BNF for Children 2011-2012

BNFC 2011–2012 6.5.1 Hypothalamic and anterior pituitary hormones 383Indication and doseTest of anterior pituitary function. By intravenous injection over 30 secondsChild 1 month–18 years 1 microgram/kg (max.100 micrograms) as a single doseCRH Ferring c (Shire) AInjection, corticorelin 100 microgramsGonadotrophinsGonadotrophins are occasionally used in the treatmentof hypogonadotrophic hypogonadism and associatedoligospermia. There is no justification for their use inprimary gonadal failure.Chorionic gonadotrophin is used in the investigation oftesticular function in suspected primary hypogonadismand incomplete masculinisation. It has also been used indelayed puberty in boys to stimulate endogenous testosteroneproduction, but it has little advantage overtestosterone (section 6.4.2).CHORIONIC GONADOTROPHIN(Human Chorionic Gonadotrophin; HCG)A preparation of a glycoprotein fraction secreted by the placentaand obtained from the urine of pregnant women havingthe action of the pituitary luteinising hormoneCautions cardiac impairment, asthma, epilepsy,migraine; prepubertal boys (risk of premature epiphysealclosure or precocious puberty)Contra-indications androgen-dependent tumoursRenal impairment use with cautionSide-effects oedema (reduce dose), headache, tiredness,mood changes, gynaecomastia, local reactionsLicensed use unlicensed in children for test of testicularfunctionIndication and doseTest of testicular function. By intramuscular injectionShort stimulation test:Child 1 month–18 years 1500–2000 units oncedaily for 3 daysProlonged stimulation test:Child 1 month–18 years 1500–2000 units twiceweekly for 3 weeksHypogonadotrophic hypogonadism. By intramuscular injectionChild 1 month–18 years 1000–2000 units twiceweekly, adjusted to responseUndescended testes. By intramuscular injectionChild 7–18 years initially 500 units 3 timesweekly (1000 units twice weekly if over 17 years);adjusted to response; up to 4000 units 3 timesweekly may be required; continue for 1–2 monthsafter testicular descentChoragon c (Ferring) LInjection, powder for reconstitution, chorionicgonadotrophin. Net price 5000-unit amp (with solvent)= £3.26. For intramuscular injectionPregnyl c (Organon) LInjection, powder for reconstitution, chorionicgonadotrophin. Net price 1500-unit amp = £2.12;5000-unit amp = £3.15 (both with solvent). For subcutaneousor intramuscular injectionGrowth hormoneGrowth hormone is used to treat proven deficiency ofthe hormone, Prader-Willi syndrome, Turner’ssyndrome, growth disturbance in children born smallfor gestational age, chronic renal insufficiency, and shortstature homeobox-containing gene (SHOX) deficiency(see NICE guidance below). Growth hormone is alsoused in Noonan syndrome and idiopathic short stature[unlicensed indications] under specialist management.Treatment should be initiated and monitored by apaediatrician with expertise in managing growth-hormonedisorders; treatment can be continued under ashared-care protocol by a general practitioner.Growth hormone of human origin (HGH; somatotrophin)has been replaced by a growth hormone ofhuman sequence, somatropin, produced using recombinantDNA technology.NICE guidanceSomatropin for the treatment of growthfailure in children (May 2010)Somatropin is recommended for children withgrowth failure who:. have growth-hormone deficiency;. have Turner’s syndrome;. have Prader-Willi syndrome;. have chronic renal insufficiency;. are born small for gestational age with subsequentgrowth failure at 4 years of age or later;. have short stature homeobox-containing gene(SHOX) deficiency.Treatment should be discontinued if growth velocityincreases by less than 50% from baseline in the firstyear of treatment.Mecasermin, a human insulin-like growth factor-I(rhIGF-I), is licensed to treat growth failure in childrenwith severe primary insulin-like growth factor-I deficiency(section 6.7.4).SOMATROPIN(Recombinant Human Growth Hormone)Cautions diabetes mellitus (adjustment of antidiabetictherapy may be necessary), papilloedema (see underSide-effects), relative deficiencies of other pituitaryhormones (notably hypothyroidism—manufacturersrecommend periodic thyroid function tests but limitedevidence of clinical value), history of malignant disease,disorders of the epiphysis of the hip (monitor forlimping), resolved intracranial hypertension (monitorclosely), initiation of treatment close to puberty notrecommended in child born small for gestational age;Silver-Russell syndrome; rotate subcutaneous injectionsites to prevent lipoatrophy; interactions:Appendix 1 (somatropin)Contra-indications evidence of tumour activity(complete antitumour therapy and ensure intracraniallesions inactive before starting); not to be used afterrenal transplantation or for growth promotion inchildren with closed epiphyses (or near closure in6 Endocrine system