Key Benefits:
The Minister of Health, Youth, Sports and Associative Life and the Minister of Budget, Public Accounts and Public Service,
Considering the Public Health Code;
Considering the social security code;
Having regard to the decree of 8 December 1994 taken for the application of article R. 163-2 of the Social Security Code and relating to repayable specialties;
Having regard to the decrees of 5 February 1997, 11 April 2002, 24 February 2003 and 16 August 2007 amending the list of repayable pharmaceutical specialties to social insured persons;
In the opinion of the Transparency Commission,
Stop:
The list of repayable pharmaceutical specialties to social insured persons is amended in accordance with the provisions contained in annex I. Therapeutic Information SheetArticle R. 163-2 of the Social Security Code for Umatrope is contained in annex II to the present decision.
The Umatrope Therapeutic Information Sheet, which was annexed to the above-mentioned 16 August 2007 Order, is repealed.
The Director General of Health and the Director of Social Security are responsible, each with respect to him, for the execution of this Order, which will be published and its annexes to the Official Journal of the French Republic.
Annex I
(Extension of indications) Therapeutic indications that are entitled to care or reimbursement by health insurance are now for the following specialties:
| CIP CODE | PRESENTATION |
| 342 158-7 | UMATROPE 6 mg/3 ml (somatropine), powder and solvent for injectable multidose cartridge solution, cartridge powder + 3.15 ml of syringe solvent (B/1) (laboratories LILLY FRANCE SAS). |
| 342 159-3 | UMATROPE 12 mg/3 ml (somatropine), powder and solvent for injectable multidose cartridge solution, cartridge powder + 3.15 ml of syringe solvent (B/1) (laboratories LILLY FRANCE SAS). |
| 342 160-1 | UMATROPE 24 mg/3 ml (somatropine), powder and solvent for injectable multidose cartridge solution, cartridge powder + 3.15 ml of syringe solvent (B/1) (laboratories LILLY FRANCE SAS). |
ANNEX II
THERAPEUTICAL INFORMATION
Exceptional medicine
Growth hormones
UMATROPE
UMATROPE 6 mg powder and solvent for multidose injectable solution.
UMATROPE 12 mg powder and solvent for multidose injectable solution.
UMATROPE 24 mg powder and solvent for multidose injectable solution.
Umatrope (somatropine) is a biosynthetic growth hormone, produced by genetic recombination from a strain ofEscherichia coli modified by inserting the coding gene for human growth hormone.
Several specialties based on growth hormone are marketed. Each of these specialties has been assessed in indications and according to specific criteria. Not all have the same indications. When several of them have the same indication, for historical or administrative reasons (national MMA or mutual recognition), the wording of the indication is not always superposable. There are also slight variations in dosage ranges in MMAs, given clinical trials in record records.
Umatrope, biosynthetic human growth hormone, is a restricted prescription drug whose treatment conditions fall under the exceptional medication procedure.
List I.
Annual initial hospital requirement for specialists in paediatrics and/or endocrinology and metabolic diseases in specialized services in paediatrics and/or endocrinology and metabolic diseases.
1. Reimbursable therapeutic indications
In the child
Long-term treatment of children with growth retardation associated with an endogenous normal growth hormone deficiency.
Treatment of small size in children with Turner syndrome, confirmed by chromosomal analysis.
Treatment of growth retardation in the pre-primary child has chronic kidney failure.
Treatment of patients with growth retardation associated with a SHOX gene deficiency (Short Stature HOmeoboX-Containing gene) confirmed by a DNA test.
Umatrope is also indicated in the treatment of growth retardation (current size ― ― 3 DS and adjusted parent size < ― 1 DS) in children born small for gestational age, with a birth size < ― 2 DS, not having caught up in their growth delay (growth rate 0 0 DS in the last year) at the age of 4 or older.
In the adult
Alternative treatment in adult subjects with severe growth hormone deficiency.
These patients are defined as having a severe somatotrope deficit acquired at adulthood, secondary to a known hypothalamo-hypophysary pathology and associated at least with another hypophysary hormone deficiency (except the prolactin deficiency). A single dynamic test will be performed to assert or exclude a growth hormone deficiency.
In patients with a somatotrope deficiency acquired in childhood (without hypothalamo-hypophysary disease or cranial irradiation antecedent), two dynamic tests are recommended, except in case of low IGF-1 (― ― 2 DS), which can be considered as a test. The limit values of dynamic tests must be strictly defined.
2. Dosage and mode of administration
The dosage and administration diagram must be customized for each patient; However, for:
Children with a somatotrope deficit :
The recommended dosage is 0.025 to 0.035 mg/kg bw per day, in subcutaneous injection, approximately 0.7 to 1 mg/m2 per day.
Adults with somatotrope deficit :
The dosage recommended for initiation of treatment is 0.15 to 0.30 mg/day. A lower start dose may be preferable in older and/or obese patients. The dose must be increased gradually depending on the patient's needs, depending on the clinical response and the serum rate of IGF-I. The daily intake should generally not exceed 1 mg. The concentration in IGF-I shall be maintained at values not exceeding the normal upper age limit. The effective minimum dose should be used; needs can decrease with age. The dose of somatropine should be reduced in case of persistent oedema or severe paresthesia, to avoid carpal canal syndrome (see Adverse effects).
Patients with Turner syndrome :
The recommended dosage is 0.045 to 0.050 mg/kg bw per day, administered in preferably in the evening undercutaneous injection, approximately 1.4 mg/m2 per day.
Prepubious children with chronic kidney failure :
The recommended dosage is 0.045 to 0.050 mg/kg bw per day, administered in subcutaneous injection.
Patients with a delayed growth associated with a SHOX gene deficiency confirmed by a DNA test :
The recommended dosage is 0.045 to 0.050 mg/kg bw per day in subcutaneous injection.
Children born small for gestational age :
The recommended dosage is 0.035 mg/kg body weight per day, in subcutaneous injection (i.e. 1.0 mg/m2 of body surface per day) until the final size is reached (cf. Pharmacodynamic). The treatment should be interrupted after the first year of treatment, if the growth rate is less than + 1.0 SDS. The treatment should be interrupted if the growth rate is < 2 cm per year and, if a confirmation is required, the bone age is 14 years (for girls) or 16 years (for boys), corresponding to the welding of the conjugation cartilages.
In order to avoid lipoatrophies, subcutaneous injection sites must vary.
3. Clinical interest
In the child, the growth hormone (growth hormone, GH) biosynthetic helps to correct the growth delay associated with a somatotrope deficit. It can also be useful to treat some children with a retardation of growth without a somatotrope deficit, in order to increase their growth rate (Turner syndrome, prepuberant child with chronic kidney failure, child with a growth retardation associated with a SHOX gene deficiency confirmed by a DNA test, child born small for gestational age).
In adults with a deep growth hormone deficiency, GH treatment may in some cases improve the quality of life and well-being of patients and lead to a change in body composition with an increase in lean mass.
3.1. In the child
3.1.1. Growth gap associated with a somatotrope deficit
Growth hormone deficiency may be secondary to an organic cause (pothalamo-hypophysary Smoking), irradiation (cranio-spinal or total body) or congenital. It is mostly idiopathic in current practice.
The formation of historical series shows that in the absence of GH substitute treatment the adult size of children with severe GH deficits would be between 130 and 150 cm in boys and between 130 and 140 cm in girls. These series are not representative of patients currently treated as the less profound deficits benefit from GH treatment.
In GH-treated children, clinical studies show a particularly net status catchup in the first year with a growth rate of 8 to 9 cm, reduced the following year. The follow-up of treated children confirms the continuation of a statusal gain in the third year, but catching up is generally no longer significant. For patients whose treatment began in the early 1990s, the average final size is 166 cm in the boy and 154 cm in the girl, bringing them closer to the average size observed in France. There are large inter-individual variations, so the assessment of the effect of treatment on the final size is delicate, especially in the moderate forms of deficit. However, patients with a deep and early deficit best respond to treatment.
Subcutaneous administration (SC) is preferable due to improved bioavailability and higher growth speed compared to intramuscular pathway (IM). In addition, the effect on growth is all the more marked as the frequency of injections is greater, which led to recommendations for the administration of SC 7 days a week.
Treatment is more effective in children with organic deficits than those with idiopathic deficits. Cranio-spinal irradiation is associated with the most unfavourable results.
The final size is higher when a gonadotrope deficit is associated with the somatotrope deficit and the two deficits are corrected, when the GH treatment was early and when the statusal delay was moderate.
3.1.2. Growth gap associated with Turner syndrome
Turner syndrome is characterized by an abnormal number and/or structure of X chromosome. Growth delay can be present from birth. It gradually increases to less than two standard deviations ( – 2 DS) to 5-6 years and 4 DS at the age of 12-13 years.
In the absence of any treatment, there is no peak of pubertal growth, and growth extends beyond the usual age. The adult size is reached between 18 and 20 years; It is an average of 142 cm outside of any GH treatment.
The indication of exogenous GH treatment is based on the strengthening of the endogenous GH effect. In these children, a higher dose than in the treatment of GH deficit results in a significant increase in growth speed.
The increase in growth speed in the first year is between 2 and 5 cm for a dosage of 0.035 mg/kg/day but tends to decrease in the following years. The average final gain is from 4 to 9 cm compared to the projected size.
The GH is not alone involved in the statusrale growth; ovarian insufficiency of these patients also plays a role. Too early induction of puberty can cause GH to lose profit. However, the optimal age and therapeutic scheme of steroid replacement treatment remain controversial.
3.1.3. Growth gap associated with kidney failure
chronic (CRI) in children
Chronic kidney failure (CRI) is defined by a reduced kidney function of at least 50% compared to normal. About half of the children with CRIs have an important statusal delay compared to children of the same age.
In GH-treated children, significant status gains are observed in the first year, less net in the second year, as observed in other GH indications; there is little data on adult sizes after GH treatment.
The effect on growth seems less marked when children are dialysis. The therapeutic response is inversely correlated with the clearing of creatinine at the time of treatment. It was not evidence of significant acceleration of bone maturation.
3.1.4. Patients with retarded growth
associated with a SHOX gene deficit
Before being processed, the SHOX gene deficiency must be confirmed by a DNA test.
The available data are not of sufficient quality to allow to assess the objective benefit on the evolution of the size in children with a retarded growth associated with a SHOX gene deficiency. In patients with anomaly of the SHOX gene treated by Umatrope, the growth rate, after 1-2 years (+2.96 and +2.31 SDS), was higher than in patients in the untreated group ( – 0.73, ― 0.44 SDS).
There is little data on adult sizes after GH treatment. After 2 years of treatment, 41% (n = 11 of 27) of treated SHOX patients and 4% (n = 1 of 25) of non-treated patients had a normal size for age and sex (standard ― 2 DS).
3.1.5. Growth gap in children born small
for gestational age
Children born small for gestational age have a size below the reference numbers for a given gestation duration. The limit is less than 2 standard deviations (2 DS) of the reference curves.
In these children, in most cases, post-natal growth is marked by an acceleration allowing them to control their delays from the end of the second year. However, 10-20% of them, according to the studies, maintain a statusal disability with a size below ―2 DS compared to the average population.
In children who have not recovered their statusal delay at the age of 3, the constitution of a historical series has established that the adult sizes of untreated children whose size before puberty was < ― 2.5 DS are very much below the normal area. The adult size is about 158 cm in the boy and 146 cm in the girl.
Uncertainties about the final size remain, as there may be an acceleration of bone maturation during treatment and a slowdown of growth after its stop, leading to a loss of approximately 0.25 DS in the year following the stop, in a number of children.
It should be emphasized that in non-deficit children, the benefit of growth hormone treatment is not demonstrated in terms of improvement of the final size. In addition, there are uncertainties among these same children about the long-term tolerance of such treatment.
Given these uncertainties, the growth hormone is only refunded in this indication for children whose size at the time of treatment is less than or equal to ― 3 DS. The Transparency Commission wishes to reassess growth hormones with a similar indication as soon as possible.
3.2. Somatotrope challenge in adults
Among the causes of somatotrope deficit in adults, tumoral pathologies occupy the first place. Hypophysary adenomas are the most common. Most Idiopathic Idiopathic deficits isolated in GH from childhood do not persist in adulthood. Normal growth hormone secretion is found in 70 to 80% of patients reassessed after puberty. In the event of antehypophysary insufficiency, even if it is correctly substituted on the thyreotrope, corticotrope and gonadotrope axes, symptoms attributed to the GH deficit not substituted persist.
The adult's somatotrope deficit leads to a change in body composition with an increase in fatty mass mainly at the abdominal level, a decrease in lean mass and muscular mass, increased fatigue and a decrease in bone density. Retrospective epidemiological studies show an increase in the incidence of cardiovascular disease mortality in patients with overall antehypophysal insufficiency despite the usual hormone replacement treatments. However, the real place of the somatotrop deficit in this decrease in life expectancy is not known.
Treatment by GH modifies the body composition with increase of lean mass and decrease of fat. This results in a reduction in the size/ hip ratio as well as the cutaneous fold. In addition, treated patients reported a subjective improvement in their physical capacity and strength to effort. The first days or weeks can be marked by a discreet weight gain and by the occurrence of malleolary edemas related to hydrosodized retention caused by GH treatment.
GH treatment seems to modestly improve the lipid profile. The evolution of blood glucose and insulinemia is very variable from one study to another. Currently available studies do not allow for an assessment of the effect of HG treatment with respect to atheronatal risk and the mortality of patients with HG deficits.
GH treatment for 12 months is moderately increasing bone mineral density. There are few studies assessing the effect of GH treatment on the incidence of fractures.
Long-term data on the efficacy and tolerance of growth hormone treatment are not available.
4. Terms of use
Treatment must be established in the hospital by specialists in paediatrics and/or endocrinology and metabolic diseases in specialized services in paediatrics and/or endocrinology and metabolic diseases.
Every year, the treatment interest must be reassessed to the hospital by these same specialists.
Renewal of the initial prescription to the same dosage is possible, in intermediate periods, by any doctor.
There are cases of non-respondent patients, for which no predictive factors have been identified, both in children and adults.
To allow better patient follow-up, the change in GH is not recommended during the treatment, unless the hospital prescriptor who initiated the treatment the justified esteem.
The cessation of treatment is imperative in the event of the onset or evolution of a tumor process.
The specificity of the child: the treatment by GH that does not improve the growth of patients whose epiphyses are welded, it is important to well weigh the decision to establish treatment by sexual steroid hormones.
Compliance with updated legal records of the MMA is essential. Parents and/or families should be informed of the possible occurrence of certain adverse effects and patients subject to regular medical supervision.
4.1. Treatment
The authorized specialist must ensure that the patient meets the treatment criteria; the absence of contraindications must be verified; the prescribed specialty must possess the required indication.
4.1.1. In the child
Growth gap associated with a somatotrop deficit:
Two conditions are necessary to begin treatment:
― size ≤ ― 2 DS according to French reference data;
– growth rate in the past year below normal for age ( – 1 DS) or < 4 cm/year.
In addition, the diagnosis of the GH deficit must be duly proved by appropriate explorations. Since GH secretion is variable in the nycthemer, a single dose is insufficient to assert the GH deficit.
Two distinct stimulation tests shall be performed on different dates including at least one coupled: insulin/arginin, glucagon/propranolol, glucagon/betaxolol, clonidine/betaxolol. It is recommended to use, as a standard, a recombinant GH (1 mg = 3 IU). The results are expressed in mUI/l (or in μg/l). The whole data concludes that:
– a complete GH deficit: two tests < 10 mUI/l (3.3 μg/l);
- a possible partial deficit: peaks between 10 and 20 mUI/l (3.3 μg/l to 6.6 μg/l).
A single test having resulted in a response of GH ✱ 20 mUI/l (6.6 μg/l) must cause the diagnosis of somatotrope deficit to be removed.
In the case of a partial deficit associated with a 20 % overweight, the results of GH stimulation tests are falsely lowered and difficult to interpret. The diagnosis is based on the dose of IGF-1: a normal or higher result than normal excludes the diagnosis of GH deficit associated with obesity and invites to practice re-evaluation about 6 months after caloric restriction and weight loss.
In the case of a partial deficit associated with a small size of one or both parents, the GH treatment decision is based on the size ( – 2 DS) and the growth rate over the past year (― ― 1 DS for age or < 4 cm/year), the bone age and the predicted size at adult age (lower to target size).
The search for a cause (MRI or hypophysal scanner) and associated hypophysal deficits is an important step in the process.
In case of leukemia or tumor history, it is strongly advised to wait for one year of remission before the start of treatment.
Growth gap associated with Turner syndrome:
The diagnosis is based on the caryotype. This allows to define the number and/or structure anomalies of the X chromosome.
There is no lower age limit for treatment, but the upper limit for treatment is a bone age of 12 years.
Estrogen replacement treatment should be introduced lately to progressive dosage in order not to lose the GH-induced profit.
Growth gap associated with chronic kidney failure:
When conservative treatment is not sufficient to maintain adequate growth speed for age, GH treatment can be indicated. The kidney function, determined by the measurement of creatinine clearance, shall be less than 60 ml/min/1.73 m2 (normal 120 ± 20 ml/min/1.73 m2).
In order to confirm the growth delay, growth should have been followed for one year before starting the treatment.
The criteria for starting hormone treatment by the GH are:
― size ≤ ― 2 DS according to French reference data;
– growth rate in the past year below normal for age ( – 1 DS);
• chronological age ≥ 2 years;
- bone age < 13 years in the girl and < 14 years in the boy;
― prepubber children or early puberty (testicular volume less than 10 ml or breast development stage ≤ S3).
Symptomatic treatment known as curative of chronic renal insufficiency (correction of dehydration and acidosis, prevention of kidney osteodystrophy and optimization of nutritional intakes) should have been introduced in advance (at least one year) and will be maintained throughout the duration of growth hormone treatment.
Patients with a delayed growth associated with a SHOX gene deficit:
Before being processed, the SHOX gene deficiency must be confirmed by a DNA test.
The decision to use growth hormone supplementation treatment should be taken with caution in non-deficit children. The long-term effects of exposure to supraphysiological amounts of growth hormone are indeed very incompletely known. The pathological effects of excess growth hormone are well known in adults. The stimulation of IGF-1's production, cytokine capable of stimulating tumor growth, should not be neglected.
The stimulation of growth in children can only be done before welding epiphyses.
Growth rate among children born small for gestational age:
The decision to use growth hormone supplementation treatment should be taken with caution in children who are not carencil. The long-term effects of exposure to supraphysiological amounts of growth hormone are indeed very incompletely known. The pathological effects of excess growth hormone are well known in adults. The stimulation of IGF-1's production, cytokine capable of stimulating tumor growth, should not be neglected.
Other causes or treatments that may cause growth delays must be excluded before starting treatment.
The stimulation of growth in children can only be done before welding epiphyses.
The experience of a treatment start just before puberty in children born small for gestational age is limited. Therefore, it is not recommended to start treatment just before puberty.
The criteria for starting GH treatment are:
– birth size below ― 2 DS for gestational age;
― size at time of treatment ≤ ― 3 DS for chronological age;
- children who have not recovered their growth retardation (growth rate < 0 DS in the last year) at the age of 4 years or older;
― Adjusted parental size ― ― 1 DS.
4.1.2. In the adult
Growth hormone treatment should not be systematic in subjects with biological growth hormone deficit criteria.
There is no data to recommend initiation of GH treatment in adults over 60 years of age.
Explorations must be carried out only in patients with a disease that refers to a somatotrope deficit and which must be:
either a hypothalamo-hypophysary pathology operated or not;
― undergoing cerebrotic radiation;
– had a somatotrope deficit in childhood.
It is not necessary to seek a somatotrope deficit in patients with a hypophysary micro-adenoma (size less than 1 cm in diameter) unless another antehypophysary deficiency (except the prolactin deficiency) is present.
Alternative treatment of other hormonal deficits has to be adapted and stable for three months. A plasma value of GH isolatedly low does not prove the somatotrope deficit.
The diagnosis of somatotrope deficit must be confirmed at adulthood. The necessary criterion is a GH peak less than 10 mUI/l (3.3 μg/l) during the growth hormone stimulation test by insulin hypoglycemia, apart from its contraindications.
The hypoglycemia test caused by intravenous injection of insulin with glycaemia < .40 g/l (2.2 mmol/l) allows to distinguish the somatotrope deficit from the reduction of GH secretion that usually accompanies aging or obesity.
This test must be performed in endocrine services accustomed to its realization. It is contraindicated in patients with electrocardiographic signs or a history of ischemic and/or epilepsy heart disease. In these cases, another stimulation test will be used.
Further explorations may be required according to the patient's clinical characteristics.
Deficit somatotrope acquired during childhood:
Somatotrope deficits isolated from childhood must be reassessed in a particular way. In these patients, the adult GH deficit is less likely. In these cases, two GH stimulation tests are necessary, namely the insulin hypoglycemia test and a second test (GHRH test, coupled test: GHRH-arginine, GHRH-ornithine, glucagon-betaxolol, glucagon-propranolol), except in case of low IGF-1 (― ― 2 DS)
Deficit somatotrope acquired at adulthood:
Patients must have:
- a secondary somatotrope deficit to a hypothalamic or hypophysary pathology; and,
– at least another antehypophysary deficit associated (except the prolactin deficit) and correctly substituted (in this case, a single GH stimulation test may suffice).
The treatment must be reserved for patients who have met the above criteria and have a marked deterioration in the quality of life as well as a modification of the body composition (absolute condition with an increase in the size/hanches ratio).
Before starting a GH alternative treatment, all hypophysal deficits must be properly substituted. This obvious attitude in the case of thyreortop deficit (L-thyroxine) and corticotrope (hydrocortisone acetate) must also apply to the gonadotrope deficit (sexual steroids) in the absence of contraindication.
The objective of the treatment is to obtain a maximum benefit by limiting the side effects. It is recommended to begin treatment with low dosages of the order from 0.15 to 0.30 mg/j in subcutaneous. The objective of the treatment is to obtain a normal insulin-like growth factor-1 (IGF-1) concentration for sex and age.
At the beginning of the treatment, patients must be evaluated every 1-2 months, clinically and by an IGF-1 dose; the dose of GH should be adapted to the clinical tolerance and concentrations of IGF-1. The effective minimum dose should be used. The introduction of treatment with low doses associated with progressive increase every 1 to 2 months reduces the occurrence of adverse effects. Depending on the results and tolerance, dosage can be increased within 3 to 6 months without exceeding the maximum doses of the MMA.
Patients should be informed of frequently occurring adverse effects: limb edemas, arthralgia and myalgia, stiffness of ends, paresthesia. These symptoms are usually transient and dose-dependent. Posologies should be reduced in case of persistent symptoms.
In the event of a tumor process, in the absence of a precise diagnosis of tumor disease or if the tumor is clinically known to frequently recurrence, it is not advisable to introduce HG treatment. In other cases, before alternative treatment is introduced, the non-resumption of the evolutionary process should be ensured by a prior monitoring whose frequency is to be determined with oncologists and/or neurosurgeon through imaging (MRI).
4.2. Monitoring of treatment
4.2.1. In the child
4.2.1.1. General
Children treated by GH will be followed every 3 to 6 months in consultation with at least one clinical examination (size, weight, blood pressure, growth speed, pubertal signs...). The bone age will be determined every year, especially around the ages of puberty.
Due to the effect of growth hormone on the glucidic metabolism, patients must be monitored by dosage of the blood sugar to jeun every year.
A hypothyroidism can be revealed to the decoder of treatment; untreated, it can interfere with the response to GH treatment. An annual control of thyroid function (T4 free) must be carried out and, if necessary, substitute treatment will be introduced.
In case of corticotropic deficit, effective minimum doses of hydrocortisone must be used.
A concomitant treatment by glucocorticoid (prednisolone, high-dose inhaled corticosteroids, corticosteroid pommades) can inhibit the effect on the growth of GH treatment and is to be avoided to the extent possible.
In the case of severe or repeated headaches, visual disorders, nausea and/or vomiting, it is recommended to make a background to look for a possible papillary edema and eliminate benign intracranial hypertension. This diagnosis can cause GH to stop the treatment.
The decision to continue the treatment must be taken on a case-by-case basis, depending on observance, tolerance to treatment and statusal catching.
In the child, transient skin reactions to the injection point are frequent.
Patients with endocrine disorders, including those related to a GH deficit, have an increased risk of epiphysiolysis. Any child with claudication or pain in the hip or knee, during growth hormone treatment, will be subject to appropriate clinical and radiological examination.
Dosage must be adapted every quarter depending on the child's weight or body surface.
4.2.1.2. Special cases according to indications
Growth gap associated with a somatotrop deficit:
When the somatotrope deficit is secondary to an intracranial lesion, radiological explorations (IRM) will be carried out regularly, in collaboration with oncologists and/or neurosurgeons, in order to detect a possible progression or relapse.
In patients with panhypopituitarism, the balance of associated substitute treatments should be monitored regularly.
The growth gain after the first year of treatment must have been at least 2 cm from the year before the treatment to conclude effectiveness. The following years, the growth rate must be at least equal to the mean for chronological age and/or for bone age and better than before treatment.
Growth gap associated with Turner syndrome:
Treatment is continued if the growth gain in the first year is at least 2 cm from the previous year. The following years, the growth speed must be:
≥ 4.5 cm/year up to 12 years;
≥ 3 cm/year when bone age has reached or exceeded 12 years.
Growth gap associated with chronic kidney failure:
Although the decline in glomerular filtration does not appear to be altered by the GH, the kidney function must be monitored to detect excessive degradation. The growth gain after the first year of treatment must have been at least 2 cm from the year before the treatment. The following years, the growth rate must be at least equal to the average for age and better than before treatment. Initial dosage may be increased if necessary.
Growth gap associated with a SHOX gene deficit
The dosage and administration diagram must be customized for each patient.
The recommended dosage is 0.045 to 0.050 mg/kg bw per day in subcutaneous injection.
In order to avoid lipoatrophies, subcutaneous injection sites must vary.
Growth rate among children born small for gestational age:
The administration scheme must be adapted to each patient.
The usual recommended dosage is 0.035 mg/kg body weight per day (1 mg/m2 of body surface per day) until the final size is reached.
4.2.2. In the adult
There is currently no validated criterion for assessing the effectiveness of adult treatment. Improvement is essentially subjective.
A follow-up of the requirements will be performed with patients newly treated by Umatrope. The attending physician must participate in the collection of data set up by the Lilly laboratory, at the request of the Transparency Commission, in the outpatient and hospital sectors.
Patients treated by the GH must be clinically tested (weight, hip/sized circumference, blood pressure) every 1 to 2 months until they obtain optimal doses. When treatment is stabilized, one or two visits per year are sufficient.
An assessment of the quality of life and the parameters of body composition, comparing them to the data of the pre-treatment examination, makes it possible to determine the continuation of the treatment.
When the deficit is secondary to an intracranial injury, patients will need to be examined regularly (followed by MRI) in order to detect possible progression or recurrence. Any recurrence or progression of the tumor involves stopping the treatment.
Observance and results of the alternate treatment of associated antehypophysary deficits must be verified at least once a year.
The experience of long-term treatment by adult growth hormone is limited.
4.3. Termination of treatment
4.3.1. In the child
Growth gap associated with a somatotrope deficit, or associated with Turner syndrome:
― the emergence or evolution of a tumor process;
– growth speed under treatment less than 3 cm/year regardless of age;
• bone age ≥15 years or size ≥ 170 cm in the boy; 13 years old or size 160 cm in the girl.
These last two treatment cessation criteria can be discussed in case of severe growth hormone deficiency, if the genetic statusal potential is not reached.
Growth gap associated with chronic kidney failure:
― the emergence or evolution of a tumor process;
– growth speed under treatment less than 3 cm/year regardless of age;
• bone age ≥15 years or size ≥ 170 cm in the boy; 13 years old or size 160 cm in the girl.
These last two treatment cessation criteria can be discussed in the event of a severe growth hormone deficiency, if the genetic statusal potential is not reached;
- kidney transplant.
Growth rate associated with a SHOX gene deficit:
― the emergence or evolution of a tumor process;
- in case of welding of epiphyses.
Growth rate among children born small for gestational age:
Appearance or evolution of a tumor process.
According to the RCP, the treatment should be discontinued after the first year of treatment:
- if growth speed is less than + 1 DS;
• if growth speed is < 2 cm/year;
― and if the bone age is 14 (for girls) and 16 (for boys), corresponding to the welding of epiphyses.
4.3.2. In the adult
There is no criterion for stopping GH treatment in adults. In studies, 12 to 35% of patients stop treatment after 12 months and 75% to 24 months. The need for daily subcutaneous injections is one of the main reasons for these treatment interruptions.
5. Conditions of use
These specialties are to be manipulated according to the strict conditions of asepsy.
Umatrope must be reconstituted with the solvent provided by the laboratory. The reconstituted solution should not be vigorously agitated because it can distort the active principle.
These presentations are supplemented by a preservative, meta-resol, which could lead to rare allergic reactions and pain at the injection point.
Conservation: maximum duration and special precautions
| RECONSTITUTION | APRÈS RECONSTITUTION | |||
| Maximum period | Precautions | Maximum period | Precautions | |
| UMATROPE 6 mg | 3 years | Between + 2 and + 8 °C Abri de la lumière | 28 days | Between + 2 and + 8 °C |
| UMATROPE 12 mg | 3 years | Between + 2 and + 8 °C Abri de la lumière | 28 days | Between + 2 and + 8 °C |
| UMATROPE 24 mg | 3 years | Between + 2 and + 8 °C Abri de la lumière | 28 days | Between + 2 and + 8 °C |
6. Warning of prescriptors
Prescriptors should be cautioned that the benefit/risk ratio is only evaluated for the therapeutic indications retained by the MMA. The use of growth hormones in situations that have no justification in medical practice is not devoid of risks and raises ethical reserves.
The medical body must be aware of the risks associated with this misuse.
7. Economic and social specifications
Conditions of limitation and issuance
List I.
Annual initial hospital requirement for specialists in paediatrics and/or endocrinology and metabolic diseases in specialized services in paediatrics and/or endocrinology and metabolic diseases.
Renewal of the initial prescription to the same dosage (even dosage per kg or m2 for the child), in intermediate periods, possible by any doctor.
The pharmacist must ensure that the qualification of the prescriptor appearing on the initial hospital order is consistent; upon renewal of the prescription, it ensures that the hospital order is submitted for less than 1 year.
Care conditions
Refund rate: 100%.
The prescription must be drafted on an exceptional drug order, in accordance with the therapeutic indications that are entitled to the refund mentioned in this form.
Cost of treatment
| | CIP CODE | CONDITION | PRIX PUBLIC (in euros) |
| UMATROPE 6 mg, cartridge | 342 158-7 | B/1 | 201.26 |
| UMATROPE 12 mg, cartridge | 342 159-3 | B/1 | 385.12 |
| UMATROPE 24 mg, cartridge | 342 160-1 | B/1 | 752.36 |
Similar drugs
| | CROISSANCE RETARD | ADULTE | |||||||
| | Deficit hormone Growth | Partner Syndrome by Turner | Linked to one kidney failure in the child prepubber | Linked to one insufficient kidney at home the child pubes | Partner with a Syndrome Prader-Willi | Partner with a deficit SHOX gene | Retard of growth children born small for age gestationnel | Retard of growth intrauterine | Deficit en hormone Growth |
| Génotonorm® | + | + | + | + | + | No. | + | No. | + |
| Maxomat® | + | + | No. | No. | No. | No. | No. | + | No. |
| Norditropine® | + | + | + | No. | No. | No. | + | No. | + |
| Nutropinaq® | + | + | + | No. | No. | No. | No. | No. | + |
| Saizen® | + | + | + | No. | No. | No. | + | No. | + |
| Umatrope® | + | + | + | No. | No. | + | + | No. | + |
| Zomacton® | + | + | No. | No. | No. | No. | No. | No. | No. |
| Omnitrope® | + | + | + | + | + | No. | + | No. | + |
Done in Paris, November 27, 2008.
The Minister of Health,
youth, sports
and associative life,
For the Minister and by delegation:
Deputy Director
Financing
the care system,
J.-P. Vinquant
Deputy Director
Policy on Practices
and health products,
C. Lefranc
Minister of Budget, Public Accounts
and the Public Service,
For the Minister and by delegation:
Deputy Director
Financing
the care system,
J.-P. Vinquant
