Fuel metabolism in growth hormone-deficient adults

Safety of current recombinant human growth hormone treatments for adults with growth hormone deficiency and unmet needs

INTRODUCTION

Growth hormone (GH) deficiency (GHD) in adults is characterized by abnormal body composition, unfavorable cardiovascular risk factors, and poor quality of life. The diagnosis is made within appropriate clinical settings and according to established guidelines. Numerous studies have shown that GH treatment improves body composition, cardiovascular risk factors, physical capacity, and quality of life while issues on safety, in particular long-term safety, remain.

AREAS COVERED

Short- and long-term safety of GH replacement in adults with GHD.

EXPERT OPINION

Adults with GHD are an inhomogeneous group of patients and GH replacement requires individual considerations. Most adverse effects are mild and transient and related to fluid retention and GH dose. In patients without comorbidities long-term GH treatment is safe and development of diabetes, cardiovascular disease, or tumors are not increased. Furthermore, mortality is not increased. Patients with risk factors should be identified before GH treatment is initiated and an optimal balance between benefit and risk established. Studies with sufficient duration and power to identify the development of cardiovascular diseases and cancers are still awaited. Effective management of comorbidities can be expected to decrease morbidity and mortality and improve quality of life. Studies with long-acting GH formulations are ongoing and available data indicate similar effects and short-time safety.

Pharmacokinetics of Recombinant Human Growth Hormone (rhGH) in Beagles by ELISA

Background::

Somatropin is recombinant human growth (GH) used for the treatment of growth failure in children and GH deficiency in adults. At present, rhGH marketed in China is mostly freeze-dried powder injection. As the lyophilization process is unstable, time-consuming and costly, rhGH has been prepared into an aqueous solution for administering directly.

Introduction::

In this study, the pharmacokinetics of two dosage forms of rhGH in beagle dogs after single subcutaneous administration was determined by enzyme-linked immunosorbent assay (ELISA).

Methods:

Twelve healthy beagles (male, 6:female, 6) were used for the pharmacokinetic study and were equally divided into two groups. Subcutaneous injection of 0.2 IU/kg with rhGH in the two formulations. The blood samples were taken from forearms, 0, 0.033, 0.083, 0.25, 0.5, 1, 2, 3, 4, 7, 10, 24 h and collected the beagle plasma on time. The pharmacokinetic parameters of rhGH after subcutaneous (s.c.) injection were determined experimentally on beagles. Primary PK endpoints were area under the serum concentration-time curve (AUC0-t) and maximum serum concentration (Cmax). Serum rhGH level was determined by enzyme-linked immunosorbent assay.

Results::

The calibration curves obtained were linear over the concentration range of 25 to 1600 ng/ml for recombinant human growth. The results of the intra- and inter-day precision and accuracy studies were well within the acceptable limits. The analysis samples were stable under different storage conditions and temperature.

Conclusions::

The developed ELISA method has been successfully applied to the studies of pharmacokinetic of recombinant human growth hormone in beagles.

The current state of long-acting growth hormone preparations for growth hormone therapy

PURPOSE OF REVIEW

To discuss the rationale of developing long-acting growth hormone (LAGH) preparations, to describe the technologies designed to prolong GH action, and to address key issues regarding efficacy, safety, and monitoring while on treatment.

REVIEW FINDINGS

Recombinant human GH is currently approved for daily use and has been shown to restore longitudinal growth, and improve body composition with relatively few side-effects in children and adults with GH deficiency, respectively. However, daily injections can be inconvenient, painful and distressing for some patients, resulting in decreased adherence and efficacy. Over a dozen pharmaceutical companies have designed LAGH preparations that are at various stages of development using a number of different methods to prolong GH action.

SUMMARY

LAGH will represent an advancement over daily recombinant human GH injections because of fewer injections that may offer increased acceptance, tolerability, and therapeutic flexibility to patients that potentially can improve treatment outcomes. However, given the unphysiological profile of LAGH preparations, long-term surveillance of efficacy and safety are needed. This review summarizes recent developments of LAGH preparations, and highlights the importance of long-term surveillance registries to assess for efficacy and safety that will be essential for understanding the impact of prolonged exposure to these compounds.

The impact of diet-based glycaemic response and glucose regulation on cognition: evidence across the lifespan

The brain has a high metabolic rate and its metabolism is almost entirely restricted to oxidative utilisation of glucose. These factors emphasise the extreme dependence of neural tissue on a stable and adequate supply of glucose. Whereas initially it was thought that only glucose deprivation (i.e. under hypoglycaemic conditions) can affect brain function, it has become apparent that low-level fluctuations in central availability can affect neural and consequently, cognitive performance. In the present paper the impact of diet-based glycaemic response and glucose regulation on cognitive processes across the lifespan will be reviewed. The data suggest that although an acute rise in blood glucose levels has some short-term improvements of cognitive function, a more stable blood glucose profile, which avoids greater peaks and troughs in circulating glucose is associated with better cognitive function and a lower risk of cognitive impairments in the longer term. Therefore, a habitual diet that secures optimal glucose delivery to the brain in the fed and fasting states should be most advantageous for the maintenance of cognitive function. Although the evidence to date is promising, it is insufficient to allow firm and evidence-based nutritional recommendations. The rise in obesity, diabetes and metabolic syndrome in recent years highlights the need for targeted dietary and lifestyle strategies to promote healthy lifestyle and brain function across the lifespan and for future generations. Consequently, there is an urgent need for hypothesis-driven, randomised controlled trials that evaluate the role of different glycaemic manipulations on cognition.

Status of long-acting-growth hormone preparations--2015

Growth hormone (GH) treatment has been an established therapy for GH deficiency (GHD) in children and adults for more than three decades. Numerous studies have shown that GH treatment improves height, body composition, bone density, cardiovascular risk factors, physical fitness and quality of life and that the treatment has few side effects. Initially GH was given as intramuscular injections three times per week, but daily subcutaneous injections were shown to be more effective and less inconvenient and the daily administration has been used since its introduction in the 1980s. However, despite ongoing improvements in injection device design, daily subcutaneous injections remain inconvenient, painful and distressing for many patients, leading to noncompliance, reduced efficacy and increased health care costs. To address these issues a variety of long-acting formulations of GH have been developed. In this review we present the current status of long-acting GH preparations and discuss the specific issues related to their development.

Growth hormone replacement in adults - current standards and new perspectives

Growth hormone deficiency (GHD) in adults is an established clinical syndrome characterised by adverse body composition with more body fat than lean body mass, unfavourable blood lipids, decreased physical fitness and poor quality of life. No specific biomarker for GHD exists and the sometimes difficult diagnosis should be made in accordance with, established guidelines. Measurements of insulin-like growth factor I (IGF-I) is often not sufficient for the diagnosis and stimulation tests of the GH reserve are required. After diagnosis of GHD, treatment with GH should be initiated with a low dose, and gradually increased aiming at obtaining an IGF-I level within the upper part of the normal range for age matched healthy controls. Most side effects are mild and transient and attenuated by gradual dose increments. Numerous studies have shown that GH treatment can improve body composition, cardiovascular risk factors, physical capacity and quality of life. However, studies on effects beyond 5 years are few and despite encouraging preliminary reports the ultimate endpoint demonstrating that GH treatment has beneficial effects on mortality, cardiovascular events and fractures without an increase in cancer incidence remain to be solidly demonstrated and studies to resolve these issues are awaited. Trials with long acting GH formulations are ongoing and available data indicate similar effects on outcome measures compared to the effects of daily injections. This review will give an overview of clinically relevant issues of GHD including advice for management of these patients.

Growth hormone-mediated alteration of fuel metabolism in the aged rat as determined from transcript profiles

Age-related changes in body composition and serum lipids resemble symptoms of adult-onset growth hormone (GH) deficiency. GH treatment has been shown to normalize these changes in both GH-deficient adult patients and elderly subjects. The aim of this study was to identify GH-responsive genes that might mediate positive effects of GH treatment on fuel metabolism and body composition. cDNA microarrays were used to analyze age- and GH-induced changes in gene expression patterns in male rats. Tissues analyzed were liver, adipose tissue, and skeletal muscle from animals on or off GH treatment. A value of 1.5 was chosen to denote differences (increased or decreased expression) in the level of mRNA expression. In the liver, 7.3% of the expressed genes were affected by age and 6.5% by GH. Similar values for the other tissues were 8.3% and 5.3% (fat), and 7.9% and 9.6% (muscle), respectively. Among the differentially expressed genes, we identified several that encode proteins involved in fuel metabolism. Old rats were shown to have induced expression of genes involved in hepatic glucose oxidation and lipid synthesis, whereas these pathways were reduced in adipose tissue. GH treatment induced the expression of genes for lipid oxidation in liver and for glucose oxidation in skeletal muscle. In adipose tissue, GH reduced the expression of genes involved in lipogenesis even further. Changes in transcript levels were reflected in serum in terms of altered lipid profiles. Serum levels of triglycerides, high-density lipoprotein (HDL) cholesterol, and total cholesterol were higher in the old animals than in the young and normalized by GH treatment.

The metabolic syndrome as a vicious cycle: does obesity beget obesity?

Most attempts at weight loss are frustrated by the body's propensity to maintain fat mass. There are genetic and environmental mechanisms behind this phenomenon, such as thrifty genes, sedentary lifestyle and abundant food resources. We will outline a physiologic mechanism that may perpetuate obesity once it develops. Specifically, we suggest that obesity-induced hyperinsulinemia facilitates fuel storage as fat. This can be exacerbated by high glucocorticoid activity, low growth hormone (GH) activity and the paradoxical increase in free fatty acid (FFA) flux resulting from basal lipolysis in an expanded fat mass. We also outline mechanisms by which obesity may perpetuate low GH and increased glucocorticoid activity in the metabolic syndrome.

Decreased lipolysis and enhanced glycerol and glucose utilization by adipose tissue prior to development of obesity in monosodium glutamate (MSG) treated-rats

OBJECTIVE

To determine the metabolic alterations that lead to the neonatal administration of monosodium glutamate (MSG), which results in arrested growth and obesity. ANIMALS AND DESIGN: Wistar rats were injected 5 times, every other day, with 4 g of MSG/kg b.w. or with hyperosmotic saline (controls), within the first 10 days of life, and were studied at the age of 30 days.

RESULTS

Body weight was lower, whereas adipocyte lipid content, cell diameter, surface area and volume were higher in MSG rats than in controls. Plasma glucose, insulin, NEFA, glycerol and triglyceride levels, and in vitro production of NEFA by lumbar fat pad pieces incubated under basal conditions or in the presence of epinephrine and epinephrine plus glucose in the media were lower in MSG than in control rats. In the same fat pad pieces, the conversion of 1-14C-glycerol into fatty acids was always enhanced and its conversion into glyceride glycerol was enhanced when incubations were carried out in the presence of epinephrine or glucose. Both the hormone sensitive lipase activity and mRNA expression were lower in adipose tissue from MSG rats. Besides, the number of insulin receptors, lipid synthesis from U14C glucose, 3H-2-deoxy D-glucose uptake and cellular GLUT4 translocation index were higher in adipocytes from MSG rats than from the controls.

CONCLUSION

It is proposed that an enhanced insulin sensitivity in 1 month old MSG rats is responsible for the decreased lipolytic activity and enhanced glucose uptake. In addition, the enhanced lipogenesis and glycerol reutilization seen in their adipose tissue, disturbs the normal balance between fat depots breakdown and accumulation in favor of the latter.

Effects of growth hormone treatment on visceral adipose tissue

It is now evident that an increased amount of intra-abdominal (visceral) adipose tissue is associated with an impaired metabolic profile, increasing the risk of CVD and NIDDM. Visceral obesity also appears to be associated with impaired GH action. GH replacement therapy in patients with GHD, or GH treatment of viscerally obese individuals, is able to induce a profound reduction in the amount of visceral adipose tissue and to improve the metabolic profile.

Basal growth hormone levels in women are positively correlated with high-density lipoprotein cholesterol and apolipoprotein A-I independently of insulin-like growth factor 1 or insulin

Previous studies in growth hormone (GH)-deficient or acromegalic patients yielded contradictory results on the effect of GH on lipoprotein metabolism. In a cross-sectional study, we analyzed the relationships between unstimulated GH, insulin-like growth factor 1 (IGF1), insulin, and lipoprotein metabolism in 44 non-obese young women. On univariate analysis, basal serum levels of GH correlated positively with triglycerides, high-density lipoprotein (HDL) cholesterol, apolipoprotein A-I (apoA-I) and apoA-II and negatively with lipoprotein lipase (LPL) activity. These associations remained significant on multivariate analyses that, in addition to GH, took into account the effects of insulin or C-peptide, as well as the effects of total, protein-bound, or free IGF1. In most cases, the relationships of these lipid parameters with insulin/C-peptide and IGF1 and its free or protein-bound subfractions were opposite of those with GH and not significant. Thus, GH appears to regulate the metabolism of HDL and triglycerides independently of IGF1 and insulin.

Adult vs childhood onset GHD: is there a real clinical difference?

As growth hormone (GH) secretion and insulin-like growth factor I (IGF-I) levels decrease with age, it is important to have reliable age- and sex-specific control data for both GH stimulation tests and circulating IGF-I levels. This is particularly true for elderly patients with a history of pituitary disease but with normal production of the anterior pituitary hormones other than GH. The potential impact of these factors on GH deficiency (GHD) has led to a need for the development of reliable, sensitive and specific tests to assess GH reserve. Before starting treatment with recombinant human GH in adults with suspected GHD, it is important to differentiate between adults with childhood onset GHD (CO-GHD) and those with adult onset GHD (AO-GHD). Adults with untreated CO-GHD have significantly lower values for body weight, body mass index, lean body mass and height than those with AO-GHD, while patients with AO-GHD show a more pronounced deviation from normal in psychosocial distress. Following treatment with GH, 12.5 microg/kg/day s.c., patients with AO-GHD showed a decrease in waist/hip ratio and low-density lipoprotein. Quality of life, as measured using the Nottingham Health Profile, changed significantly in both patient groups after 18 months of therapy, though these results were only consistent in subjects with AO-GHD. Improvements were also reported in physical mobility and energy. Side-effects were mainly reported in patients with AO-GHD, and this may have been due to the GH dosage being too high for older patients. In conclusion, CO-GHD in adults appears to be a developmental disorder in patients who have not attained full somatic maturation. The hormonal/metabolic balance and lifestyle of these individuals have adapted to their condition. AO-GHD is a metabolic disorder characterized by a hormonal imbalance affecting the health status, physical condition and quality of life of previously normal adults.