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4. Clinical particulars
4.1 Therapeutic indications

Zomacton is indicated for the long-term treatment of children who have growth failure due to inadequate secretion of growth hormone and for the long-term treatment of growth retardation due to Turner’s Syndrome confirmed by chromosome analysis.

 

4.2 Posology and method of administration

Posology

Zomacton therapy should be used only under the supervision of a qualified physician experienced in the management of patients with growth hormone deficiency.

The dosage and schedule of administration of Zomacton should be individualised for each patient.

The duration of treatment, usually a period of several years, will depend on maximum achievable therapeutic benefit.

Growth Hormone Deficiency

Generally, a dose of 0.17 – 0.23 mg/kg bodyweight (approximating to 4.9 mg/m2 – 6.9 mg/m2 body surface area) per week divided into 6 – 7 s.c. injections is recommended (corresponding to a daily injection of 0.02 – 0.03 mg/kg bodyweight or 0.7 – 1.0 mg/m2 body surface area). The total weekly dose of 0.27 mg/kg or 8 mg/m2 body surface area should not be exceeded (corresponding to daily injections of up to about 0.04 mg/kg).

Turner’s Syndrome

Generally, a dose of 0.33 mg/kg/bodyweight (approximating to 9.86 mg/m2/body surface area) per week divided into 6 – 7 s.c. injections are recommended (corresponding to daily injection of 0.05 mg/kg/bodyweight or 1.40-1.63 mg/m2/body surface area).

Method of administration

The subcutaneous administration of growth hormone may lead to loss or increase of adipose tissue at the injection site. Therefore, injection sites should be alternated.

For instructions on reconstitution of the medicinal product before administration, see section 6.6.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1

Zomacton must not be given to premature babies or neonates as the solvent contains benzyl alcohol.

Somatropin must not be used when there is any evidence of activity of a tumour. Intracranial tumours must be inactive and antitumor therapy must be completed prior to starting GH therapy. Treatment should be discontinued if there is evidence of tumour growth.

Zomacton should not be used for growth promotion in children with closed epiphyses.

Patients with acute critical illness suffering complications following open heart surgery, abdominal surgery, multiple accidental trauma, acute respiratory failure or similar conditions should not be treated with Zomacton.

In children with chronic renal disease, treatment with Zomacton should be discontinued at renal transplantation.

4.4 Special warnings and precautions for use

The maximum recommended daily dose should not be exceeded (see section 4.2).

Due to the presence of benzyl alcohol as excipient, Zomacton may cause toxic reactions and anaphylactoid reactions in infants and children up to 3 years old and must not be given to premature babies or neonates.

Zomacton is not indicated for the long term treatment of paediatric patients who have growth failure due to genetically confirmed Prader-Willi syndrome, unless they also have a diagnosis of GH deficiency. There have been reports of sleep apnoea and sudden death after initiating therapy with growth hormone in paediatric patients with Prader-Willi syndrome who had one or more of the following risk factors: severe obesity, history of upper airway obstruction or sleep apnoea or unidentified respiratory infection.

Rare cases of benign intra-cranial hypertension have been reported. In the event of severe or recurring headache, visual problems, and nausea/vomiting, a funduscopy for papilla edema is recommended. If papilla edema is confirmed, diagnosis of benign intra-cranial hypertension should be considered and if appropriate growth hormone treatment should be discontinued (see also section 4.8). At present, there is insufficient evidence to guide clinical decision making in patients with resolved intracranial hypertension. If growth hormone treatment is restarted, careful monitoring for symptoms of intracranial hypertension is necessary.

Leukaemia has been reported in a small number of growth hormone deficient patients treated with somatropin as well as in untreated patients. However, there is no evidence that leukaemia incidence is increased in growth hormone recipients without predisposition factors.

As with all somatropin containing products, a small percentage of patients may develop antibodies to somatropin. The binding capacity of these antibodies is low and there is no effect on growth rate. Testing for antibodies to somatropin should be carried out in any patient who fails to respond to therapy.

Growth hormone increases the extrathyroidal conversion of T4 to T3 and may, as such, unmask insipiens hypothyroidism. Monitoring of thyroid function should therefore be conducted in all patients. In patients with hypopituitarism, standard replacement therapy must be closely monitored when somatropin therapy is administered.

Because somatropin may reduce insuline sensitivity , patients should be monitored for evidence of glucose intolerance. For patients with diabetes mellitus, the insuline dose may require adjustment after somatropin containing product therapy is initiated. Patients with diabetes or glucose intolerance should be monitored closely during somatropin therapy. Zomacton should also be used with caution in patients with a family history predisposing for the disease.

Introduction of somatropin treatment may result in inhibition of 11βHSD-1 and reduced serum cortisol concentrations. In patients treated with somatropin, previously undiagnosed central (secondary) hypoadrenalism may be unmasked and glucocorticoid replacement may be required. In addition, patients treated with glucocorticoid replacement therapy for previously diagnosed hypoadrenalism may require an increase in their maintenance or stress doses, following initiation of somatropin treatment (see section 4.5).

In patients with growth hormone deficiency secondary to an intra-cranial lesion, frequent monitoring for progression or recurrence of the underlying disease process is advised. In childhood cancer survivors, an increased risk of a second neoplasm has been reported in patients treated with somatropin after their first neoplasm. Intracranial tumours, in particular meningiomas, in patients treated with radiation to the head for their first neoplasm, were the most common of these second neoplasms

Discontinue Zomacton therapy if progression or recurrence of the lesion occurs.

In patients with previous malignant diseases special attention should be given to signs and symptoms of relapse.

Scoliosis may progress in any child during rapid growth. Signs of scoliosis should be monitored during somatropin treatment.

Slipped capital femoral epiphysis may occur more frequently in patients with endocrine disorders. A patient treated with Zomacton who develops a limp or complains of hip or knee pain should be evaluated by a physician.

The effects of treatment with growth hormone on recovery were studied in two placebo controlled trials involving 522 critically ill adult patients suffering complications following open heart surgery, abdominal surgery, multiple accidental trauma, or acute respiratory failure.

Mortality was higher (42 % vs. 19 %) among patients treated with growth hormones (doses 5.3 to 8 mg/day) compared to those receiving placebo. Based on this information, such patients should not be treated with growth hormones. As there is no information available on the safety of growth hormone substitution therapy in acutely critically ill patients, the benefits of continued treatment in this situation should be weighed against the potential risks involved.

Although rare, pancreatitis should be considered in somatropin-treated patients, especially children who develop abdominal pain.

 

4.5 Interaction with other medicinal products and other forms of interaction

Concomitant treatment with glucocorticoide inhibits the growth-promoting effects of somatropin containing products. Patients with ACTH deficiency should have their glucocorticoid replacement therapy carefully adjusted to avoid any inhibitory effect on growth hormone.

Growth hormone decreases the conversion of cortisone to cortisol and may unmask previously undiscovered central hypoadrenalism or render low glucocorticoid replacement doses ineffective (see section 4.4).

High doses of androgens, oestrogens, or anabolic steroids can accelerate bone maturation and may, therefore, diminish gain in final height.

Because somatropin can induce a state of insulin resistance, insulin dose may have to be adjusted in diabetic patients receiving concomitant Zomacton.

Data from an interaction study performed in GH deficient adults suggests that somatropin administration may increase the clearance of compounds known to be metabolised by cytochrome P450 isoenzymes. The clearance of compounds metabolised by cytochrome P450 3A4 (e.g. sex steroids, corticosteroids, anticonvulsants and cyclosporin) may be especially increased resulting in lower plasma levels of these compounds. The clinical significance of this is unknown.

 

4.6 Fertility, pregnancy and lactation

For Zomacton, no clinical data on exposed pregnancies are available. There is no data from the use of Zomacton during pregnancy in animals. (See section Preclinical safety data 5.3)

Therefore, Zomacton is not recommended during pregnancy and in woman of childbearing potential not using contraception.

There have been no clinical studies conducted with somatropin containing products in breast-feeding women. It is not known whether somatropin is excreted in human milk. Therefore, caution should be exercised when somatropin containing products are administered to breast-feeding women.

 

4.7 Effects on ability to drive and use machines

ZOMACTON has no or negligible influence on the ability to drive and use machines.

4.8 Undesirable effects

The subcutaneous administration of growth hormone may lead to loss or increase of adipose tissue at the injection site. On rare occasions patients have developed pain and an itchy rash at the site of injection.

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