Klimonorm film-coated tablets No. 21

Instructions for Klimonorm film-coated tablets No. 21

Composition

active ingredients: estradiol valerate, levonorgestrel;

1 yellow-coated tablet contains 2 mg of estradiol valerate;

1 brown-coated tablet contains 2 mg of estradiol valerate and 0.15 mg of levonorgestrel;

excipients: lactose, monohydrate, potato starch, gelatin, magnesium stearate, talc, sucrose (sucrose), glucose solution, macrogol 35000, povidone K 25, light magnesium carbonate, calcium carbonate, titanium dioxide (E 171), red iron oxide (E 172), yellow iron oxide (E 172), brown iron oxide (E 172), carnauba wax.

Dosage form

Film-coated tablets.

Main physicochemical properties: shiny yellow round tablets, coated with a film; shiny brown round tablets, coated with a film.

Pharmacotherapeutic group

Sex hormone. Combined preparations containing estrogens and progestogens.

ATX code G03 F B09.

Pharmacological properties

Pharmacodynamics.

The active substance, synthetic 17β-estradiol valerate, is broken down in the body to 17β-estradiol. 17β-estradiol is identical in its chemical and biological properties to endogenous estradiol. It replaces hormones that are produced in insufficient quantities in the body of a woman during menopause and minimizes the symptoms characteristic of this period.

The cyclic combination of estradiol valerate and levonorgestrel inhibits the mitogenic effect of estrogen in the endometrium. Thus, the risk of endometrial hyperplasia and cancer caused by estrogen monotherapy in women is reduced.

Clinical trial data

Reduction of estrogen deficiency symptoms and improvement of bleeding profile. Reduction of menopausal symptoms was observed within the first weeks of treatment. Withdrawal bleeding occurred in 84.4% of cycles during the first year of treatment. The average duration of bleeding was 5 days.

Breakthrough bleeding and/or spotting occurred in 12.9% of women during the first three months of treatment and in 7.9% of women at months 10-12 of treatment.

Amenorrhea (absence of bleeding or spotting) was observed in 6.4% of cycles during the first year of treatment.

Pharmacokinetics.

Estradiol valerate

Absorption: After oral administration of estradiol valerate, it is completely absorbed from the gastrointestinal tract.

Distribution. After oral administration of 4 mg of estradiol valerate, corresponding to 2 yellow tablets of the first phase of use of the drug Klimonorm, the maximum level of estradiol is reached after 8-12 hours. After oral administration of 8 mg of estradiol valerate, the maximum level of estradiol is 40-52 pg/ml. The half-life from blood plasma is on average about 1 hour. Estradiol is partially bound to blood plasma proteins.

Metabolism: Orally administered estradiol undergoes 90% first-pass metabolism, primarily to estrone, estrone sulfate, and estriol, as well as free or methylated catecholestrogens. Metabolism occurs primarily in the liver, but also in other tissues.

Excretion. Estradiol and its metabolites (estrone and estriol) are excreted in the urine within 48 hours in the form of conjugates with sulfuric and glucuronic acids, as well as in small amounts of unchanged estradiol. Some is excreted in the feces.

Levonorgestrel

Absorption: After oral administration, levonorgestrel is rapidly and completely absorbed from the gastrointestinal tract.

Distribution. After oral administration of 0.3 mg levonorgestrel, corresponding to 2 brown tablets of the second phase of use of the drug Klimonorm, the maximum level of levonorgestrel in the blood plasma is about 6 ng/ml and is reached 1-2 hours after administration. The half-life is 2 hours in the distribution phase and 10-24 hours in the elimination phase. In blood plasma, 93-95% of levonorgestrel binds to albumin and more specifically to sex steroid binding globulin (SGB).

Metabolism: No first-pass effect was detected.

Elimination. Plasma clearance is 106 ml/h/kg. Levonorgestrel is excreted as reduced and/or hydroxylated metabolites, mainly conjugated with sulfuric and glucuronic acids. Elimination occurs in equal parts with urine and feces. A small amount of levonorgestrel passes into breast milk.

Indication

Klimonorm is indicated for hormone replacement therapy (HRT) in women suffering from symptoms of estrogen deficiency due to menopause.

There is limited experience in treating women aged 65 years and over.

Contraindication

· Breast cancer, present or past, or suspected.

· Malignant tumors that are estrogen-dependent (e.g. endometrial cancer) or suspected of having them.

· Vaginal bleeding of unknown etiology.

· Untreated endometrial hyperplasia.

· Venous thromboembolism, current or history (e.g., deep vein thrombosis, pulmonary embolism).

Known thrombophilia (e.g. protein C, S or antithrombin deficiency, see section "Special warnings and precautions for use").

· High risk of developing venous or arterial thrombosis.

· Liver tumors (benign or malignant) present or in the past.

· Acute liver diseases, present or in history, until normalization of laboratory indicators of liver function.

Severe liver disease.

Known hypersensitivity to any of the components of the drug.

Porphyria.

Severe hypertriglyceridemia.

· Pregnancy or suspected pregnancy.

Interaction with other medicinal products and other types of interactions

The metabolism of estrogens and progestogens may be enhanced by concomitant administration of drugs that induce metabolizing enzymes, in particular enzymes of the cytochrome P450 system. These include anticonvulsants (e.g. phenobarbital, phenytoin, carbamazepine, oxcarbazepine, topiramate, felbamate, primidone) and drugs for the treatment of infectious diseases (e.g. rifampicin, rifabutin, nevirapine, efavirenz), griseofulvin, meprobamate, phenylbutazone and its salts.

Maximum enzyme induction may not occur for 2-3 weeks, but may then become persistent and persist for at least 4 weeks after discontinuation of drug therapy.

Although ritonavir and nelfinavir are known to be potent inhibitors, they exhibit enzyme-inducing properties when used concomitantly with steroid hormones.

Herbal medicines containing St. John's wort (Hypericum perforatum) may induce the metabolism of estrogens and progestogens.

Increased metabolism of estrogens and gestagens may lead to a decrease in the clinical effectiveness of these hormones and a change in the nature of uterine bleeding.

The levels of the active substances of Klimonorm in the blood plasma may increase due to concomitant administration of drugs (e.g. ketoconazole) that inhibit metabolizing enzymes. Estrogens may enhance the action and side effects of imipramine.

With simultaneous use of cyclosporine, blood levels of cyclosporine, creatinine and transaminases may increase due to a decrease in the hepatic clearance of cyclosporine.

Estrogens may lead to increased effectiveness of drugs containing corticosteroids.

With concomitant thyroid hormone replacement therapy, the need for levothyroxine may increase.

Due to changes in the intestinal flora due to the simultaneous administration of activated charcoal and/or antibiotics, such as ampicillin or tetracyclines, a decrease in the level of active substances may be observed, due to which the effectiveness of the drug Klimonorm may decrease and an increase in the amount of intermenstrual bleeding may be observed.

Due to the effects of estrogen on glucose tolerance (decrease) and insulin response, the dosage or need for oral antidiabetic agents or insulin may change.

Estrogens may affect the results of some laboratory tests, such as thyroid function tests (see section "Special warnings and precautions for use") or glucose tolerance.

The use of sex steroids may affect laboratory test results, including biochemical parameters of liver, adrenal, and renal function, levels of proteins (transporters) such as hormone-binding globulins, lipids/lipoprotein fractions, parameters of carbohydrate metabolism, and parameters of coagulation and fibrinolysis. Changes generally remain within the normal range of laboratory parameters.

Application features

HRT should only be initiated for the treatment of postmenopausal symptoms that seriously affect quality of life. In any case, a careful benefit-risk assessment should be performed at least annually. HRT should only be continued if the benefits outweigh the risks.

There are only limited data on the risk assessment of HRT in premature menopause. As the absolute risk of possible adverse reactions is lower in younger women, the benefit/risk ratio may be more favourable in younger women than in older women.

Medical research/control studies

Before initiating or reinstituting HRT, a complete personal and family medical history should be carefully taken. A physical examination (including a gynecological examination and breast examination) should be performed taking into account the above data, as well as the contraindications and precautions for the use of this drug. Regular follow-up examinations are recommended during treatment, the frequency and nature of which should depend on the individual characteristics of each woman.

Women should be advised of the changes in their breast area that they should report to their doctor (see “Breast cancer” below). Screening, including imaging techniques such as mammography, should be performed in accordance with current medical practice guidelines for preventive measures and according to the clinical needs of each woman.

Some patients may experience undesirable effects of estrogen stimulation, such as abnormal uterine bleeding, while taking HRT. Frequent or persistent uterine bleeding during treatment is an indication for a comprehensive evaluation of the endometrium.

The patient needs regular monitoring if she has a history or currently has one of the following conditions or diseases. The woman also needs regular monitoring if during pregnancy or previous hormonal treatment/HRT with the drug Klimonorm she identified the occurrence/worsening of the following conditions or diseases:

• leiomyoma (uterine fibroids) or endometriosis;

• risk factors for thromboembolic disorders (see below);

• risk factors for the development of estrogen-dependent tumors, for example, breast cancer, in first-degree relatives;

• arterial hypertension;

• diabetes mellitus with or without vascular complications;

• gallstone disease;

• migraine or (severe) headache;

• systemic lupus erythematosus;

• history of endometrial hyperplasia (see below);

• epilepsy;

• asthma;

• otosclerosis;

• fibrocystic mastopathy;

• Dubin-Johnson or Rotor syndrome;

• recurrence of cholestatic jaundice or cholestatic pruritus that first occurred during pregnancy or with previous use of steroid sex hormones;

• severe obesity;

• minor chorea;

• hereditary angioedema;

• sickle cell anemia.

Situations requiring immediate discontinuation of treatment

Treatment should be discontinued immediately if any contraindication or the following conditions occur:

- jaundice or liver dysfunction;

- significant increase in blood pressure;

- the appearance of a migraine-like headache;

- pregnancy;

- recurrence of cholestatic jaundice or cholestatic pruritus that first occurred during pregnancy or with previous use of steroid sex hormones;

- migraine or frequent and unusually severe headaches that occur for the first time or other symptoms that may be prodromal signs of cerebrovascular disorders;

- symptoms of thrombosis or suspicion of them;

- visual impairment and other similar disorders.

Endometrial hyperplasia and cancer

In women with an intact uterus, the risk of endometrial hyperplasia and cancer increases with prolonged estrogen monotherapy. Depending on the duration of treatment and estrogen dose (see section "Adverse reactions"), there is a 2- to 12-fold increase in the risk of endometrial cancer in women with estrogen monotherapy compared with women not using HRT. After stopping treatment, this risk may remain elevated for at least 10 years. Additional cyclical progestogen intake for at least 12 days per month or during a 28-day cycle, or continuous combined estrogen and progestogen treatment in women with an intact uterus compensates for the additional risk arising from estrogen monotherapy.

Breakthrough bleeding or spotting may occur during the first months of treatment. If breakthrough bleeding or spotting occurs after a certain period of therapy or continues after discontinuation of treatment, the cause should be determined, which may include endometrial biopsy to exclude the presence of endometrial malignancy.

Fibroid tumors of the uterus (fibroids) may increase in size under the influence of estrogens. If this occurs, treatment should be discontinued.

If endometriosis develops during treatment, it is recommended to discontinue therapy.

Breast cancer

Existing evidence suggests an increased risk of breast cancer, which depends on the duration of use, in women using combined estrogens and progestogens. This may also apply to HRT using estrogen alone.

Combination therapy with estrogen and progestin

Results from the randomised placebo-controlled Women's Health Initiative (WHI) trial and epidemiological studies suggest an increased risk of breast cancer in women using combined oestrogen-progestagen HRT. The increased risk becomes apparent after approximately 3 years (see section 4.8).

Monotherapy with estrogens

The results of the WHI trial did not show an increased risk of breast cancer in women with a uterus removed when taking estrogen alone. The results of the observation indicate in most cases a slightly increased risk of breast cancer with estrogen alone, which was significantly lower than the risk in women who used a combination of estrogen and progestogen (see section "Adverse reactions").

The increased risk becomes apparent after several years of use, but returns to the initial age-appropriate level several (no later than 5) years after treatment ends.

HRT, especially combined estrogen/gestagen treatment, increases breast tissue density, which may negatively affect the radiological diagnosis of breast cancer during mammography.

Ovarian cancer is much less common than breast cancer. Long-term (at least 5-10 years) use of oestrogen-only HRT has been associated with a slightly increased risk of ovarian cancer (see section 4.8). Some studies, including the WHI trial, suggest that the risk is similar or slightly lower with long-term use of combined HRT (see section 4.8).

Venous thromboembolism (VTE)

HRT is associated with a small increased risk of venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism (PE)). VTE is more likely to occur during the first year of HRT than later (see section 4.8).

Patients with known thrombophilia are at increased risk of VTE. HRT may increase this risk and is therefore contraindicated in such patients (see section 4.3).

In a controlled randomized clinical trial and in epidemiological studies, a 2- to 3-fold increased risk was identified in women who took HRT compared with women who did not take it. It is estimated that in 1000 women not taking these hormonal drugs, about 3 cases of VTE will occur over a 5-year period in the age group 50 to 59 years and 8 cases in the age group 60 to 69 years. According to this estimate, in 1000 healthy women who will use a drug for HRT for 5 years, there will be from 2 to 6 additional cases (optimal rate = 4) of VTE in the age group 50 to 59 years and from 5 to 15 cases (optimal rate = 9) in the age group 60 to 69 years.

Generally recognized risk factors for VTE include estrogen use, older age, major surgery, prolonged immobilization, significant excess body weight (BMI > 30 kg/m2), pregnancy/postpartum period, systemic lupus erythematosus, and cancer. The possible role of varicose veins in the development of VTE remains controversial.

A possible synergistic increase in the risk of thrombosis should be considered in women with multiple risk factors or with one of the risk factors being more pronounced. In such cases, this increased risk may be greater than in the presence of multiple risk factors alone. HRT should not be prescribed if the benefit/risk ratio is negative.

The risk of VTE may be temporarily increased by prolonged immobilisation, severe trauma or major surgery. As with all patients undergoing surgery, patients taking HRT should be advised to take preventive measures to prevent VTE. Depending on the cause and duration of immobilisation, temporary discontinuation of HRT should be considered.

HRT can be continued only after the woman's physical activity is fully restored.

In women without a history of VTE but with a first-degree relative who had VTE at a young age, screening for thrombophilia should be considered. The woman should be advised that this screening has limited information (it identifies only a subset of disorders that may lead to an increased risk of thrombophilia). If an increased risk of thromboembolism is identified, there is a family history of thrombosis, or the identified disorder is severe (e.g., antithrombin, protein S and/or C deficiency, or a combination of these conditions), HRT is contraindicated.

Women receiving anticoagulant treatment require a careful analysis of the benefit-risk ratio of HRT use.

If VTE develops after starting HRT, the drug should be discontinued. Patients should be advised to seek medical attention immediately if they experience possible symptoms of thromboembolism (especially painful swelling of the lower extremities, sudden chest pain, shortness of breath).

Coronary heart disease (CHD)

The results of randomized controlled trials have not demonstrated that combined estrogen/progestin HRT or estrogen monotherapy protect women from myocardial infarction, regardless of the presence or absence of coronary artery disease.

The results of two large clinical trials (the WHI and the Heart and Estrogen/Progestin Replacement Therapy Study (HERS)) indicate an increased risk of cardiovascular disease during the first year of use, but no benefit has been found for women's overall health. There are few data from controlled, randomized trials for other HRT drugs that have examined the effects on cardiovascular disease or mortality.

Combined estrogen/gestagen therapy

The relative risk of developing coronary heart disease with combined estrogen/progestogen therapy is somewhat increased. Since the baseline risk of developing coronary heart disease is largely age-dependent, the number of additional cases associated with estrogen/progestogen HRT in healthy premenopausal women is very small. However, their number increases with age.

Monotherapy with estrogens

Stroke

Combined estrogen/progestogen therapy and estrogen monotherapy are associated with a 1.5-fold increased risk of stroke. The relative risk is independent of age and time since menopause. Since the underlying risk of stroke is largely age-dependent, the overall risk of stroke in women taking HRT increases with age (see section 4.8).

A large randomized clinical trial (WNI study) found an increased risk of acute cerebrovascular accidents (as a secondary endpoint) in healthy women taking HRT with a combination of conjugated equine estrogens and medroxyprogesterone acetate (MPA) in a continuous regimen.

It is estimated that in 1000 women who are not taking HRT, there will be about 3 cases of acute cerebrovascular accidents over a 5-year period in the age group 50 to 59 years and 11 cases in the age group 60 to 69 years. Among 1000 women who will take a combination of conjugated equine estrogens and MPA for 5 years, the number of additional cerebrovascular accidents will be as follows: in the age group 50 to 59 years there will be from 0 to 3 cases (optimal rate = 1), and in the age group 60 to 69 years - from 1 to 9 cases (optimal rate = 4).

Other states

Treatment with the drug has no contraceptive effect and does not protect against HIV.

The use of estrogens may lead to fluid retention. Therefore, patients with functional cardiac or renal impairment should be closely monitored. Patients with end-stage renal disease should be closely monitored, as it is expected that circulating levels of the active substances of Klimonorm will increase in these cases.

In rare cases, chloasma may occur, especially in women with a history of chloasma during pregnancy. Women with a tendency to chloasma, or with a history of chloasma, should minimize exposure to sunlight or ultraviolet radiation.

Estrogens are known to contribute to the formation of gallstones in the biliary system. Some women appear to be predisposed to developing gallbladder disease while taking estrogen.

In rare cases, benign and, even more rarely, malignant liver tumors have been observed after the use of hormonal substances, such as those contained in HRT preparations. In some cases, these tumors have led to life-threatening bleeding in the abdominal cavity.

No association has been established between HRT and the development of hypertension. Slight increases in blood pressure have been reported in women taking HRT, but clinically significant increases are rare. However, if persistently high blood pressure is observed in isolated cases during HRT, discontinuation of HRT should be considered.

Close observation is necessary in patients with mild hepatic impairment, including hyperbilirubinemia, such as Dubin-Johnson syndrome or Rotor syndrome, and periodic monitoring of liver function tests is necessary. In case of deterioration of liver function tests, HRT should be discontinued. Although HRT may affect peripheral insulin resistance and glucose tolerance, in general, no change in therapy is necessary in patients with diabetes mellitus undergoing HRT. However, during HRT, careful monitoring of the health of women with diabetes mellitus is necessary.

Patients with prolactinoma require close medical supervision (including periodic determination of prolactin levels).

Women with a history of hypertriglyceridemia require special monitoring during estrogen monotherapy or estrogen/progestogen combination HRT, since isolated cases of significant increases in plasma triglyceride levels, leading to pancreatitis, have been reported with estrogen monotherapy in the presence of this condition.

Estrogens increase thyroxine-binding globulin, which leads to an increase in circulating total thyroid hormone, as measured by protein-bound iodine, T4 (chromatographic separation or radioimmunoassay) or T3 (radioimmunoassay). T3 resin uptake is reduced, reflecting the increase in thyroxine-binding globulin (TBG). Free T4 and T3 concentrations remain unchanged. Other serum proteins may be increased, such as corticoid-binding globulin (CBG), sex steroid-binding globulin (SSGB), resulting in increased circulating corticosteroid and sex steroid concentrations, respectively. Free or biologically active hormone concentrations remain unchanged. Levels of other plasma proteins (angiotensinogen/renin substrate, alpha-1-antitrypsin, ceruloplasmin) may increase.

There is no evidence of improvement in cognitive function. However, some evidence suggests an increased risk of possible dementia in women who start continuous combined HRT or estrogen monotherapy after the age of 65.

In women with hereditary angioedema, exogenous estrogens may induce or exacerbate symptoms of angioedema.

Patients with rare hereditary fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency are contraindicated in taking Klimonorm.

Use during pregnancy or breastfeeding

Klimonorm should not be prescribed during pregnancy or breastfeeding. If pregnancy occurs during treatment with Klimonorm, treatment should be discontinued immediately.

Clinical data based on a limited number of pregnancy outcomes do not indicate a negative effect of levonorgestrel on the fetus.

The results of most epidemiological studies to date do not indicate a teratogenic or fetotoxic effect of estrogen/gestagen combinations when accidentally taken during pregnancy.

Ability to influence reaction speed when driving vehicles or other mechanisms

No effect on the ability to drive and use machines has been identified.

Method of administration and doses

Klimonorm is a drug for HRT that should be taken cyclically.

For the first 9 days, take 1 yellow tablet daily, then for 12 days, take 1 brown tablet daily.

After all the tablets have been taken for 3 weeks, there is a seven-day tablet-free break. During this period, you should expect another menstrual-like bleeding.

After a seven-day break, start taking the tablets from the next pack, regardless of whether menstrual-like bleeding has ended or is still ongoing.

How to start using Klimonorm

If HRT drugs were not used in the previous period

You can start taking the drug on any day.

Switching from another HRT drug

When switching from a combined preparation for continuous hormone replacement therapy, women can start treatment after completing the previous therapy cycle. If women are switching from cyclic hormone replacement therapy, they should start taking Klimonorm after a break in taking pills.

Both for the initial and continued treatment of postmenopausal symptoms, the lowest effective dose should be used for the shortest possible period of time (see section "Special warnings and precautions for use").

Missed pill

If you miss a pill, it should be taken within the next 12 hours.

Otherwise, you should continue taking the tablets at the usual time the next day, without taking the forgotten tablet. If you miss a tablet, you are more likely to experience breakthrough bleeding or spotting.

Method and duration of application

It is recommended to take Klimonorm at the same time each day, without chewing and with sufficient liquid. To avoid gastrointestinal disorders, it is recommended to take the tablets in the evening.

The duration of the treatment course is determined by the doctor.

Children.

Do not use in this category of patients.

Overdose

Symptoms of overdose: Nausea, vomiting, breast tenderness, and vaginal bleeding may be signs of overdose.

Therapeutic measures in case of overdose. If necessary, treatment should be symptomatic.

Adverse reactions

The frequency of adverse reactions is defined as follows: very common (≥ 1/10), common (≥ 1/100 - < 1/10), uncommon (≥ 1/1000 - < 1/100), rare (< 1/10000), frequency unknown (frequency cannot be estimated from the available data).

In clinical studies involving 588 women and post-marketing surveillance data including 10,115 women, the following adverse reactions were reported, which are possibly related to the use of the drug.

* The only reported adverse event for which a causal relationship with the use of the medicinal product is possibly in the “uncommon” category at least based on the small sample size of the clinical trials (n=588).

** Venous thromboembolism (e.g. deep vein thrombosis of the lower extremities, pelvis and pulmonary embolism) occurs more frequently in women taking HRT than in those who do not.

More detailed information is provided in the sections "Contraindications" and "Peculiarities of use".

Breast cancer

In women receiving combined estrogen and progestin therapy for more than 5 years, the risk of developing breast cancer was increased by 2 times.

In patients receiving estrogen monotherapy, the degree of increased risk is somewhat lower than in patients taking combined estrogen and progestogen preparations.

The degree of risk depends on the duration of use (see section "Special precautions for use").

The results of the largest randomized placebo-controlled trial, the WHI, and the largest epidemiological study, the Million Women Study (MWS), are presented below.

MWS – estimated additional risk of breast cancer after 5 years of HRT

WHI study in the US – additional risk of breast cancer after 5 years of HRT

Age group (years)	Incidence per 1000 women in the placebo group over 5 years	Relative risk (95% CI)	Additional cases per 1000 women using HRT for 5 years (95% CI)
Estrogen monotherapy (EMT)
50-79	21	0.8 (0.7 – 1.0)	-4 (-6-0)*
Estrogen and progestogen (CEE + MPA) #
50-79	14	1.2 (1.0 – 1.5)	+4 (0-9)
CEE: conjugated equine estrogen; MPA: medroxyprogesterone acetate * The WHI study in women with a removed uterus showed no increase in the risk of developing breast cancer. # When restricting the analysis to women who had not used HRT before the start of Specifications Characteristics Active ingredient Estradiol valerate, Levonorgestrel Adults Can ATC code G MEDICINES AFFECTING THE GENITORY SYSTEM AND SEX HORMONES; G03 SEX GLAND HORMONES AND PREPARATIONS USED IN PATHOLOGY OF THE SEXUAL SPHERE; G03F COMBINED PREPARATIONS CONTAINING PROSTAGENS AND ESTROGENS; G03F B Preparations containing prostagens and estrogens for sequential use; G03F B09 Levonorgestrel and estrogen Country of manufacture France Diabetics With caution Drivers Can For allergies With caution For children It is impossible. Form Film-coated tablets Nursing It is impossible. Pregnant It is impossible. Producer Zentiva Quantity per package 21 pcs Trade name Climonorm Vacation conditions By prescription Reviews There are no reviews for this product. + Add review Write a review Klimonorm film-coated tablets No. 21 My mark: Continue There are no reviews for this product, be the first to leave your review. Answers & questions Add your question and we will answer as soon as possible. + Ask a question Ask a question Add your question and we will answer as soon as possible. * Your question Continue No questions about this product, be the first and ask your question. You are watched new Ascorbic acid Vitaminka Krut-Frut classic No. 10 In stock 0 20.48 грн. Add to Cart new Phytotea Klyuchi Zdrowia No. 16 Sugar-lowering in filter bags of 1.5 g No. 20 In stock 0 136.06 грн. Add to Cart new Presto gel liquid soap 250 ml In stock 0 586.05 грн. Add to Cart new Urological pads Tena Lady extra plus slim No. 8 In stock 0 185.50 грн. Add to Cart new Bioderma ABCDerm Babysquam Cream 40 ml In stock 0 704.71 грн. Add to Cart new Canpol Babies 22/501 6-18 m silicone anatomical pacifier In stock 0 303.81 грн. Add to Cart new Extraterm strawberry lollipops No. 24 In stock 0 456.56 грн. Add to Cart new Rosehip oil Ecooil 50 ml In stock 0 142.86 грн. Add to Cart new Babe Laboratorios children's shower gel 100 ml In stock 0 390.26 грн. Add to Cart new Sold out Zewa Jumbo Paper Towels No. 1 Распродано 0 327.80 грн. 926.98 грн. Add to Cart