Turner's Syndrome

Clinical Practice Guidelines for Pharmaceutical Treatment of
Turner's Syndrome
Ministry of Health
Department of Health Care
Ordinance no. 223 of 10 May 2010.
Consultants: Ida Vanessa Doederlein Schwartz, Regina Helena Elnecave, Bárbara Corrêa Krug,
and Karine Medeiros Amaral
Editors: Paulo Dornelles Picon, Maria Inez Pordeus Gadelha, and Alberto Beltrame
The authors have declared no conflicts of interest.
1 LITERATURE SEARCH STRATEGY
A literature search limited to meta-analyses, clinical trials, and randomized clinical trials was
conducted using MEDLINE/PubMed (http://www.ncbi.nlm.nih.gov/pubmed) and Embase
(http://www.embase.com/). The following search terms were used: “turner syndrome”[MeSH] AND
“growth hormone”[MeSH] AND “drug therapy”[MeSH]. Of a total of 40 articles retrieved, 22 were
used this CPG.
Non-indexed studies relevant to the topic were also used. UpToDate
(http://www.uptodateonline.com/online/index/do), version 17.2, and medical textbooks were also
consulted.
2 INTRODUCTION
Turner’s syndrome is the most common sex-chromosome abnormality in females, affecting 1 in
1,500-2,500 female live births. 1 Chromosomal constitution may be associated with X chromosome
absence (karyotype 45,X), chromosomal mosaicism (karyotype 45,X/46,XX), in addition to other X
chromosome structural abnormalities.
Typical abnormalities associated with Turner’s syndrome include short stature, gonadal dysgenesis,
webbed neck, low posterior hairline, characteristic facies, broad chest with widely spaced nipples,
lymphedema, cubitus valgus, autoimmune thyroiditis with or without hypothyroidism, renal,
cardiovascular, and auditory abnormalities. Cognitive impairment in some activities is also found,
although average intelligence is considered normal. 2
Short stature is the most common finding in Turner’s syndrome. Short stature in this syndrome is
characterized by mild intrauterine growth retardation, progressive reduction in growth velocity
during childhood, and marked growth failure during the pubertal period. 3 Untreated patients with
Turner’s syndrome have an average adult height of 136 to 147 cm. 4
3 INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH
PROBLEMS (ICD-10)
• Q96.0 Karyotype 45,X
• Q96.1 Karyotype 46,X iso (Xq)
• Q96.2 Karyotype 46,X with abnormal sex chromosome, except iso (Xq)
• Q96.3 Mosaicism, 45,X/46,XX or XY
• Q96.4 Mosaicism, 45,X/other cell line(s) with abnormal sex chromosome
• Q96.8 Other variants of Turner’s syndrome
4 DIAGNOSIS
The definitive diagnosis of Turner’s syndrome requires karyotype confirmation.
5 INCLUSION CRITERIA
Patients may be included in this CPG if they have a diagnosis of Turner’s syndrome confirmed by
karyotype analysis and meet the following eligibility criteria:
• minimum age of 2 years and maximum of 12 years;

• age < 5 years: height should be below the 5th percentile of height expected for age, according to
the World Health Organization growth curve;
• age ≥ 5 years: height should be below the 5th percentile of height expected for age, according to
the National Center for Health Statistics (NCHS) growth curve of 1977.
6 EXCLUSION CRITERIA
Patients should be excluded from this CPG if they meet any of the following conditions:
• active neoplastic disease;
• uncorrected renal or cardiovascular congenital anomalies;
• severe acute disease;
• benign intracranial hypertension;
• proliferative or preproliferative diabetic retinopathy;
• hypersensitivity or intolerance to the drug or to one or more components in the formulation.
7 SPECIAL CASES
In cases of severe acute disease, treatment should be discontinued for 1-2 months or until patient
recovery. In cancer cases, treatment with somatropin may only be employed if a favorable,
documented opinion for starting treatment has been reached by the oncologist (2 years after
treatment completion and complete remission). 5
In cases of congenital anomalies requiring surgical correction, treatment should be delayed or
discontinued for the performance of corrections and until patient recovery.
8 TREATMENT
Treatment of patients with Turner’s syndrome should focus primarily on the associated clinical
manifestations. Therapeutic strategies include surgical treatment of associated malformations
(mainly cardiac anomalies), estrogen replacement therapy (due to gonadal dysgenesis), somatropin
supplementation, and therapeutic approaches. Hypoacusis, hypertension, autoimmune diseases,
and psychological problems are also common findings and may require specific treatment.
The mechanisms that determine short stature in patients with Turner’s syndrome have yet to be
fully elucidated, since no growth hormone deficiency is observed. Short stature probably results
from an impaired response to growth hormone combined with an underlying skeletal dysplasia. 6
Somatropin, a biosynthetic form of growth hormone, became available in 1985 and has been used
in the treatment of different causes of short stature since then, including Turner's syndrome. 7,8
Since girls with Turner’s syndrome do not show growth hormone deficiency, the effects of a
supraphysiologic dose of somatropin have been investigated in patients with this syndrome. There
is evidence that somatropin administration produces a significant increase in growth velocity and in
the patient’s final height. A meta-analysis by Baxter et al. 9 identified 4 randomized clinical trials 10-14
involving 365 individuals with Turner’s syndrome who were treated with somatropin (0.3 to 0.375
mg/kg/week). Only one clinical trial 10,11 reported the final height achieved by 61 treated women (148
cm), which was higher than that reported for 43 untreated women (141 cm, mean difference of 7
cm, 95%CI 6-8). The remaining studies evaluated a shorter period of time and demonstrated an
increase in growth velocity after 1 year (mean of 3 cm/year, 95%CI 2-4) and after 2 years (mean of
2 cm/year, 95%CI 1-2.3) of treatment. Treatment did not accelerate bone age, and adverse events
were rarely observed.
The main predictor of best response is age at onset of treatment, with better results associated with
earlier treatment, 6,15 but the ideal age to start treatment has yet to be defined. Studies evaluating
the impact of treatment on quality of life and neuropsychological variables have shown controversial
results. 16-19 Other studies suggest a beneficial effect of somatropin on lipid profile, blood pressure,
voice/speech changes, and body proportions in patients with Turner's syndrome. 20-22
The set of studies on somatropin therapy in patients with Turner’s syndrome shows considerable
variability in terms of treatment protocol, dose, age at onset, and concomitant administration of
estrogen or anabolic steroids. Estrogen replacement therapy, which should be used to induce the
development of secondary sexual characteristics in patients with Turner’s syndrome and
hypogonadism, decreases the response to somatropin. Therefore, the initiation of estrogen therapy
should be timed as to prevent any negative effect on growth while inducing puberty at an
appropriate age. 23,24

8.1 DRUG
• Somatropin: vials of 4 and 12 IU
In the conversion formula, 3 IU stand for 1 mg. Since the available formulations may have different
diluent volumes for the same dose of hormone, such aspects should be observed when prescribing
drugs and providing pharmaceutical guidance to patients.
8.2 ADMINISTRATION
Somatropin: 0.135-0.15 IU/kg/day (0.045-0.050 mg/kg/day or 0.3-0.375 mg/kg/week), administered
subcutaneously in the evening, 6-7 times/week 25
8.3 TREATMENT DURATION – CRITERIA FOR DISCONTINUATION
Treatment with somatropin should be discontinued in the following conditions:
• failure to respond to treatment, defined as an increase in growth velocity in the first year of
treatment by less than 50% over the previous growth velocity or growth velocity < 2 cm/year, 11
provided that patients are on treatment for at least 1 year;
• bone age ≥ 14 years, as estimated by x-ray. 11
8.4 EXPECTED BENEFITS
• Increase in final height and growth velocity
9 MONITORING
Monitoring of somatropin treatment should be performed during follow-up visits, including
anthropometric measurements every 6 months. Monitoring of treatment response should be based
on the growth curves for girls with Turner’s syndrome established by Lyon et al.. 26 Laboratory
screening for assessment of fasting glucose and thyroid function and radiographic examination for
assessment of bone age should be performed annually. 27 Complementary IGF-1 assessment
should also be performed annually or whenever dose adjustment is required, since this molecule is
a marker of adherence to somatropin treatment and one of the parameters for dose adjustment.
Ideally, values should be within the normal range. 28 Increased IGF-1 levels require a reduction in
somatropin dose; in the presence of decreased IGF-1 levels, patient compliance to treatment
should be verified and, if satisfactory, somatropin dose may be increased.
Somatropin is a safe drug, with rare severe adverse effects. Attention should be given to the risk of
developing impaired glucose tolerance, hypothyroidism, and benign intracranial hypertension. 29
Other associated events include scoliosis, slipped femoral epiphysis, and pancreatitis; an
association with the development of malignancies and aortic dissection/rupture remains
controversial. 30,31
10 REGULATION/CONTROL/MANAGER ASSESSMENT
Aspects such as criteria for inclusion and exclusion of patients in this CPG, treatment duration and
monitoring, regular evaluation of the doses prescribed and dispensed, adequacy of drug therapy,
and criteria for discontinuation of treatment should be observed. Patients should be treated by
specialists from the fields of genetics and endocrinology and should be monitored in a specialized
service for long-term benefits and adverse effects associated with treatment.
11 INFORMED CONSENT AND LIABILITY FORM
It is a legal requirement that patients or their legal guardians be informed of the potential risks,
benefits, and adverse effects associated with the pharmacological treatment recommended in this
guideline. Informed consent should be obtained with the appropriate form when prescribing drugs
included in the Specialized Program for Pharmaceutical Assistance.
12 REFERENCES
1. Saenger P. Turner’s Syndrome. N Engl J Med. 1996;335(23):1749-54.
2. Nussbaum RL, McInnes RR, Willand HF. Thompson & Thompson Genetics in Medicine. 6th ed.
Philadelphia: WB Saunders; 2001.
3. Saenger P, Wikland KA, Conway GS, Davenport M, Gravholt CH, Hints R, et al. Recommendations for the
Diagnosis and Management of Turner Syndrome. J Clin Endocrionol Metab. 2001;86(7):3061-9.

4. Rochiccioli P, David M, Malpuech G, Colle M, Limal JM, Battin J, et al. Study of final height in Turner’s
syndrome: ethnic and genetic influences. Acta Paediatr. 1994;83(3):305-8.
5. Guidelines for the use of growth hormone in children with short stature. A report by the Drug and
Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. J Pediatr. 1995;127(6):857-67.
6. Gault EJ, Donaldson MDC. Efficacy of growth hormone therapy in Turner’s syndrome [Internet]. Bristol:
BSPED; [cited 2003 Jun 13]. Available from: http://www.bsped.org.uk/professional/position/docs/turner.htm.
7. Cave CB, Bryant J, Milne R. Recombinant growth hormone in children and adolescents with Turner’s
syndrome. Cochrane Database Syst Rev. 2003;(3):CD003887.
8. Gharib H, Cook DM, Saenger PH, Bengtsson BA, Feld S, Nippoldt TB, et al. American Association of
Clinical Endocrinologists medical guidelines for clinical practice for growth hormone use in adults and children
– 2003 update. Endocr Pract. 2003;9(1):65-76.
9. Baxter L, Bryant J, Cave CB, Milne R. Recombinant growth hormone for children and adolescents with
Turner syndrome. Cochrane Database Syst Rev. 2007;(1):CD003887. Update of: Cochrane Database Syst
Rev. 2003;(3):CD003887.
10. Stephure DK, Holland FJ, Alexander D, Bailey J, Best T, Boulton BC, et al. Human growth hormone and
low dose ethinyl estradiol treatment in Turner syndrome: a prospective randomized controlled trial to final
height. In: Hibi I, Takano K, editors. Basic and clinical approach to Turner syndrome. Amsterdam: Elsevier;
1993. p. 287-91.
11. Stephure DK; Canadian Growth Hormone Advisory Committee. Impact of Growth Hormone
Supplementation on Adult Height in Turner Syndrome: Results of the Canadian Randomised Controlled Trial. J
Clin Endocrinol Metab. 2005;90(6):3360-6. Epub 2005 Mar 22.
12. Rosenfeld RG. Acceleration of growth in Turner Syndrome patients treated with growth hormone: summary
of three years results. J Endocrinol Invest. 1989;12(8 Suppl 3):49-51.
13. Kollmann F, Damm M, Reinhardt D, Stover B, Heirich U, Brendel L, et al. Growth-promoting effects of
human recombinant growth hormone in subjects with Ullrich-Turner syndrome (UTS). In: Ranke MB, Rosenfeld
RG, editors. Turner Syndrome: Growth Promoting Therapies. Vol. 924, Amsterdam: Elsevier; 1991. p. 201-7.
14. Quigley CA, Crowe BJ, Anglin DG, Chipman JJ. Growth hormone and low dose estrogen in Turner
Syndrome: results of a United States multi-center trial to near-final height. J Clin Endocrinol Metab.
2002;87(5):2033-41.
15. Davenport ML, Crowe BJ, Travers SH, Rubin K, Ross JL, Fechner PY, et al. Growth hormone treatment of
early growth failure in toddlers with Turner syndrome: a randomized, controlled, multicenter trial. J Clin
Endocrinol Metab. 2007;92(9):3406-16. Epub 2007 Jun 26.
16. Rovet J, Holland J. Psychological aspects of the Canadian randomized controlled trial of human growth
hormone and low dose ethinyl estradiol in children with Turner Syndrome. Horm Res. 1993;39(Suppl 2):60-4.
17. Ross JL, Feuillan P, Kushner H, Roeltgen D, Cutler GB Jr. Absence of growth hormone effects on cognitive
function in girls with Turner Syndrome. J Clin Endocrinol Metab. 1997;82(6):1814-7.
18. Van Pareren YK, Duivenvoorden HJ, Slijper FM, Koot HM, Drop SL, de Muinck Keizer-Schrama SM.
Psychosocial functioning after discontinuation of long-term growth hormone treatment in girls with Turner
syndrome. Horm Res. 2005;63(5):238-44. Epub 2005 May 17.
19. Carel JC, Elie C, Ecosse E, Tauber M, Léger J, Cabrol S, et al. Self-esteem and social adjustment in young
women with Turner syndrome – influence of pubertal management and sexuality: population-based cohort
study. J Clin Endocrinol Metab. 2006;91(8):2972-9. Epub 2006 May 23.
20. Bannink EM, van der Palen RL, Mulder PG, de Muinck Keizer-Schrama SM. Long-term follow-up of GHtreated
girls with Turner syndrome: metabolic consequences. Horm Res. 2009;71(6):343-9. Epub 2009 Jun 9.
21. Bannink EM, van der Palen RL, Mulder PG, de Muinck Keizer-Schrama SM. Long-term follow-up of GHtreated
girls with Turner syndrome: BMI, blood pressure, body proportions. Horm Res. 2009;71(6):336-42.
Epub 2009 Jun 8.
22. Andersson-Wallgren G, Ohlsson AC, Albertsson-Wikland K, Barrenäs ML. Growth promoting treatment
normalizes speech frequency in Turner syndrome. Laryngoscope. 2008;118(6):1125-30.
23. Chernausek SD, Attie KM Cara J, Rosenfeld RG, Frane J. Growth hormone therapy of Turner Syndrome:
the impact of age of estrogen replacement on final height. J Clin Endocrinol Metab. 2000;85(7):2439-45.
24. Van Pareren YK, Keizer-Schrama SMPF, Stijnen T, Sas TC, Jansen M, Otten BJ, et al. Final height in girls
with Turner syndrome after long term growth hormone treatment in three dosages and low dose estrogens. J
Clin Endocrinol Metab. 2003;88(3):1119-25.
25. National Institute for Clinical Excellence (NICE). Guidance on the use of human growth hormone
(somatropin) in children with growth failure [Internet]. London: NICE; 2002 [cited 2010 May 21]. Available from:
http://www. nice.org.uk/nicemedia/live/11458/32368/32368.pdf.
26. Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child.
1988;60(10):932-5.
27. Bettendorf M, Doerr HG, Hauffa BP, Lindberg A, Mehis O, Partsch CJ, et al. Prevalence of autoantibodies
associated with thyroid and celiac disease in Ullrich-Turner syndrome in relation to adult height after growth
hormone treatment. J Pediatr Endocrinol Metab. 2006;19(2):149-54.

28. Cutfield WS, Lundgren F. Insulin-like growth factor I and growth responses during the first year of growth
hormone treatment in KIGS patients with idiopathic growth hormone deficiency, acquired growth hormone
deficiency, turner syndrome and born small for gestational age. Horm Res. 2009;71(suppl 1):39-45. Epub 2009
Jan 21.
29. Drug facts and comparisons. 56th ed. St Louis (MO): Facts and Comparisons; 2002.
30. Bolar K, Hoffman AR, Maneatis T, Lippe B. Long-term safety of recombinant human growth hormone in
turner syndrome. J Clin Endocrinol Metab. 2008;93(2):344-51. Epub 2007 Nov 13.
31. Van den Berg J, Bannink EM, Wielopolski PA, Pattynama PM, de Muinck Keizer-Schrama SM, Helbing
WA. Aortic distensibility and dimensions and the effects of growth hormone treatment in the turner syndrome.
Am J Cardiol. 2006;97(11):1644-9. Epub 2006 Apr 19.

Informed Consent and Liability Form
Somatropin
I, ____________________________________________________ (name of patient), declare that I
have been clearly informed of the benefits, risks, contraindications, and major adverse effects
associated with the use of somatropin, indicated for the treatment of Turner’s syndrome.
The medical terms have been explained and all my questions were answered by the physician, Dr.
_______________________________________________________ (name of the prescribing
physician).
Therefore, I declare that I have been clearly informed that the drug that I will receive may result in
the following benefits:
• increase in final height and growth velocity.
I have also been clearly informed of the following contraindications, potential adverse effects, and
risks of using this drug:
• there is evidence of risk to fetuses, but a potential benefit may outweigh the risks. If I get pregnant,
I should notify the physician immediately;
• the drug may be excreted in breast milk; therefore, consult the physician before breastfeeding;
• adverse effects – ear diseases, allergic reactions, abnormal vision, headache, nausea, vomiting,
pain at the injection site, inflammation in the pancreas, abnormal breast development, muscle pain,
joint pain, swelling, fatigue, weakness, increased blood glucose, and abnormal thyroid.
• the risk of adverse effects increases with overdose;
• contraindicated in cases of hypersensitivity (allergy) to the drug or to one or more components in
the formulation.
I am aware that this drug can be used only by myself, and I commit myself to returning the drug if I
do not want or cannot use it, or if treatment is discontinued. I am also aware that I will continue to
receive medical care even if I quit using the drug.
I authorize the Ministry of Health and the Departments of Health Care to make use of information
concerning my treatment, provided that my privacy is protected.
Place: Date:
Patient's name:
National Health Card:
Name of legal guardian:
Identification document of legal guardian:
_____________________________________
Signature of patient or legal guardian
Physician in charge: License number: State:
___________________________
Signature and stamp of physician
Date: ___________________
Note: This Form is required when requesting drugs included in the Specialized Program for
Pharmaceutical Assistance and should be completed in duplicate: one copy should be filed in the
pharmacy, the other delivered to the user or their legal guardian.

Flow Chart of Medical Treatment
Turner's Syndrome
[arquivo anexo]

Dispensing Flow Chart: Somatropin
Turner's Syndrome
[arquivo anexo]

Drug Therapy Registration Form
Turner's Syndrome
1 Patient Data
Name: _________________________________________________________________________
National Health Card: ___________________________ ID: _______________________________
Name of caregiver: _______________________________________________________________
National Health Card: ________________________________ ID: __________________________
Sex: □ Male □ Female DOB: ___ / ___ / ____ Age: ____ Weight: _______ Height: _____________
Address: _______________________________________________________________________
Telephones: _____________________________________________________________________
Primary physician: _________________________________________ License number: ________
Telephones: _____________________________________________________________________
2 Drug Therapy Evaluation
2.1 Patient has other diagnosed diseases:
□ no
□ yes → Please describe: __________________________________________________________
_______________________________________________________________________________
Treatment with somatropin is contraindicated in active neoplastic disease (unless a favorable
opinion has been provided by the oncologist), uncorrected renal or cardiovascular congenital
anomalies, severe acute disease, benign intracranial hypertension, and proliferative or
preproliferative diabetic retinopathy.
2.2 Patient uses other drugs: □ no □ yes → Please describe:
Trade name Generic name Total dose/day and route Start date Prescription
□ no □ yes
□ no □ yes
□ no □ yes
□ no □ yes
2.3 Patient has had allergic reactions to drugs:
□ no
□ yes → What types of reactions? To what drugs? _______________________________________
3 Treatment Monitoring
Anthropometric Measurements
Baseline 6th month 12th month 18th month 24th month
Scheduled date
Date
Weight
Height
Laboratory Tests
Baseline 1st
month
2nd
month
Scheduled date
Date
Fasting glucose
TSH
IGF-1*
* New tests are required after each dose adjustment.
3rd
month
4th
month
5th
month
6th
month

3.1 Patients presented laboratory findings within normal parameters:
no → Dispense drug and refer patient to the primary physician
yes → Dispense drug
3.2 Patient underwent annual x-ray for assessment of bone age:
no → Dispense drug and refer patient to the primary physician
yes → Dispense drug
3.3 Patient developed severe acute disease during treatment:
no → Dispense drug
yes → Dispense drug and refer patient to the primary physician (treatment should be discontinued
for 1-2 months or until patient recovery)
3.4 Patient presented symptoms suggestive of adverse events (fill in the Adverse Event Record):
no → Dispense drug
yes → Go to question 3.5
3.5 Patient needs to be assessed by the primary physician regarding the adverse event:
no → Dispense drug
yes → Dispense drug and refer patient to the primary physician
Adverse Event Record
Date of interview Adverse event *Intensity ♠Management strategy
Main adverse reactions previously reported: injection site reactions (pain, edema, inflammation),
headache, myalgia, asthenia, hip and knee pain, and fatigue
* Intensity: (Mi) mild; (Mo) moderate; (S) severe
♠ Management strategy: (P) pharmacological (indication of over-the-counter drugs); (NP) nonpharmacological
(dietary practices, water intake, exercise, others); (RP) referral to the primary
physician; (OT) other (please describe)
Dispensing Record
Date
Trade name
Batch/Expiration date
Prescribed dose
Amount dispensed
Next dispensation date (medical
opinion required: yes/no)
Pharmacist in charge/license
number
Notes
1st
month
7th
month
2nd
month
8th
month
3rd
month
9th
month
4th
month
10th
month
5th
month
11th
month
6th
month
12th
month

Date
Trade name
Batch/Expiration date
Prescribed dose
Amount dispensed
Next dispensation date (medical
opinion required: yes/no)
Pharmacist in charge/license
number
Notes

Patient Orientation Guide
Somatropin
This guide presents information on the drug that you are receiving free from the
Brazilian Public Health System. By following these guidelines, you have more
chances of benefiting from treatment. This drug is used in the treatment of
Turner’s syndrome.
1 Disease
• Turner’s syndrome is a condition that may be detected at birth or at puberty. Short stature is the
most common characteristic in Turner’s syndrome. Other common findings include webbed neck,
broad chest with widely spaced nipples, and delayed sexual development. Kidney, heart, and
thyroid disorders may also occur.
2 Drug
• This drug promotes an increase in final height and growth velocity.
3 Drug storage
• The drug should be stored in the refrigerator, but it should not be frozen.
4 Drug administration
• The drug should be administered by subcutaneous injections.
• If you are having the injections at home, basic rules for drug injection should be followed. In this
case, consult the doctor or a nursing professional for further guidance. Do not prepare or inject the
drug until you are well trained.
• Consult the pharmacist on how to properly dispose syringes and needles after use.
• Try to have the injections always on the time established at the beginning of treatment.
• Take the exact dose prescribed by the doctor.
5 Unpleasant reactions
• Despite the benefits of this drug, a few unpleasant reactions may occur, such as pain or swelling
at the injection site, headache, joint and muscle pain, and weakness.
• If any of these or other signs/symptoms occur, report them to the doctor or pharmacist.
• Further information on adverse reactions can be found in the Informed Consent and Liability Form,
a document signed by you or your legal guardian and by the doctor.
6 Use of other drugs
• Do not use other drugs without the doctor's consent or without obtaining guidance from a health
professional.
7 Other important information
• Due to the variety of pharmaceutical formulations of somatropin currently available, carefully
observe the drug formulation that you received and the amount to be injected. In case of doubt,
consult a health professional (doctor, nurse, or pharmacist of the Brazilian Public Health System).
8 Laboratory tests
• The performance of laboratory tests ensures an accurate evaluation of the effect of the drug on
your body. In some cases, dose adjustments or even discontinuation of treatment may be
necessary.
9 To continue receiving the drug

• Return to the pharmacy every month, with the following documents:
− Current prescription
− National Health Card or ID
− Tests: IGF-1 measurement (whenever dose adjustment is required and every year); fasting
glucose, TSH, and x-ray for assessment of bone age every year.
10 In case of doubt
• If you have any questions that have not been addressed in this guide, consult the doctor or
pharmacist of the Brazilian Public Health System before taking any action.
11 Additional information
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________
Bring a cooler to transport the drug(s) from the pharmacy
to your home and store it in the refrigerator immediately.
If, for any reason, you do not use the drug(s) received,
return it to the pharmacy of the Brazilian Public Health System.