
seroconverted within 18 months of initiation of treatment, increasing to approximately 33-44% with 
up to 45 months of treatment. An investigation into the consequence of seroconversion showed that 
the presence of antibodies was not synonymous with a loss of clinical response, and did not have an 
impact on the overall safety profile. However, the clinical relevance of the presence of antibodies as 
determined by the mouse neutralisation/ mouse protection assay is uncertain.   
 
The extent and time course of seroconversion were similar in patients with prior toxin A exposure and 
those who were toxin A naïve, and between toxin A resistant and toxin A responsive patients.  
  
5.2 Pharmacokinetic properties 
 
NeuroBloc injected intramuscularly produces localised muscle weakness by chemical denervation. 
Following local intramuscular injection of NeuroBloc serious adverse events that may have been due 
to systemic effects of Botulinum Toxin Type B, were observed in 12% of adverse reaction cases 
reported during the post-marketing experience (including the following adverse reactions: dry mouth, 
dysphagia and blurred vision). However, no pharmacokinetic or Absorption, Distribution, Metabolism 
and Excretion (ADME) studies have been performed. 
 
5.3 Preclinical safety data 
 
Single dose pharmacology studies in cynomolgus monkeys have shown no effects other than the 
anticipated dose-dependent paralysis of injected muscles, together with some diffusion of toxin at high 
doses producing similar effects in neighbouring non-injected muscles. 
 
Single dose intramuscular toxicology studies have been performed in cynomolgus monkeys. The 
systemic No Observed Effect Level (NOEL) was shown to be approximately 960 U/kg. The dose 
resulting in death was 2400 U/kg. 
 
Because of the nature of the product, no animal studies have been carried out to establish the 
carcinogenic effects of NeuroBloc. Standard tests to investigate the mutagenicity of NeuroBloc have 
not been performed.  
 
Development studies in rats and rabbits have shown no evidence of foetal malformations or changes to 
fertility. In the development studies, the No Observed Adverse Effect Dose Level (NOAEL) in rats 
was 1000 U/kg/day for maternal effects and 3000 U/kg/day for foetal effects. In rabbits, the NOAEL 
was 0.1 U/kg/day for maternal effects and 0.3 U/kg/day for foetal effects. In the fertility studies the 
NOAEL was 300 U/kg/day for general toxicity in both males and females and 1000 U/kg/day for 
fertility and reproductive performance. 
 
6. PHARMACEUTICAL PARTICULARS 
 
6.1 List of excipients 
 
Disodium succinate  
Sodium chloride  
Human serum albumin  
Hydrochloric acid (for pH adjustment) 
Water for injections 
 



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6.2 Incompatibilities 
 
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal 
products. 
 
6.3 Shelf life 
 
5 years, as packaged for sale. 
 
Use immediately if diluted (see section 4.2 and section 6.6).  
 
From a microbiological point of view, unless the method of opening/dilution precludes the risk of 
microbial contamination the product should be used immediately. 
 
6.4 Special precautions for storage 
 
Store in a refrigerator at 2oC-8oC.   
Do not freeze.   
 
Keep the container in the outer carton in order to protect from light. 
 
Within its shelf-life, the product may be removed from the refrigerator for a single period of up to 
3 months at a temperature not above 25°C, without being refrigerated again. At the end of this period, 
the product should not be put back in the refrigerator and should be disposed of. 
 
For storage conditions after dilution of the medicinal product, see section 6.3. 
 
6.5 Nature and contents of container 
 
0.5 ml, 1 ml or 2 ml solution in a 3.5 ml Type I glass vial, with siliconised butyl rubber stoppers 
oversealed by aluminium crimped caps. 
 
Pack size of 1. 
 
6.6 Special precautions for disposal and other handling 
 
NeuroBloc is provided in vials for single use only.  
 
The medicinal product is ready to use and no reconstitution is required. Do not shake. 
 
To allow division of the total dose between several injections, NeuroBloc may be diluted with sodium 
chloride 9 mg/ml (0.9%) solution for injection (see section 4.2). Such dilutions with sodium chloride 
should be done in a syringe, pulling out the desired amount of Neurobloc into the syringe first, and 
then adding sodium chloride to the syringe. In non clinical experiments, NeuroBloc solution has been 
diluted up to 6-fold without any resulting change in potency. Once diluted, the medicinal product must 
be used immediately as the formulation does not contain a preservative.  
 
Any unused solution, all vials of expired NeuroBloc and equipment used in the administration of the 
medicinal product should be carefully discarded as Medical Bioharzardous Waste in accordance with 
local requirements. Vials should be visually inspected prior to use. If the NeuroBloc solution is not 
clear and colourless/light yellow or if the vial appears damaged, the product should not be used, but 
discarded as Medical Biohazardous Waste in accordance with local requirements.  
 
Decontaminate any spill with 10% caustic solution, or sodium hypochlorite (household chlorine 
bleach –2 ml (0.5%): 1 litre water) solution. Wear waterproof gloves and soak up the liquid with an 
appropriate absorbent. Place the absorbed toxin in an autoclave bag, seal it and process as Medical 
Biohazardous Waste in accordance with local requirements. 
 
 



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7. MARKETING AUTHORISATION HOLDER 
 
Sloan Pharma S.à.r.l. 
33, Rue du Puits Romain 
8070 Bertrange 
Luxembourg 
 
8.  MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/00/166/001 – 2500 U 
EU/1/00/166/002 – 5000 U 
EU/1/00/166/003 – 10,000 U 
 
 
9.  DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 
 
Date of first authorisation:  22 January 2001 
Date of latest renewal: 29 November 2010 
 
 
10. DATE OF REVISION OF THE TEXT 
 
Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.



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ANNEX II 
 

A. MANUFACTURER OF THE BIOLOGICAL ACTIVE SUBSTANCE AND 
MANUFACTURER RESPONSIBLE FOR BATCH RELEASE  

 
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE 

 
C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING 

AUTHORISATION 
 

D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND 
EFFECTIVE USE OF THE MEDICINAL PRODUCT 

 
 
 



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A. MANUFACTURER OF THE BIOLOGICAL ACTIVE SUBSTANCE AND 
MANUFACTURER RESPONSIBLE FOR BATCH RELEASE  

 
Name and address of the manufacturer of the biological active substance 
 
Merz Pharma GmbH & Co. KGaA 
AmPharmapark 
Dessau-Rosslau 
Germany 
 
Name and address of the manufacturer responsible for batch release 
 
Almac  Pharma Services Limited 
Seagoe Industrial Estate 
Portadown 
Craigavon  
BT63 5UA 
United Kingdom 
 
And 
 
Almac Pharma Services (Ireland) Limited 
Finnabair Industrial Estate 
Dundalk 
Co. Louth 
A91 P9KD 
Ireland 
 
The printed package leaflet of the medicinal product must state the name and address of the 
manufacturer responsible for the release of the concerned batch. 
 
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE 
 
Medicinal product subject to restricted medical prescription (see Annex I: Summary of Product 
Characteristics, section 4.2). 
 
C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING 

AUTHORISATION 
 
•  Periodic Safety Update Reports  
 
The marketing authorisation holder shall submit periodic safety update reports for this product in 
accordance with the requirements set out in the list of Union reference dates (EURD list) provided for 
under Article 107c(7) of Directive 2001/83/EC and published on the European medicines web-portal. 
 
 
D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND 

EFFECTIVE USE OF THE MEDICINAL PRODUCT 
 
• Risk Management Plan (RMP) 
 
The MAH shall perform the required pharmacovigilance activities and interventions detailed in the 
agreed RMP presented in Module 1.8.2 of the Marketing Authorisation and any agreed subsequent 
updates of the RMP. 
An updated RMP should be submitted: 
 • At the request of the European Medicines Agency; 



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• Whenever the risk management system is modified, especially as the result of new information 
being received that may lead to a significant change to the benefit/risk profile or as the result of 
an important (pharmacovigilance or risk minimisation) milestone being reached. 

 
If the dates for submission of a PSUR and the update of a RMP coincide, they can be submitted at the 
same time. 



14 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANNEX III 
 

LABELLING AND PACKAGE LEAFLET 



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A. LABELLING 
 

 



16 
 
 

 
 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING 
 
OUTER CARTON 0.5 ml vial 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
NeuroBloc 5000 U/ml solution for injection 
Botulinum Toxin Type B 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each ml contains 5000 U Botulinum Toxin Type B.  
One vial of 0.5 ml contains 2500 U of Botulinum Toxin Type B. 
 
3. LIST OF EXCIPIENTS 
 
Disodium succinate, sodium chloride, human serum albumin solution, hydrochloric acid and water for 
injections. 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
Solution for injection 
1 vial 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Do not shake. 
Read the package leaflet before use. 
Intramuscular use.  
For single use only. 
 
6. SPECIAL WARNINGS THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
The potency of Neurobloc is 5000 U/ml. The units expressed are Type B Units, which are not 
interchangeable with the units used to express the potency of other Botulinum toxin preparations. 
 
8. EXPIRY DATE 
 
EXP 
After dilution, use immediately 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in a refrigerator (2°C-8°C).   
Do not freeze. 



17 
 
 

 
Keep the container in the outer carton in order to protect from light. 
 
Within its shelf-life, the product may be removed from the refrigerator for one single period of up to 
3 months at a temperature not above 25°C without being refrigerated again. At the end of this period, 
the product should not be put back in the refrigerator and should be disposed of. 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
Read package leaflet for special precautions for handling, in-use storage and disposal. 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Marketing Authorisation Holder: 
Sloan Pharma S.à.r.l. 
33, Rue du Puits Romain 
8070 Bertrange 
Luxembourg  
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/00/166/001 
 
13. BATCH NUMBER 
 
Lot 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
Justification for not including Braille accepted. 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC:  
SN:  
NN:  
 
 



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MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS 
 
VIAL LABEL 0.5 ml vial  
 
 
1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION 
 
NeuroBloc 5000 U/ml solution for injection 
IM 
 
 
2. METHOD OF ADMINISTRATION 
 
 
3. EXPIRY DATE 
 
EXP 
 
 
4. BATCH NUMBER 
 
Lot 
 
 
5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT 
 
2500 U 



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PARTICULARS TO APPEAR ON THE OUTER PACKAGING 
 
OUTER CARTON 1.0 ml vial 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
NeuroBloc 5000 U/ml Solution for injection  
Botulinum Toxin Type B 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each ml contains 5000 U Botulinum Toxin Type B.  
One vial of 1 ml contains 5000 U of Botulinum Toxin Type B. 
 
3. LIST OF EXCIPIENTS 
 
Disodium succinate, sodium chloride, human serum albumin solution, hydrochloric acid and water for 
injections.  
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
Solution for injection 
1 vial 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Do not shake.  
Read the package leaflet before use. 
Intramuscular use.  
For single use only. 
 
6. SPECIAL WARNINGS THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
The potency of Neurobloc is 5000 U/ml. The units expressed are Type B Units, which are not 
interchangeable with the units used to express the potency of other Botulinum toxin preparations. 
 
8. EXPIRY DATE 
 
EXP  
After dilution, use immediately 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in a refrigerator (2°C-8°C).   
Do not freeze. 
 



20 
 
 

Keep the container in the outer carton in order to protect from light. 
 
Within its shelf-life, the product may be removed from the refrigerator for one single period of up to 
3 months at a temperature not above 25°C without being refrigerated again. At the end of this period, 
the product should not be put back in the refrigerator and should be disposed of. 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
Read package leaflet for special precautions for handling, in-use storage and disposal. 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Marketing Authorisation Holder: 
Sloan Pharma S.à.r.l. 
33, Rue du Puits Romain 
8070 Bertrange 
Luxembourg 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/00/166/002 
 
13. BATCH NUMBER 
 
Lot 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
Justification for not including Braille accepted 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC:  
SN:  
NN:  
 
 



21 
 
 

 
 
MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS 
 
VIAL LABEL 1.0 ml vial  
 
 
1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION 
 
NeuroBloc 5000 U/ml solution for injection 
IM 
 
2. METHOD OF ADMINISTRATION 
 
 
3. EXPIRY DATE 
 
EXP  
 
4. BATCH NUMBER 
 
Lot 
 
5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT 
 
5000 U 



22 
 
 

 
 
PARTICULARS TO APPEAR ON THE OUTER PACKAGING 
 
OUTER CARTON 2.0 ml vial 
 
 
1. NAME OF THE MEDICINAL PRODUCT 
 
NeuroBloc 5000 U/ml Solution for injection  
Botulinum Toxin Type B 
 
2. STATEMENT OF ACTIVE SUBSTANCE(S) 
 
Each ml contains 5000 U of Botulinum Toxin Type B.  
One vial of 2 ml contains 10,000 U of Botulinum Toxin Type B.  
 
3. LIST OF EXCIPIENTS 
 
Disodium succinate, sodium chloride, human serum albumin solution, hydrochloric acid and water for 
injections. 
 
4. PHARMACEUTICAL FORM AND CONTENTS 
 
Solution for injection 
1 vial 
 
5. METHOD AND ROUTE(S) OF ADMINISTRATION 
 
Do not shake.  
Read the package leaflet before use. 
Intramuscular use.  
For single use only. 
 
6. SPECIAL WARNINGS THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 

OF THE SIGHT AND REACH OF CHILDREN 
 
Keep out of the sight and reach of children. 
 
7. OTHER SPECIAL WARNING(S), IF NECESSARY 
 
The potency of Neurobloc is 5000 U/ml. The units expressed are Type B Units, which are not 
interchangeable with the units used to express the potency of other Botulinum toxin preparations. 
 
8. EXPIRY DATE 
 
EXP  
After dilution, use immediately 
 
9. SPECIAL STORAGE CONDITIONS 
 
Store in a refrigerator (2°C-8°C).   
Do not freeze.  



23 
 
 

 
Keep the container in the outer carton in order to protect from light. 
 
Within its shelf-life, the product may be removed from the refrigerator for one single period of up to 
3 months at a temperature not above 25°C without being refrigerated again. At the end of this period, 
the product should not be put back in the refrigerator and should be disposed of. 
 
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 

OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE 

 
Read package leaflet for special precautions for handling, in-use storage and disposal. 
 
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER 
 
Marketing Authorisation Holder: 
Sloan Pharma S.à.r.l. 
33, Rue du Puits Romain 
8070 Bertrange 
Luxembourg 
 
12. MARKETING AUTHORISATION NUMBER(S) 
 
EU/1/00/166/003 
 
13. BATCH NUMBER 
 
Lot 
 
14. GENERAL CLASSIFICATION FOR SUPPLY 
 
Medicinal product subject to medical prescription. 
 
15. INSTRUCTIONS ON USE 
 
 
16. INFORMATION IN BRAILLE 
 
Justification for not including Braille accepted. 
 
17. UNIQUE IDENTIFIER – 2D BARCODE 
 
2D barcode carrying the unique identifier included. 
 
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA 
 
PC:  
SN:  
NN:  
 
 



24 
 
 

 
 
MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS 
 
VIAL LABEL 2.0 ml vial 
 
 
1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION 
 
NeuroBloc 5000 U/ml solution for injection 
IM 
 
2. METHOD OF ADMINISTRATION 
 
 
3. EXPIRY DATE 
 
EXP  
 
4. BATCH NUMBER 
 
Lot 
 
5. CONTENTS BY WEIGHT,  BY VOLUME OR BY UNIT 
 
10,000 U 



25 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

B. PACKAGE LEAFLET 



26 
 
 

 
Package leaflet: Information for the user  

 
NeuroBloc 5000 U/ml Solution for Injection 

Botulinum Toxin Type B 
 
 
Read all of this leaflet carefully before you start using this medicine because it contains 
important information for you. 
- Keep this leaflet. You may need to read it again. 
- If you have further questions, please ask your doctor or pharmacist. 
- If you get any side effects, talk to your doctor or pharmacist. This includes any possible side 

effects not listed in this leaflet. See section 4. 
 
What is in this leaflet 
 
1. What NeuroBloc is and what it is used for 
2. What you need to know before you use NeuroBloc 
3. How to use NeuroBloc 
4. Possible side effects 
5. How to store NeuroBloc 
6. Contents of the pack and other information 
 
 
1. What NeuroBloc is and what it is used for 
 
NeuroBloc injection works by reducing or stopping muscle contractions. It contains the active 
ingredient ‘Botulinum Toxin Type B’.  
  
NeuroBloc is used to treat an illness called cervical dystonia (torticollis). This is where you have 
contractions of your neck or shoulder muscles that you cannot control. 
 
2. What you need to know before you use NeuroBloc 
 
Do not use NeuroBloc: 
- if you are allergic to Botulinum Toxin Type B or any of the other ingredients of NeuroBloc 

(listed in section 6) 
- if you have other problems with your nerves or muscles, such as amyotrophic lateral sclerosis 

(Lou Gehrig's disease), peripheral neuropathy, myasthenia gravis or Lambert-Eaton syndrome 
(muscle weakness or numbness or pain) 

- if you have been experiencing shortness of breath or difficulty swallowing 
 
You must not be given NeuroBloc if any of the above applies to you. If you are not sure talk to your 
doctor or pharmacist. 
 
Warnings and precautions 
Talk to your doctor or pharmacist before using NeuroBloc: 
- if you have a bleeding problem such as haemophilia  
- if you have lung problems 
- if you have difficulty swallowing. This is because swallowing problems could make you breathe 

food or liquids into your lungs, which could then cause very serious pneumonia 
 



27 
 
 

General precaution: 
NeuroBloc has been approved for the treatment of cervical dystonia only and should not be used to 
treat anything else. The safety of NeuroBloc when used to treat other conditions is not known: some 
side effects may be fatal. 
 
Children and adolescents 
NeuroBloc is not to be used in children aged less than18 years.  
 
Other medicines and NeuroBloc 
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other 
medicines. This is because NeuroBloc can affect the way some medicines work and other medicines 
can also affect the way NeuroBloc works. 
 
In particular, tell your doctor or pharmacist if you are taking any of the following medicines: 
- aminoglycoside antibiotics for an infection 
- medicines to stop blood clotting, such as warfarin 
 
If you are not sure if any of the above applies to you, talk to your doctor or pharmacist before you are 
given NeuroBloc. 
 
Before having an operation 
If you are going to have an operation, please tell your doctor that you have been given NeuroBloc. 
This is because NeuroBloc can affect the medicines you may be given before a general anaesthetic. 
 
Pregnancy, breast-feeding and fertility 
- you will not normally be given NeuroBloc if you are pregnant or breast-feeding. This is because 

it is not known how NeuroBloc affects patients who are pregnant and it is not known if 
NeuroBloc passes into a nursing mother’s breast milk 

- if you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, 
ask your doctor or pharmacist for advice before taking this medicine 

 
Driving and using machines 
You may have muscle weakness or eye problems such as blurred vision or eyelid drooping after being 
given NeuroBloc. If this happens, do not drive or use any tools or machines. 
 
NeuroBloc contains less than 1 mmol sodium (23 mg) per 10,000 units of NeuroBloc. This means it 
is essentially “sodium free”. 
 
3. How to use NeuroBloc 
 
NeuroBloc will be given to you by a doctor with specialist experience in the treatment of cervical 
dystonia and in the use of botulinum toxins. 
 
How much will be given 
- your doctor will decide how much NeuroBloc to give you  
- the usual dose is 10,000 units, however, it can be higher or lower 
- if you have had NeuroBloc injections before, your doctor will take into account how well it 

worked the other times 
 
How NeuroBloc is given 
- NeuroBloc will be injected into your neck or shoulder muscles, depending on which ones are 

causing the problem  
- your doctor may inject part of the dose into different places in your muscles 
 
Having more injections of NeuroBloc 
- the effects of NeuroBloc will usually last about 12 to 16 weeks  
- your doctor will decide if you need another injection and how much to give you 
 
If you think that the effect of NeuroBloc is too strong or too weak, talk to your doctor. 



28 
 
 

 
If you are given more NeuroBloc than you should 
- if you have been given more NeuroBloc than you need, some of your muscles that were not 

injected may feel weak or you may develop symptoms away from the injected muscles, like 
difficulty in swallowing or breathing. This may occur when higher doses of up to 15,000 units 
are given  

- if you have difficulty breathing or you are worried by any symptoms you develop away from 
the place of the injection, talk to your doctor immediately. If he/she is unavailable seek 
emergency assistance. You may need urgent medical treatment 

 
A serious condition called “botulism” which causes paralysis of muscles and respiratory failure could 
occur if too much of the active ingredient (botulinum toxin) is injected into the body. If your doctor 
suspects that botulism may have occurred, you will be admitted to hospital and your breathing 
(respiratory function) will be monitored. Recovery usually takes place over a period of time. 
 
4. Possible side effects 
 
Like all medicines, this medicine can cause side effects, although not everybody gets them. They may 
happen days to weeks after you have had the injection. You may feel pain at the place where you had 
the injection, but this should wear off after a few minutes. 
 
You may get a dry mouth and it might become difficult to swallow. In rare cases difficulty in 
swallowing may be severe and choking is possible. If your swallowing difficulty gets worse or you 
have choking or breathing problems, see a doctor immediately. You may need urgent medical 
treatment. 
 
Aspiration pneumonia caused by food particles or vomit entering into the lungs, and respiratory 
disease, have been reported after treatment with botulinum toxins (Type A and Type B). These side 
effects have sometimes resulted in death and are possibly related to the spread of botulinum toxin to 
body parts away from the place where the injection is given. 
 
Other side effects include: 
Very common (may affect more than 1 in 10 people) 
- dry mouth 
- difficulty swallowing 
- headache 
 
Common (may affect up to 1 in 10 people) 
- blurred vision or drooping of your upper eyelid  
- indigestion or being sick (vomiting) 
- constipation 
- neck pain 
- feeling weak, pain or stiff muscles around your body 
- loss of strength or energy 
- changes in the taste of your food and drink 
- changes in the sound of your voice 
- flu-like symptoms 
 
Skin allergies such as rash with or without paleness, redness, patches, severe itching; and skin 
eruptions such as welts or hives have also been reported after receiving NeuroBloc. The frequency of 
these side effects is not known. 
 
It is possible that cervical dystonia could become worse after you have had your injection. 
 
 
 



29 
 
 

Reporting of side effects 
If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects 
not listed in this leaflet. You can also report side effects directly via the national reporting system 
listed in Appendix V. By reporting side effects you can help provide more information on the safety of 
this medicine. 
 
5. How to store NeuroBloc 
 
- keep this medicine out of the sight and reach of children 
- do not use this medicine after the expiry date which is stated on the carton and on the vial after 

EXP 
- store in a refrigerator (2°C-8°C). Do not freeze  
- keep the vial in the outer carton in order to protect from light 
- within its shelf-life, NeuroBloc may be removed from the refrigerator for a single period of up 

to 3 months at a temperature not above 25oC. At the end of this period, the product should not 
be put back in the refrigerator and should be disposed of 

- the date at which the medicine was taken out from the refrigerator will be put on the outer 
carton  

- if the medicine is diluted, the doctor will use it immediately 
- before using the medicine the doctor will check that the solution is clear and colourless/light 

yellow. If there are any visible signs of deterioration, the medicine should not be used, but 
discarded  

- any unused solution should be discarded 
- due to the special nature of NeuroBloc, the doctor will ensure that all used vials, needles and 

syringes must be processed as Medical Biohazardous Waste in accordance with local 
requirements 

 
6. Contents of the pack and other information 
 
What NeuroBloc contains 
The active substance is Botulinum Toxin Type B. One millilitre (ml) contains 5000 U. 
 
One vial of 0.5 ml contains 2500 U of Botulinum Toxin Type B. 
One vial of 1 ml contains 5000 U of Botulinum Toxin Type B. 
One vial of 2 ml contains 10,000 U of Botulinum Toxin Type B. 
 
The other ingredients are disodium succinate, sodium chloride, human serum albumin solution, 
hydrochloric acid (for pH adjustment) and water for injections. 
 
What NeuroBloc looks like and contents of the pack  
NeuroBloc is presented as a solution for injection in a vial that contains 0.5 ml (2500 Units), 1.0 ml 
(5000 Units) or 2.0 ml (10,000 Units). The solution is clear and colourless to pale yellow. 
 
Pack size of 1.  
 
Marketing Authorisation holder 
Sloan Pharma S.à.r.l. 
33, Rue du Puits Romain 
8070 Bertrange 
Luxembourg 

https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.ema.europa.eu%2Fdocs%2Fen_GB%2Fdocument_library%2FTemplate_or_form%2F2013%2F03%2FWC500139752.doc


30 
 
 

Manufacturer  
Almac  Pharma Services Limited 
Seagoe Industrial Estate 
Portadown 
Craigavon  
BT63 5UA 
United Kingdom 
 
And 
 
Almac Pharma Services (Ireland) Limited 
Finnabair Industrial Estate 
Dundalk 
Co. Louth 
A91 P9KD 
Ireland 
 
For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder: 
 
ae@sloanpharma.com 
 
This leaflet was last revised in <{MM/YYYY}> <{month YYYY}> 
 
Other sources of information 
 
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu. 
 



31 
 
 

------------------------------------------------------------------------------------------------------------------------- 
The following information is intended for healthcare professionals only: 
 
INSTRUCTIONS FOR USE, HANDLING AND DISPOSAL 
 
NeuroBloc is provided in vials for single use only.  
 
The medicinal product is ready to use and no reconstitution is required. Do not shake. 
 
To allow division of the total dose between several injections, NeuroBloc may be diluted with sodium 
chloride 9 mg/ml (0.9%) solution for injection (see section 4.2 of Summary of Product 
Characteristics). Such dilutions with sodium chloride should be done in a syringe, pulling out the 
desired amount of NeuroBloc into the syringe first, and then adding sodium chloride to the syringe. In 
non clinical experiments, NeuroBloc solution has been diluted up to 6-fold without any resulting 
change in potency. Once diluted, the medicinal product must be used immediately as the formulation 
does not contain a preservative. 
 
Any unused solution, all vials of expired NeuroBloc and equipment used in the administration of the 
medicinal product should be carefully discarded as Medical Biohazardous Waste in accordance with 
local requirements. Vials should be visually inspected prior to use.  If the NeuroBloc solution is not 
clear and colourless/light yellow or if the vial appears damaged, the product should not be used, but 
discarded as Medical Biohazardous Waste in accordance with local requirements.  
 
Decontaminate any spill with 10% caustic solution, or sodium hypochlorite (household chlorine 
bleach –2 ml (0.5%): 1 litre water) solution. Wear waterproof gloves and soak up the liquid with an 
appropriate absorbent. Place the absorbed toxin in an autoclave bag, seal it and process as Medical 
Biohazardous Waste in accordance with local requirements. 
 
Do not use after the expiration date stamped on the vial. 


	SUMMARY OF PRODUCT CHARACTERISTICS
	A. MANUFACTURER OF THE BIOLOGICAL ACTIVE SUBSTANCE ANDMANUFACTURER RESPONSIBLE FOR BATCH RELEASE
	B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE
	C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETINGAUTHORISATION
	D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE ANDEFFECTIVE USE OF THE MEDICINAL PRODUCT
	A. LABELLING
	B. PACKAGE LEAFLET