Special Warning : אזהרת שימוש

4.4 Special warnings and precautions for use
The maximum recommended daily dose should not be exceeded (see section 4.2).
Very rare cases of myositis have been observed and may be due to the metacresol used as preservative.
In the case of myalgia or disproportionate pain at the injection site, myositis should be considered and, if confirmed, a Zomacton presentation without metacresol should be used.
Patients with Prader-Willi syndrome
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.
Intra-cranial hypertension
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
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.
Development of antibodies
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.
Hypothyroidism
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.
Patients with diabetes mellitus
Because somatropin may reduce insulin sensitivity, patients should be monitored for evidence of glucose intolerance. For patients with diabetes mellitus, the insulin 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.
Patients with intra-cranial lesion
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
Scoliosis may progress in any child during rapid growth. Signs of scoliosis should be monitored during somatropin treatment.

Patients with endocrine disorders
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.
Patients suffering complications following surgery
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.
Experience of local tolerability to administration of ZOMACTON 10 mg/ml with ZomaJet 10 needle-free device has been studied before marketing authorisation in a 12 week study including only Caucasian children.
Although rare, pancreatitis should be considered in somatropin-treated patients, especially children who develop abdominal pain.
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).

Effects on Driving

4.7 Effects on ability to drive and use machines
Somatropin has no influence on the ability to drive and use machines.