Medicine Travel Cooler Request Form

I confirm that I’m a US resident and I am 18 years of age and older.

Thank you for your interest in the Medicine Travel Cooler! This cooler helps keep your Myalept between 36°F and 46°F while you're on the go. We hope this cooler makes it easier to stay consistent with your treatment and manage your care.*

To receive your Medicine Travel Cooler by mail, please fill out the form below. Please note that the Medicine Travel Cooler may only be delivered to US states and territories. There is a limit of one Medicine Travel Cooler per patient.

This cooler is provided to help you carry and store your medication for short periods of time. Please follow the storage instructions for your medication and contact your healthcare provider or pharmacist if you have any questions. Chiesi and Accredo® Specialty Pharmacy are not responsible for changes to your medication that may happen if it is exposed to temperatures outside the recommended range of 36°F to 46°F.

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Mailing Address to Receive Medicine Travel Cooler Line 2 (optional):

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By completing this form, I am providing consent to Chiesi USA, Inc. to process and retain my personal data for the purpose of receiving a Medicine Travel Cooler. I also confirm that I have read and agree to the terms of the Privacy Policy located at www.chiesiusa.com/privacy. To opt-out of this use of your personal data, you may submit a request via our Privacy Center (depending on your State of residence), email us.privacy@chiesi.com or contact us via phone at 1-866-271-8587.

For California residents: You may also view Chiesi USA, Inc.'s California Notice at Collection at www.chiesiusa.com/privacy.

Chiesi Total Care℠ offers additional support and resources for eligible patients. Learn more or sign up at chiesitotalcare.com.

We will not sell or transfer your name, address, or any other information to any other party for their marketing use. You may unsubscribe at any time by following the instructions in any communication you receive from us.

Important Safety Information

What is Myalept?

Myalept^® (metreleptin) is a leptin replacement therapy used with a doctor-recommended diet to treat problems caused by not having enough leptin (leptin deficiency) in people with generalized lipodystrophy.

It is not known if Myalept is safe and effective when used to treat problems (complications) caused by partial lipodystrophy or to treat liver disease, including non-alcoholic steatohepatitis (NASH)
Myalept should not be used to treat people with HIV-related lipodystrophy or people with metabolic disease, including diabetes mellitus and hypertriglyceridemia, without signs or symptoms of congenital or acquired generalized lipodystrophy.

Important Safety Information

Myalept is only available through a restricted program called the Myalept Risk Evaluation and Mitigation Strategy (REMS) Program. Your doctor must be enrolled and certified in the program in order to prescribe Myalept.

Myalept may cause serious side effects, including:

risk for developing certain proteins called neutralizing antibodies that may reduce how well your own leptin or Myalept works. Side effects of these antibodies may include infection, problems with blood sugar (including diabetes), or an increase in triglycerides.
increased risk of a type of blood cancer called lymphoma.

You should not take Myalept if you:

have general obesity not caused by a congenital leptin deficiency.
are allergic to metreleptin or any of the ingredients in Myalept. Symptoms of an allergic reaction include rash, itching (hives), swelling of face, lips, tongue, or throat, problems breathing or swallowing, fainting or dizziness, rapid heartbeat.

Before using Myalept, tell your doctor if you have any medical conditions including if you:

have or have had problems with your blood cells, including low blood cell counts (especially your white blood cells), bone marrow, immune system, pancreas, swollen lymph nodes, lymphoma, high blood triglyceride levels, or use insulin or a sulfonylurea.
are pregnant or plan to become pregnant as it is unknown if Myalept will harm your unborn baby. If you become pregnant while using Myalept, talk to your healthcare provider about registering with a program to collect information about the outcomes of moms and babies exposed to Myalept during pregnancy. You can enroll in the Myalept program by calling 1-855-669-2537.
are nursing or plan to nurse. You should not nurse while you take Myalept.

Other possible side effects

The most common side effects of Myalept include headache, low blood sugar, decreased weight, and/or abdominal pain.

You may get low blood sugar (hypoglycemia) if you take Myalept with other medicines used to lower blood sugar, such as insulin or sulfonylurea. Your doses of these medications may need to be lowered while you use Myalept. Tell your doctor right away if you experience shakiness, sweating, headache, drowsiness, weakness, dizziness, confusion, irritability, hunger, fast heartbeat, or a jittery feeling because these may be signs of low blood sugar (hypoglycemia).

For newborns and infants, mix Myalept with sterile water for injection (preservative-free) (WFI). Serious side effects including death have happened in newborns or infants who have received the preservative benzyl alcohol. Bacteriostatic water for injection contains benzyl alcohol and it should not be used to mix Myalept for newborns and infants.

Myalept may worsen symptoms caused by certain problems in your immune system (autoimmune disorder). Ask your doctor about what symptoms you should watch for that may require further testing.

Talk to your doctor about any side effect that bothers you or that does not go away. These are not all the possible side effects of Myalept. For more information, speak to your doctor or pharmacist. Tell your doctor about all the medications you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. Take Myalept exactly as your doctor instructs you.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.

This is the most important information about Myalept. For more detailed information, please see the patient Medication Guide and Full Prescribing Information including Boxed Warning.

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