Zomacton: Indications, Dosage, Precautions, Adverse Effects
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Zomacton - Product Information

Manufacture: Ferring Pharmaceuticals
Country: Australia
Condition: Pediatric Growth Hormone Deficiency
Class: Growth hormones, Hormones
Form: Liquid solution, Subcutaneous (SC), Powder
Ingredients: somatropin, mannitol, sodium chloride, benzyl alcohol and water

Somatropin (rbe)

Name of the Drug

ZOMACTON contains somatropin which is a protein having the structure (191 amino acid residues) of the major component of growth hormone produced by the human pituitary gland. It is produced in E.coli., by a method based on recombinant DNA technology.

Description

ZOMACTON is a sterile white lyophilised powder intended for injection after reconstitution. It is supplied with preserved diluent. The multidose vials are intended to be used for a single patient only. The composition of each strength of ZOMACTON and accompanying diluent is specified below:

  ZOMACTON 4 mg ZOMACTON 10 mg
Powder Somatropin 4 mg
Mannitol 25.9 mg
Somatropin 10 mg
Mannitol 10 mg
Sodium phosphate - dibasic dodecahydrate 3.57 mg
Sodium phosphate - monobasic dihydrate 0.79 mg
Diluent Benzyl alcohol 45 mg
Sodium chloride 45 mg
Water for injections to 5 mL
Meta-cresol 3.3 mg
Water for injections to 1 mL

Pharmacology

Pharmacodynamic properties of ZOMACTON are identical to human growth hormone. Human growth hormone stimulates linear growth and increased IGF-1 (Insulin-like growth factor/somatomedin-C) concentrations in children with growth hormone deficiency. The measurable increase in linear growth results from the effect of ZOMACTON on the epiphyseal growth plates of long bone. ZOMACTON is intended to supply the lack of naturally secreted hormone. Somatropin increases skeletal and cell growth in patients with growth hormone deficiency. It increases protein and carbohydrate metabolism.

Clinical Trials

A clinical study in 162 children showed an increase during 24 weeks to 24 months of treatment from an annualised growth velocity of 32 mm to 91 mm at 6 months, 83 mm at 12 months and 75 mm at 24 months. Seventy children were studied for 24 months and there are no data for final height. The dose administered was usually 0.1 mg/kg thrice weekly.

Pharmacokinetics following intravenous administration of 0.1 mg/kg ZOMACTON showed the elimination half life was about 25 minutes and the mean plasma clearance was 133 mL/min in healthy male volunteers. In the same volunteers, after a subcutaneous injection of 0.1 mg/kg ZOMACTON to the forearm, the mean peak serum concentration was 80 ± 50 ng/mL which occurred approximately 7 hours post injection and the apparent elimination half life was approximately 2.7 hours. Compared to intravenous administration, the extent of systemic availability from subcutaneous administration was approximately 70%.

Both strengths of ZOMACTON when administered by conventional subcutaneous injection and by the ZOMAJET needle-free device were compared in bioequivalence studies conducted in adults. Local tolerability of ZOMACTON administered via the ZOMAJET device was evaluated in an open safety study in children aged 3 to 17 years. Efficacy studies in the paediatric population comparing ZOMACTON administration via the ZOMAJET device and conventional needle injections have not been evaluated.

Indications

For the long-term treatment of children who have growth failure due to inadequate secretion of growth hormone.

Contraindications

ZOMACTON should not be used in subjects with closed epiphyses.

ZOMACTON should not be used if there is evidence of an active tumour. Intracranial tumours should be inactive and anti-tumour therapy complete before initiating use of ZOMACTON (see PRECAUTIONS).

ZOMACTON should not be used in adults. No studies have been carried out to support its use in adults.

Multi-dose ZOMACTON vials, reconstituted with bacteriostatic saline, should not be used in patients with hypersensitivity to any of the excipients. ZOMACTON 4 mg must not be given to premature babies or neonates as the solvent contains benzyl alcohol (see PRECAUTIONS).

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

Precautions

Because of the diabetogenic effect of somatropin, ZOMACTON should be used with caution in patients with diabetes mellitus. Regular blood glucose testing and close supervision is imperative in such cases. Patients should be observed for evidence of glucose intolerance because growth hormone may induce a state of insulin resistance. ZOMACTON should be used with caution in patients with diabetes mellitus or with a family history predisposing for the disease. Strict monitoring of urine and blood glucose is necessary in these patients. In children with diabetes, the dose of insulin may need to be increased to maintain glucose control during ZOMACTON therapy.

Patients should be euthyroid before ZOMACTON treatment is initiated. Periodic monitoring of thyroid function is recommended to detect hypothyroidism emerging during treatment. During treatment with somatropin an enhanced T4 to T3 conversion has been found which may result in a reduction in serum T4 and an increase in serum T3 concentrations. In general, the peripheral thyroid hormone levels have remained within the reference ranges for healthy subjects. The effects of somatropin on thyroid hormone levels may be of clinical relevance in patients with subclinical hypothyroidism in whom hypothyroidism theoretically may develop. Conversely, in patients receiving replacement therapy with thyroxine mild hyperthyroidism may occur. It is therefore particularly advisable to test thyroid function after starting treatment with somatropin and after dosage adjustments.

Patients with growth hormone deficiency secondary to intracranial lesions should be closely observed to detect progression or recurrence of the underlying disease. Discontinue ZOMACTON therapy if progression or recurrence of the lesion occurs (see CONTRAINDICATIONS).

Rare cases of benign intra-cranial hypertension have been reported. In the event of severe or recurring headache, visual problems, and nausea/vomiting, a fundoscopy for papilloedema is recommended. If papilloedema is confirmed, diagnosis of benign intra-cranial hypertension should be considered and if appropriate growth hormone treatment should be discontinued (see ADVERSE EFFECTS).

Steroid dosage greater than 15 mg/m2 hydrocortisone or its equivalent may inhibit growth. Slipped epiphyses are more likely to occur in children receiving growth hormone, and any child with a limp should be evaluated as this may indicate a slipped epiphysis.

Local reaction at injection site should be avoided by changing the injection site to avoid the risk of lipoatrophy.

Although ZOMACTON is not indicated for use in patients who have Prader-Willi syndrome it should be noted that somatropin in contraindicated in patients with Prader-Willi Syndrome who are severely obese or have severe respiratory impairment.

Myositis is a very rare adverse event that may be related to the preservative meta-cresol in the diluent for ZOMACTON 10 mg. In the case of myalgia or disproportionate pain at the injection site, myositis should be considered and, if confirmed, a ZOMACTON presentation without meta-cresol should be used.

Due to the presence of benzyl alcohol as an excipient in the diluent for ZOMACTON 4 mg, toxic reactions and anaphylactoid reactions can occur in infants and children up to 3 years old (see CONTRAINDICATIONS).

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.

Treatment with ZOMACTON should be discontinued at renal transplantation.

Effects on Fertility

Studies in animals have not been conducted to assess the effect of ZOMACTON on fertility.

Carcinogenicity

Associations between elevated serum IGF-1 concentrations and risks of certain cancers have been reported in epidemiological studies. Causality has not been demonstrated. The clinical significance of these associations, especially for subjects treated with somatropin who do not have growth hormone deficiency and who are treated for prolonged periods, is not known.

Genotoxicity

Somatropin showed no evidence of mutagenic activity in bacterial or mammalian cells and showed no activity in an assay for DNA damage in rodent hepatic cells.

Use in Pregnancy (Category B2)

The use, safety and efficacy of ZOMACTON in pregnant women have not been established.

Use in Lactation

There have been no studies conducted with ZOMACTON in lactating women. It is not known whether this drug is excreted in human milk however, absorption of intact protein from the gastrointestinal tract of the infant is unlikely. Because many drugs are excreted in human milk, caution should be exercised when ZOMACTON is administered to lactating women.

Interactions with Other Medicines

Glucocorticoid therapy may inhibit the growth promoting effect of ZOMACTON. Patients with co-existing ACTH deficiency should have their glucocorticoid replacement dose carefully adjusted to avoid impairment of the growth promoting effect of ZOMACTON.

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 on growth hormone 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 cyclosporine) may be especially increased resulting in lower plasma levels of these compounds. The clinical significance of this is unknown.

Adverse Effects

In clinical trials (n = 164) the following side effects were noted: headaches (14%), injection site pain (8%), injection site haematoma (4%), oedema (2%), hypothyroidism (6%). The incidence of side effects is similar to that seen in other growth hormone clinical studies.

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.

Somatropin has given rise to the formation of antibodies in approximately 1% of patients. The binding capacity of these antibodies has been low and no clinical changes have been associated with their formation.

Symptoms of fluid retention can be experienced, especially in the early phase of ZOMACTON therapy.

Rare cases of benign intra-cranial hypertension have been reported with somatropin (see PRECAUTIONS).

Leukaemia has been reported in a small number of patients treated with other growth hormone products. It is uncertain whether this risk is related to the pathology of growth hormone deficiency itself, growth hormone therapy, or other associated treatments such as radiation therapy for intracranial tumours.

  Common
≥1/100 and
<1/10
Uncommon
≥1/1,000 and
<1/100
Rare
≥1/10,000 and
<1/1,000
Very rare
<1/10,000
Neoplasms,
benign and
malignant
      Leukaemia
Immune system
disorders
Formation of
antibodies
     
Endocrine
disorders
Hypoglycaemia   Diabetes
mellitus type II
 
Nervous system
disorders
  Carpal Tunnel
Syndrome

Paraesthesia
Transient
headache

Benign
intracranial
hypertension
 
Musculoskeletal,
connective tissue
and bone
disorders
  Stiffness in the
extremities,
arthralgia,
myalgia
   
General
disorders and
administration
site disorders
Injection site
reaction
Peripheral
oedema
Pain and itchy
rash at injection
site
Injection site fat
atrophy or
hypetrophy

Dosage and Administration

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

ZOMACTON dosage must be individualised for each patient.

A dosage schedule of up to 0.1 mg/kg body weight administered three times weekly by subcutaneous injection is recommended.

As an alternative, a dose of 0.17 – 0.23 mg/kg bodyweight (approximately 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 0.07 – 1.0 mg/m2 body surface area). The total weekly dose of 0.27 mg/kg or 8 mg/m2 should not be exceeded (corresponding to daily injections of up to about 0.04 mg/kg).

After the dose has been determined, each vial is to be reconstituted only with the diluent supplied. The following volumes of diluent are recommended for reconstitution of ZOMACTON:

ZOMACTON 4 mg: to achieve a concentration of 3.3 mg/mL use 1.3 mL of diluent.

ZOMACTON 10 mg: to achieve a concentration of 10 mg/mL use entire contents of pre-filled diluent syringe.

To prepare the ZOMACTON, inject the diluent into the vial of ZOMACTON aiming the stream of liquid against the vial wall. Then swirl the product vial with a gentle rotary motion until the contents are completely dissolved. Do not shake.

After reconstitution, vial contents should be clear, without particulate matter. Occasionally, after refrigeration, some cloudiness may occur. This is not unusual for proteins like ZOMACTON. Allow the product to warm to room temperature. If the cloudiness persists or particulate matter is noted, the contents must not be used.

ZOMACTON may be administered using sterile disposable syringes and needles. The syringes should be of small enough volume that the prescribed dose can be withdrawn from the vial with reasonable accuracy. Before and after injections, the septum of the vial should be wiped with alcohol to prevent contamination of the contents after repeated needle insertions.

Use with ZOMAJET Device

ZOMACTON may also be administered by using the ZOMAJET needle free device. The ZOMAJET 2 Vision model is for use with ZOMACTON 4 mg and the ZOMAJET Vision X is for use with ZOMACTON 10 mg. Detailed instructions for use of the ZOMAJET are supplied with each device.

The ZOMAJET device is a needle free injection device designed to deliver growth hormone subcutaneously. There are three different sized heads, designated A, B and C which can be used with the device. Head A is appropriate for most patients; however, heads B or C may be required for a minority of patients to allow adequate administration of the somatropin.

The selection of the appropriate head is made when patients commence treatment. Patients are trained on the use of the device and to evaluate their injections in order to choose the optimal head. All patients initially begin using head A (smallest diameter). The injection is either complete (‘dry’) or incomplete (‘wet’) when used in accordance with the instructions. If the head is suitable, the injection will be ‘dry’. If the injection is ‘wet’, they try head B and subsequently, if required, head C. Patients who still have problems with ‘wet’ injections using

the largest head (head C) are not good candidates for this type of administration. Once the optimal head is chosen, the patient continues with this head for all their injections, replacing the head after every 7 injections. This process ensures reproducible injections that do not impact on the systemic exposure of the growth hormone.

Detailed information on how to choose the optimal head is provided in the instructions for use supplied with the device. Once the optimal head is chosen and the correct administration technique is followed, the patient is confident that a complete (‘dry’) injection has resulted.

The clinical data demonstrates bioequivalence of ZOMACTON administered via ZOMAJET (when used correctly and a ‘dry’ injection is achieved) and ZOMACTON administered via a conventional needle.

Overdosage

Long-term overdosage could result in some clinical features of acromegaly. Short-term overdosage may manifest as disturbances in glucose metabolism.

Presentation

ZOMACTON 4 mg powder for injection vial with diluent vial (5mL); 1s

ZOMACTON 10 mg powder for injection vial with diluent prefilled syringe and adaptor (1 mL); 1s

Storage

ZOMACTON, before and after reconstitution, must be stored at 2 – 8ºC. Do not freeze. The reconstituted vials should be used within 14 days (4 mg) or 28 days (10 mg).

Name and Address of Sponsor

Ferring Pharmaceuticals Pty Ltd

Suite 2, Level 1, Building 1

20 Bridge Street

Pymble NSW 2073

Poison Schedule of the Medicine

Prescription only medicine