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Johannsson G, Ragnarsson O. Growth hormone deficiency in adults with hypopituitarism-What are the risks and can they be eliminated by therapy? J Intern Med 2021; 290:1180-1193. [PMID: 34605087 DOI: 10.1111/joim.13382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Growth hormone (GH) deficiency develops early in patients with hypothalamic-pituitary disorders and is therefore common among these patients. GH deficiency in adults is associated with increased morbidity, increased body fat mass, abdominal obesity, dyslipidaemia, reduced exercise capacity, impaired cardiac function as well as reduced self-reported well-being and impaired quality of life. Since recombinant human GH became available as replacement therapy more than 25 years ago, randomised controlled trials and long-term studies, together with meta-analyses, have shown improved outcomes in adult patients with hypopituitarism receiving GH. Many of the features associated with GH deficiency in adults improve, or even normalize, and the safety profile is reassuring. The increased interest in GH deficiency in adults with hypothalamic-pituitary disorders has also contributed to the identification of other factors of importance for an outcome such as the replacement of other pituitary hormone deficiencies, and the management of the underlying hypothalamic-pituitary disease, most commonly a pituitary tumour. In this narrative review, we summarize the burden of GH deficiency in adults with hypopituitarism, the impact of GH replacement on the outcome, as well as safety. Based on currently available data, GH replacement should be considered routine management of adults with hypopituitarism.
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Affiliation(s)
- Gudmundur Johannsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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2
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Tavares ABW, Collett-Solberg PF. Growth hormone deficiency and the transition from pediatric to adult care. J Pediatr (Rio J) 2021; 97:595-602. [PMID: 33773961 PMCID: PMC9432185 DOI: 10.1016/j.jped.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To discuss the approach to patients diagnosed with growth hormone deficiency (GHD) in childhood during the transition period from puberty to adulthood, focusing on the following: (1) physiology; (2) effects of recombinant human GH (rhGH) interruption/reinstitution after adult height achievement; (3) re-evaluation of somatrotropic axis; (4) management of rhGH reinstitution, when necessary. SOURCE OF DATA Narrative review of the literature published at PubMed/MEDLINE until September 2020 including original and review articles, systematic reviews and meta-analyses. SYNTHESIS OF DATA Growth hormone is crucial for the attainment of normal growth and for adequate somatic development, which does not end concomitantly with linear growth. Retesting adolescents who already meet the criteria that predict adult GHD with high specificity is not necessary. Patients with isolated GHD have a high likelihood of normal response to GH testing after puberty. Adolescents with confirmed GHD upon retesting should restart rhGH replacement and be monitored according to IGF-I levels, clinical parameters, and complementary exams. CONCLUSION Patients with isolated idiopathic GHD in childhood are a special group who must be reevaluated for GHD as many of them have normal GH provocative tests upon retesting after puberty. Patients who confirm the persistence of GHD in the transition period should maintain rhGH replacement in order to reach an ideal peak bone mass, satisfactory body composition, lipid and glucose profiles, and quality of life.
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Affiliation(s)
- Ana Beatriz Winter Tavares
- Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil; Faculdade de Medicina de Petrópolis, Petrópolis, RJ, Brazil.
| | - Paulo Ferrez Collett-Solberg
- Universidade do Estado do Rio de Janeiro, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Serviço de Endocrinologia, Rio de Janeiro, RJ, Brazil
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3
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Davani-Davari D, Karimzadeh I, Khalili H. The potential effects of anabolic-androgenic steroids and growth hormone as commonly used sport supplements on the kidney: a systematic review. BMC Nephrol 2019; 20:198. [PMID: 31151420 PMCID: PMC6545019 DOI: 10.1186/s12882-019-1384-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
Background Anabolic-androgenic steroids and growth hormone are among the most commonly used supplements by sportsmen and sportswomen. The aim of this systematic review is to collect and report available data about renal safety of anabolic-androgenic steroids and growth hormone (GH). Methods The search strategy was in accordance with the PRISMA guideline. Seven databases such as Scopus, Medline, Embase, and ISI Web of Knowledge were searched using keywords, such as “growth hormone”, “anabolic-androgenic steroids”, and “kidney injury”. Articles published from 1950 to December 2017 were considered. Randomized clinical trials, prospective or retrospective human studies, case series as well as case reports, and experimental (in vivo) studies were included. Twenty one clinical and experimental articles were selected (12 for anabolic-androgenic steroids and 9 for GH). Results Anabolic-androgenic steroids can affect the kidney in different aspects. They can induce or aggravate acute kidney injury, chronic kidney disease, and glomerular toxicity. These adverse effects are mediated through pathways such as stimulating renin-angiotensin-aldosterone system, enhancing the production of endothelin, producing reactive oxygen species, over-expression of pro-fibrotic and pro-apoptotic mediators (e.g., TGF-β1), as well as inflammatory cytokines (e.g., TNF-α, IL-1b, and IL-6). Although GH may affect the kidney in different aspects, such as size, glomerular filtration rate, and tubule functions, either directly or indirectly, there is no conclusive clinical evidence about its detrimental effects on the kidney in athletes and body builders. Conclusion Evidence regarding effects of anabolic-androgenic steroids exists; However, GH’s exact effect on the kidney at doses used by athletes and body builders has not yet been clarified. Cohort clinical studies with long-term follow-up are warranted in this regard.
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Affiliation(s)
- Dorna Davani-Davari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Karafarin street, P O Box: 7146864685, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Karafarin street, P O Box: 7146864685, Shiraz, Iran.
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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4
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Pivonello R, Di Somma C, Colao A. Cardiovascular risk after cessation of growth hormone treatment in people born small for gestational age. Lancet Diabetes Endocrinol 2017; 5:930-932. [PMID: 29102565 DOI: 10.1016/s2213-8587(17)30323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/04/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | | | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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5
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Feeney C, Sharp DJ, Hellyer PJ, Jolly AE, Cole JH, Scott G, Baxter D, Jilka S, Ross E, Ham TE, Jenkins PO, Li LM, Gorgoraptis N, Midwinter M, Goldstone AP. Serum insulin-like growth factor-I levels are associated with improved white matter recovery after traumatic brain injury. Ann Neurol 2017; 82:30-43. [PMID: 28574152 PMCID: PMC5601275 DOI: 10.1002/ana.24971] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
Objective Traumatic brain injury (TBI) is a common disabling condition with limited treatment options. Diffusion tensor imaging measures recovery of axonal injury in white matter (WM) tracts after TBI. Growth hormone deficiency (GHD) after TBI may impair axonal and neuropsychological recovery, and serum insulin‐like growth factor‐I (IGF‐I) may mediate this effect. We conducted a longitudinal study to determine the effects of baseline serum IGF‐I concentrations on WM tract and neuropsychological recovery after TBI. Methods Thirty‐nine adults after TBI (84.6% male, median age = 30.5 years, 87.2% moderate–severe, median time since TBI = 16.3 months, n = 4 with GHD) were scanned twice, 13.3 months (range = 12.1–14.9) apart, and 35 healthy controls were scanned once. Symptom and quality of life questionnaires and cognitive assessments were completed at both visits (n = 33). Our main outcome measure was fractional anisotropy (FA), a measure of WM tract integrity, in a priori regions of interest: splenium of corpus callosum (SPCC) and posterior limb of internal capsule (PLIC). Results At baseline, FA was reduced in many WM tracts including SPCC and PLIC following TBI compared to controls, indicating axonal injury, with longitudinal increases indicating axonal recovery. There was a significantly greater increase in SPCC FA over time in patients with serum IGF‐I above versus below the median for age. Only the higher IGF‐I group had significant improvements in immediate verbal memory recall over time. Interpretation WM recovery and memory improvements after TBI were greater in patients with higher serum IGF‐I at baseline. These findings suggest that the growth hormone/IGF‐I system may be a potential therapeutic target following TBI. Ann Neurol 2017;82:30–43
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Affiliation(s)
- Claire Feeney
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's and Charing Cross Hospitals, London, United Kingdom
| | - David J Sharp
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Peter J Hellyer
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Amy E Jolly
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - James H Cole
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Gregory Scott
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - David Baxter
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham, United Kingdom
| | - Sagar Jilka
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ewan Ross
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Timothy E Ham
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Peter O Jenkins
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lucia M Li
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nikos Gorgoraptis
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Mark Midwinter
- Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham, United Kingdom.,Academic Section for Musculoskeletal Disease, Chapel Allerton Hospital, University of Leeds, Leeds
| | - Anthony P Goldstone
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's and Charing Cross Hospitals, London, United Kingdom.,PsychoNeuroEndocrinology Research Group, Neuropsychopharmacology Unit, Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
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6
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Höybye C, Weber MM, Pournara E, Tønnes Pedersen B, Biller BMK. Is GH dosing optimal in female patients with adult-onset GH deficiency? An analysis from the NordiNet ® International Outcome Study. Clin Endocrinol (Oxf) 2017; 86:798-805. [PMID: 28306165 DOI: 10.1111/cen.13330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/06/2017] [Accepted: 03/12/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate gender differences in GH dosing, IGF-I and cardiovascular risk markers in adults with GH deficiency (GHD). DESIGN NordiNet® International Outcome Study (NCT00960128), a noninterventional, multicentre study, evaluates the long-term effectiveness and safety of Norditropin® (Novo Nordisk A/S) in the real-life clinical setting. PATIENTS Nondiabetic patients (n = 252; 41·7% female) with adult-onset GHD (age ≥20 years at GH start), ≥4 years' GH therapy and glycosylated haemoglobin (HbA1c ) data at baseline and 4 years. MEASUREMENTS Effects of gender (adjusted for baseline age and body mass index [BMI], average GH dose, treatment duration and concomitant medication) on change from baseline to 4 years (∆) in HbA1c , fasting plasma glucose (FPG), IGF-I, lipids and waist circumference were evaluated. RESULTS GH dose (mean [SE]; mg/day) was similar between females (0·22 [0·02]) and males (0·21 [0·01]) at baseline, but higher in females from year 1 (year 4, females, 0·45 [0·03]; males, 0·32 [0·02]). Mean IGF-I standard deviation score [SDS] was lower in females vs males at each treatment year; more than one-third of females still had an IGF-I SDS below 0 at year 4, compared with only 21·8% of men. An adverse lipid profile at baseline remained poor in more females than males at 4 years. Improvement in total cholesterol was significantly associated with gender (P < 0·0001), improving less in females than in males. CONCLUSIONS These data highlight that, even after 4 years, GH dose is suboptimal in many female patients, which may impact clinical outcomes; therefore, GH titration for women requires further improvement.
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Affiliation(s)
- Charlotte Höybye
- Department of Endocrinology, Metabolism and Diabetology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Matthias M Weber
- Department of Endocrinology and Metabolism, Medical Clinic, University of Mainz, Mainz, Germany
| | - Effie Pournara
- Global Medical Affairs, Novo Nordisk Health Care AG, Zürich, Switzerland
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7
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Strasburger CJ, Vanuga P, Payer J, Pfeifer M, Popovic V, Bajnok L, Góth M, Olšovská V, Trejbalová L, Vadasz J, Fima E, Koren R, Amitzi L, Bidlingmaier M, Hershkovitz O, Hart G, Biller BMK. MOD-4023, a long-acting carboxy-terminal peptide-modified human growth hormone: results of a Phase 2 study in growth hormone-deficient adults. Eur J Endocrinol 2017; 176:283-294. [PMID: 27932411 PMCID: PMC5292974 DOI: 10.1530/eje-16-0748] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/23/2016] [Accepted: 12/08/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Growth hormone (GH) replacement therapy currently requires daily injections, which may cause distress and low compliance. C-terminal peptide (CTP)-modified growth hormone (MOD-4023) is being developed as a once-weekly dosing regimen in patients with GH deficiency (GHD). This study's objective is to evaluate the safety, pharmacokinetics (PK), pharmacodynamics (PD) and efficacy of MOD-4023 administered once-weekly in GHD adults. DESIGN 54 adults with GHD currently treated with daily GH were normalized and randomized into 4 weekly dosing cohorts of MOD-4023 at 18.5%, 37%, 55.5% or 123.4% of individual cumulative weekly molar hGH dose. The study included 2 stages: Stage A assessed the effectiveness and PK/PD profiles of the 4 dosing regimens of MOD-4023. Stage B was an extension period of once-weekly MOD-4023 administration (61.7% molar hGH content) to collect further safety data and confirm the results from Stage A. RESULTS Dose-dependent response was observed for both PK and PD data of weekly MOD-4023 treatment. Insulin-like growth factor I (IGF-I) SDS levels were maintained within normal range. The 18.5% cohort was discontinued due to low efficacy. MOD-4023 was well tolerated and exhibited favorable safety profile in all dose cohorts. The reported adverse events were consistent with known GH-related side effects. CONCLUSIONS Once-weekly MOD-4023 administration in GHD adults was found to be clinically effective while maintaining a favorable safety profile and may obviate the need for daily injections. Weekly GH injections may improve compliance and overall outcome. The promising results achieved in this Phase 2 study led to a pivotal Phase 3 trial, which is currently ongoing.
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Affiliation(s)
- Christian J Strasburger
- Department of Medicine for EndocrinologyDiabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - Peter Vanuga
- Department of EndocrinologyNational Institute of Endocrinology and Diabetology, Lubochna, Slovakia
| | - Juraj Payer
- Department of Internal Medicine VUniversity Hospital Ruzinov, Bratislava, Slovakia
| | - Marija Pfeifer
- Department of EndocrinologyUniversity Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vera Popovic
- Neuroendocrine UnitClinical Centre of Serbia, Belgrade, Serbia
| | - László Bajnok
- 1st Department of MedicineUniversity of Pécs, Pécs, Hungary
| | - Miklós Góth
- 2nd Department of Internal MedicineMilitary Hospital – State Health Center, Budapest, Hungary
| | - Veˇra Olšovská
- II Internal Clinic in University Hospital St AnnaBrno, Czech Republic
| | - L‘udmila Trejbalová
- I Department of Internal MedicineUniversity Hospital Bratislava, Bratislava, Slovakia
| | - Janos Vadasz
- 1st Department of Internal MedicineHetényi Géza Hospital and Out-Patient Clinic, Szolnok, Hungary
| | | | | | | | - Martin Bidlingmaier
- Medizinische Klinik – InnenstadtLudwig Maximilian University, Munich, Germany
| | | | - Gili Hart
- OPKO BiologicsKiryat Gat, Israel
- Correspondence should be addressed to G Hart;
| | - Beverly M K Biller
- Neuroendocrine UnitMassachusetts General Hospital, Boston, Massachusetts, USA
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8
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Isgaard J, Cittadini A. Growth hormone and the heart in growth hormone deficiency-what have we learned so far? Endocrine 2017; 55:331-332. [PMID: 27981513 DOI: 10.1007/s12020-016-1206-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/08/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Jörgen Isgaard
- Department of Internal Medicine and Nutrition, Sahlgrenska Academy at the University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Antonio Cittadini
- Department of Translational Medical Science, Federico II University, Naples, Italy
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9
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Di Somma C, Scarano E, Savastano S, Savanelli MC, Pivonello R, Colao A. Cardiovascular alterations in adult GH deficiency. Best Pract Res Clin Endocrinol Metab 2017; 31:25-34. [PMID: 28477729 DOI: 10.1016/j.beem.2017.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There is a growing body of evidence indicating that patients with adult GH deficiency (GHD) are characterized by a cluster of traditional and emerging cardiovascular risk factors and markers, which can significantly increase their cardiovascular morbidity and mortality possibly linked to aberrations in GH status. Patients with adult GHD present multiple different cardiovascular abnormalities. In addition, cardiovascular risk in adult GHD is increased due to altered body composition, abnormal lipid profile, insulin resistance and impaired glucose metabolism. Cardiovascular risk factors can be reversed, at least partially, after GH replacement. However, evidence on the effects of GH replacement on cardiovascular events and mortality is too limited in adult GHD patients. Aim of this review is to provide an at-a-glance overview of the role of the GH/IGF-I on the cardiovascular system and the state of art of the effects of GH replacement on cardiovascular system.
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Affiliation(s)
| | - Elisabetta Scarano
- Dipartimento di Medicina Clinica e Chirurgia, Divisione di Endocrinologia, Università "Federico II", Napoli, Italy.
| | - Silvia Savastano
- Dipartimento di Medicina Clinica e Chirurgia, Divisione di Endocrinologia, Università "Federico II", Napoli, Italy.
| | | | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Divisione di Endocrinologia, Università "Federico II", Napoli, Italy.
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Divisione di Endocrinologia, Università "Federico II", Napoli, Italy.
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10
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Abstract
Hypopituitarism refers to deficiency of one or more hormones produced by the anterior pituitary or released from the posterior pituitary. Hypopituitarism is associated with excess mortality, a key risk factor being cortisol deficiency due to adrenocorticotropic hormone (ACTH) deficiency. Onset can be acute or insidious, and the most common cause in adulthood is a pituitary adenoma, or treatment with pituitary surgery or radiotherapy. Hypopituitarism is diagnosed based on baseline blood sampling for thyroid stimulating hormone, gonadotropin, and prolactin deficiencies, whereas for ACTH, growth hormone, and antidiuretic hormone deficiency dynamic stimulation tests are usually needed. Repeated pituitary function assessment at regular intervals is needed for diagnosis of the predictable but slowly evolving forms of hypopituitarism. Replacement treatment exists in the form of thyroxine, hydrocortisone, sex steroids, growth hormone, and desmopressin. If onset is acute, cortisol deficiency should be replaced first. Modifications in replacement treatment are needed during the transition from paediatric to adult endocrine care, and during pregnancy.
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Affiliation(s)
- Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Shalet
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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11
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Svensson J, Sjögren K, Levin M, Borén J, Tivesten Å, Ohlsson C. Increased diet-induced fatty streak formation in female mice with deficiency of liver-derived insulin-like growth factor-I. Endocrine 2016; 52:550-60. [PMID: 26627099 PMCID: PMC4879167 DOI: 10.1007/s12020-015-0809-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/17/2015] [Indexed: 01/28/2023]
Abstract
The role of endocrine IGF-I for atherosclerosis is unclear. We determined the importance of circulating, liver-derived IGF-I for fatty streak formation in mice. Mice with adult, liver-specific IGF-I inactivation (LI-IGF-I(-/-) mice, serum IGF-I reduced by approximately 80 %) and control mice received an atherogenic (modified Paigen) diet between 6 and 12 months of age. At study end, Oil Red O staining of aortic root cryosections showed increased fatty streak area and lipid deposition in female but not in male LI-IGF-I(-/-) mice compared to controls. Mac-2 staining of aortic root and measurements of CD68 mRNA level in femoral artery revealed increased macrophage accumulation in proportion to the increased fatty streak area in female LI-IGF-I(-/-) mice. Moreover, female LI-IGF-I(-/-) mice displayed increased serum cholesterol and interleukin-6 as well as increased vascular cell-adhesion molecule 1 (VCAM1) mRNA levels in the femoral artery and elevated VCAM1 protein expression in the aortic root. Thus, increased diet-induced fatty streak formation in female LI-IGF-I(-/-) mice was associated with increased serum cholesterol and signs of systemic inflammation, endothelial activation, lipid deposition, and macrophage infiltration in the vascular wall.
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Affiliation(s)
- Johan Svensson
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden.
- Department of Internal Medicine, Sahlgrenska University Hospital, Gröna Stråket 8, 413 45, Göteborg, Sweden.
| | - Klara Sjögren
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden
| | - Malin Levin
- Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden
| | - Jan Borén
- Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden
| | - Åsa Tivesten
- Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 413 45, Göteborg, Sweden
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12
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Hershkovitz O, Bar-Ilan A, Guy R, Felikman Y, Moschcovich L, Hwa V, Rosenfeld RG, Fima E, Hart G. In Vitro and in Vivo Characterization of MOD-4023, a Long-Acting Carboxy-Terminal Peptide (CTP)-Modified Human Growth Hormone. Mol Pharm 2016; 13:631-9. [PMID: 26713839 DOI: 10.1021/acs.molpharmaceut.5b00868] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
MOD-4023 is a novel long-acting version of human growth hormone (hGH), containing the carboxy-terminal peptide (CTP) of human chorionic gonadotropin (hCG). MOD-4023 is being developed as a treatment for adults and children with growth hormone deficiency (GHD), which would require fewer injections than currently available GH formulations and thus reduce patient discomfort and increase compliance. This study characterizes MOD-4023's binding affinities for the growth hormone receptor, as well as the pharmacokinetic and pharmacodynamics, toxicology, and safety profiles of repeated dosing of MOD-4023 in Sprague-Dawley rats and Rhesus monkeys. Although MOD-4023 exhibited reduced in vitro potency and lower affinity to the GH receptor than recombinant hGH (rhGH), administration of MOD-4023 every 5 days in rats and monkeys resulted in exposure comparable to daily rhGH, and the serum half-life of MOD-4023 was significantly longer. Repeated administration of MOD-4023 led to elevated levels of insulin-like growth factor 1 (IGF-1), and twice-weekly injections of MOD-4023 resulted in larger increase in weight gain with fewer injections and a lower accumulative hGH dose. Thus, the increased half-life of MOD-4023 in comparison to hGH may increase the frequency of protein-receptor interactions and compensate for its decreased in vitro potency. MOD-4023 was found to be well-tolerated in rats and monkeys, with minimal adverse events, suggesting an acceptable safety profile. These results provide a basis for the continued clinical development of MOD-4023 as a novel treatment of GHD in children and adults.
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Affiliation(s)
| | | | - Rachel Guy
- OPKO Biologics , Nes Ziona 7414002, Israel
| | | | | | - Vivian Hwa
- Division of Endocrinology, Cincinnati Center for Growth Disorders, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio 45229, United States
| | - Ron G Rosenfeld
- Department of Pediatrics, Oregon Health & Science University , Portland, Oregon 97239, United States
| | - Eyal Fima
- OPKO Biologics , Nes Ziona 7414002, Israel
| | - Gili Hart
- OPKO Biologics , Nes Ziona 7414002, Israel
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13
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Affiliation(s)
- Stefano Cianfarani
- D.P.U.O. 'Bambino Gesù' Children's Hospital - 'Tor Vergata' University, Rome, Italy
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14
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Isgaard J, Arcopinto M, Karason K, Cittadini A. GH and the cardiovascular system: an update on a topic at heart. Endocrine 2015; 48:25-35. [PMID: 24972804 PMCID: PMC4328125 DOI: 10.1007/s12020-014-0327-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/04/2014] [Indexed: 01/06/2023]
Abstract
In this review, the importance of growth hormone (GH) for the maintenance of normal cardiac function in adult life is discussed. Physiological effects of GH and underlying mechanisms for interactions between GH and insulin-like growth factor I (IGF-I) and the cardiovascular system are covered as well as the cardiac dysfunction caused both by GH excess (acromegaly) and by GH deficiency in adult hypopituitary patients. In both acromegaly and adult GH deficiency, there is also increased cardiovascular morbidity and mortality possibly linked to aberrations in GH status. Finally, the status of the GH/IGF-I system in relation to heart failure and the potential of GH as a therapeutic tool in the treatment of heart failure are reviewed in this article.
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Affiliation(s)
- Jörgen Isgaard
- Laboratory of Experimental Endocrinology, Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, 413 45, Göteborg, Sweden,
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15
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Maggio M, Lauretani F, De Vita F, Basaria S, Lippi G, Butto V, Luci M, Cattabiani C, Ceresini G, Verzicco I, Ferrucci L, Ceda GP. Multiple hormonal dysregulation as determinant of low physical performance and mobility in older persons. Curr Pharm Des 2015; 20:3119-48. [PMID: 24050169 DOI: 10.2174/13816128113196660062] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/13/2013] [Indexed: 12/16/2022]
Abstract
Mobility-disability is a common condition in older individuals. Many factors, including the age-related hormonal dysregulation, may concur to the development of disability in the elderly. In fact, during the aging process it is observed an imbalance between anabolic hormones that decrease (testosterone, dehydroepiandrosterone sulphate (DHEAS), estradiol, insulin like growth factor-1 (IGF-1) and Vitamin D) and catabolic hormones (cortisol, thyroid hormones) that increase. We start this review focusing on the mechanisms by which anabolic and catabolic hormones may affect physical performance and mobility. To address the role of the hormonal dysregulation to mobility-disability, we start to discuss the contribution of the single hormonal derangement. The studies used in this review were selected according to the period of time of publication, ranging from 2002 to 2013, and the age of the participants (≥65 years). We devoted particular attention to the effects of anabolic hormones (DHEAS, testosterone, estradiol, Vitamin D and IGF-1) on both skeletal muscle mass and strength, as well as other objective indicators of physical performance. We also analyzed the reasons beyond the inconclusive data coming from RCTs using sex hormones, thyroid hormones, and vitamin D (dosage, duration of treatment, baseline hormonal values and reached hormonal levels). We finally hypothesized that the parallel decline of anabolic hormones has a higher impact than a single hormonal derangement on adverse mobility outcomes in older population. Given the multifactorial origin of low mobility, we underlined the need of future synergistic optional treatments (micronutrients and exercise) to improve the effectiveness of hormonal treatment and to safely ameliorate the anabolic hormonal status and mobility in older individuals.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Gian Paolo Ceda
- Department of Clinical and Experimental Medicine, Section of Geriatrics via Gramsci 14, 43100, Parma, Italy.
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16
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Eskander ET, Bonert V. Acromegaly as a Complication of Growth Hormone Therapy. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14165.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Al-Zaid FS, Alhader AA, Al-Ayadhi LY. Altered ghrelin levels in boys with autism: a novel finding associated with hormonal dysregulation. Sci Rep 2014; 4:6478. [PMID: 25257829 PMCID: PMC4175729 DOI: 10.1038/srep06478] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 08/11/2014] [Indexed: 12/02/2022] Open
Abstract
Autism is a neurodevelopmental disorder with unclear pathogenesis. Many clinical observations and hormone studies have suggested the involvement of the neuroprotective hormone ghrelin in autism. The current study aimed to investigate the potential role of ghrelin in autism and to elucidate the associated hormonal dysregulation. This case-control study investigated acyl ghrelin (AG), des-acyl ghrelin (DG), total testosterone (TT), free testosterone (FT), leptin and growth hormone (GH) levels in 31 male children with autism and 28 healthy age and sex-matched controls. Hormone levels were measured in the blood using enzyme-linked immunosorbent assay and chemiluminescence immunoassay kits. AG, DG and GH levels were significantly lower in the autism group than in the control group (p ≤ 0.001, p ≤ 0.005 and p ≤ 0.05, respectively). However, TT, FT and leptin levels were significantly higher in the autism group than in the control group (p ≤ 0.05, p ≤ 0.001 and p ≤ 0.01, respectively). Our results for the first time demonstrate low AG and DG levels in autistic children. Considering the capacity of ghrelin to affect neuroinflammatory and apoptotic processes that are linked to autism, this study suggests a potential role for the hormone ghrelin in the pathogenesis of autism.
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Affiliation(s)
- Felwah S Al-Zaid
- 1] Department of Physiology, College of Medicine, Riyadh, Kingdom of Saudi Arabia [2] Autism Research and Treatment Center, AL-Amodi Autism Research Chair, College of Medicine, Riyadh, Kingdom of Saudi Arabia
| | | | - Laila Y Al-Ayadhi
- 1] Department of Physiology, College of Medicine, Riyadh, Kingdom of Saudi Arabia [2] Autism Research and Treatment Center, AL-Amodi Autism Research Chair, College of Medicine, Riyadh, Kingdom of Saudi Arabia
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18
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Dahlgren J. Easypod™ a new electronic injection device for growth hormone. Expert Rev Med Devices 2014; 5:297-304. [DOI: 10.1586/17434440.5.3.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Ghrelin is a gut-derived peptide hormone, first isolated from the stomach. Ghrelin was initially characterized as a growth hormone (GH) secretagogue, but it plays a more important role as a potent orexigen and modulator of whole-body energy homeostasis. Ghrelin itself is closely regulated by metabolic status. Bone remodeling constantly renews the skeleton in a highly energy-dependent fashion. Accordingly, bone metabolism is tightly coupled to energy metabolism through the integration of peripheral and central mechanisms, involving the sympathetic nervous system and factors such as leptin. Ghrelin has been shown to modulate osteoblast differentiation and function, both directly and perhaps also through regulation of the GH-insulin-like growth factor axis. However, recently it has also been shown that ghrelin interacts with leptin in modulating bone structure, constituting a new mechanism that couples bone metabolism with energy homeostasis. In this review, we discuss the role that ghrelin plays modulating bone cell function, and its integrative role in coupling bone metabolism with energy metabolism.
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Pawlikowska-Haddal A. Growth hormone therapy with norditropin ( somatropin ) in growth hormone deficiency. Expert Opin Biol Ther 2013; 13:927-32. [PMID: 23662811 DOI: 10.1517/14712598.2013.795941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Growth hormone (GH) is indicated for therapy of growth hormone deficiency (GHD) in pediatric and adult patients. Introduction of recombinant human GH (rhGH) improved access to GH therapy. Norditropin [ somatropin (rDNA origin) injection] is rhGH, used for the replacement of endogenous GH in children and adults with GHD. AREAS COVERED The article reviews rhGH therapy in GHD indication with focus on Norditropin Nordiflex delivery system. The goals of therapy in children are to promote linear growth and restore normal body composition. In adults with GHD rhGH restores normal body composition, improves cardiac function and normalizes cardiovascular risk factors such as low-density lipoprotein cholesterol and C-reactive protein. EXPERT OPINION Adverse reactions of rhGH therapy include intracranial hypertension, fluid retention, glucose intolerance, and children may experience worsening of scoliosis and slipped capital femoral epiphysis. Increased risk for intracranial tumors has also been reported in teenagers and young adults treated with radiation to the head as children for a first neoplasm. RhGH therapy requires daily injections, therefore improved ease of use of delivery devices may improve treatment outcomes. Several rhGH devices have been developed, and the Norditropin FlexPro prefilled pen is the newest delivery system which has small dose increments, does not require reconstitution and has flexible storage features.
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Svensson J, Carlzon D, Petzold M, Karlsson MK, Ljunggren Ö, Tivesten A, Mellström D, Ohlsson C. Both low and high serum IGF-I levels associate with cancer mortality in older men. J Clin Endocrinol Metab 2012; 97:4623-30. [PMID: 23015658 DOI: 10.1210/jc.2012-2329] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although recent population-based studies suggest a U-shaped relationship between serum IGF-I concentration and all-cause mortality, the distribution of death causes underlying this association remains unclear. We hypothesized that high IGF-I levels associate with increased cancer mortality, whereas low IGF-I levels associate with increased cardiovascular disease (CVD) mortality. METHODS Serum IGF-I levels were measured in 2901 elderly men (mean age 75.4, range 69-81 yr) included in the prospective population-based Osteoporotic Fractures in Men Study (Sweden) study. Mortality data were obtained from central registers with no loss of follow-up. The statistical analyses included Cox proportional hazards regressions with or without a spline approach. RESULTS During the follow-up (mean 6.0 yr), 586 of the participants died (cancer deaths, n = 211; CVD deaths, n = 214). As expected, our data revealed a U-shaped association between serum IGF-I levels and all-cause mortality. Low as well as high serum IGF-I (quintile 1 or 5 vs. quintiles 2-4) associated with increased cancer mortality [hazard ratio (HR) = 1.86, 95% confidence interval (CI) = 1.34-2.58; and HR = 1.90, 95% CI = 1.37-2.65, respectively]. Only low serum IGF-I associated with increased CVD mortality (quintile 1 vs. quintiles 2-4, HR = 1.48, 95% CI = 1.08-2.04). These associations remained after adjustment for multiple covariates and exclusion of men who died during the first 2 yr of follow-up. CONCLUSIONS Our findings demonstrate that both low and high serum IGF-I levels are risk markers for increased cancer mortality in older men. Moreover, low IGF-I levels associate with increased CVD mortality.
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Affiliation(s)
- Johan Svensson
- Center for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden.
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22
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Toogood A, Brabant G, Maiter D, Jonsson B, Feldt-Rasmussen U, Koltowska-Haggstrom M, Rasmussen AK, Buchfelder M, Saller B, Biller BMK. Similar clinical features among patients with severe adult growth hormone deficiency diagnosed with insulin tolerance test or arginine or glucagon stimulation tests. Endocr Pract 2012; 18:325-34. [PMID: 22068248 DOI: 10.4158/ep11146.or] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether insulin tolerance tests (ITTs), arginine stimulation tests (ASTs), and glucagon stimulation tests (GST) identify patients who have similar clinical features of growth hormone (GH) deficiency when a diagnostic GH threshold of 3 μg/L is used. METHODS Data were obtained from the KIMS database (Pfizer International Metabolic Database). Comparisons were made between patients who underwent ITT, AST, or GST for GH peak, body mass index, lipids, waist circumference, waist-to-hip ratio, and quality of life. RESULTS A total of 5453 tests were available from 4867 patients registered in the database (ITT = 3111, AST = 1390, GST = 952). Significant (P<.001) intraindividual correlations were observed between the GH peaks for ITT vs AST (r = 0.655), ITT vs GST (r = 0.445), and AST vs GST (r = 0.632). GH peaks in response to all tests were negatively correlated to the number of additional pituitary hormone deficiencies and positively correlated to the insulinlike growth factor 1 standard deviation score. Body mass index had a negative influence on all 3 tests. Most clinical variables did not differ between the groups when comparing GH-deficient patients according to the diagnostic test used. The only exceptions that showed any difference were body mass index (slightly higher in the AST and GST groups), triglyceride levels (increased in the GST group), and insulinlike growth factor 1 (standard deviation score) (lower in the ITT and AST groups than in the GST group). Waist circumference was greater and quality of life was worse in the GST group than in the other groups. CONCLUSIONS The ITT, AST, and GST produce similar GH peaks, are influenced by similar clinical factors, and identify patients with similar features of GH deficiency at a diagnostic threshold of 3 μg/L.
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Affiliation(s)
- Andrew Toogood
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
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Elbornsson M, Götherström G, Bosæus I, Bengtsson BÅ, Johannsson G, Svensson J. Fifteen years of GH replacement increases bone mineral density in hypopituitary patients with adult-onset GH deficiency. Eur J Endocrinol 2012; 166:787-95. [PMID: 22318746 PMCID: PMC3341655 DOI: 10.1530/eje-11-1072] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Few studies have determined the effects of more than 5-10 years of GH replacement in adults on bone mineral content (BMC) and bone mineral density (BMD). DESIGN/PATIENTS In this prospective, single-centre, open-label study, the effects of 15 years of GH replacement on BMC and BMD, measured using dual-energy X-ray absorptiometry, were determined in 126 hypopituitary adults (72 men) with adult-onset GH deficiency (GHD). Mean age was 49.4 (range 22-74) years at the initiation of the study. RESULTS The mean initial GH dose of 0.63 (s.e.m. 0.03) mg/day was gradually lowered to 0.41 (0.01) mg/day after 15 years. The mean serum IGF1 SDS increased from -1.69 (0.11) at baseline to 0.63 (0.16) at the study end (P<0.001 vs baseline). The 15 years of GH replacement induced a sustained increase in total body BMC (+5%, P<0.001) and BMD (+2%, P<0.001). Lumbar (L2-L4) spine BMC increased by 9% (P<0.001) and BMD by 5% (P<0.001). In femur neck, a peak increase in BMC and BMD of 7 and 3%, respectively, was observed after 7 years (both P<0.001). After 15 years, femur neck BMC was 5% above the baseline value (P<0.01), whereas femur neck BMD had returned to the baseline level. In most variables, men had a more marked response to GH replacement than women. CONCLUSIONS Fifteen-year GH replacement in GHD adults induced a sustained increase in total body and lumbar (L2-L4) spine BMC and BMD. In femur neck, BMC and BMD peaked at 7 years and then decreased towards baseline values.
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Affiliation(s)
- Mariam Elbornsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gröna Stråket 8, SE-413 45 Göteborg, Sweden.
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Elbornsson M, Götherström G, Franco C, Bengtsson BÅ, Johannsson G, Svensson J. Effects of 3-year GH replacement therapy on bone mineral density in younger and elderly adults with adult-onset GH deficiency. Eur J Endocrinol 2012; 166:181-9. [PMID: 22106341 PMCID: PMC3261573 DOI: 10.1530/eje-11-0886] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Little is known of the effects of long-term GH replacement on bone mineral content (BMC) and bone mineral density (BMD) in elderly GH-deficient (GHD) adults. DESIGN/PATIENTS/METHODS: In this prospective, single-center, open-label study, the effects of 3-year GH replacement were determined in 45 GHD patients >65 years and in 45 younger control GHD patients with a mean age of 39.5 (S.E.M. 1.1) years. All patients had adult-onset disease and both groups were comparable in terms of number of anterior pituitary hormonal deficiencies, gender, body mass index, and waist:hip ratio. RESULTS The mean maintenance dose of GH was 0.24 (0.02) mg/day in the elderly patients and 0.33 (0.02) mg/day in the younger GHD patients (P<0.01). The 3 years of GH replacement induced a marginal effect on total body BMC and BMD, whereas femur neck and lumbar (L2-L4) spine BMC and BMD increased in both the elderly and the younger patients. The treatment response in femur neck BMC was less marked in the elderly patients (P<0.05 vs younger group). However, this difference disappeared after correction for the lower dose of GH in the elderly patients using an analysis of covariance. There were no between-group differences in responsiveness in BMC or BMD at other skeletal locations. CONCLUSIONS This study shows that GH replacement increases lumbar (L2-L4) spine and femur neck BMD and BMC in younger as well as elderly GHD patients. This supports the notion that long-term GH replacement is also useful in elderly GHD patients.
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Affiliation(s)
- Mariam Elbornsson
- Department of Endocrinology, Research Centre for Endocrinology and Metabolism, Gröna Stråket 8, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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25
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Hokken-Koelega A, Keller A, Rakov V, Kipper S, Dahlgren J. Patient Acceptance, Ease of Use, and Preference for Norditropin NordiFlex with NordiFlex PenMate: Results from an Open-Label, User Survey of Everyday Use. ISRN ENDOCRINOLOGY 2011; 2011:803948. [PMID: 22363887 PMCID: PMC3262649 DOI: 10.5402/2011/803948] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/11/2011] [Indexed: 11/26/2022]
Abstract
In this 12-week open-label, uncontrolled study, patients (n = 85; mean [SD] age 11.2 [3.95] years) were trained to use an injection device with an automatic needle insertion accessory (NordiFlex/NordiFlex PenMate: Novo Nordisk A/S, Bagsvaerd, Denmark) for growth hormone (GH) injection. The opinions of patients and the physicians/nurses who trained patients on device were recorded by questionnaire. Most (88.4%) patients reported that the device was “very easy/easy" to use. The majority (82.4%) of patients were “very satisfied/satisfied" with the device and 64% wished to continue its use. Device training instructions were reported as “very easy/easy" by 96.1% of physicians/nurses, and 65.8% of participants could use the device after ≤10-minute training. In this study, NordiFlex PenMate was well accepted by patients and medical staff. Patients had a high opinion of the device and over half wished to continue its use. High patient acceptance may facilitate treatment adherence optimizing treatment outcomes.
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Affiliation(s)
- Anita Hokken-Koelega
- Department of Paediatrics, Division of Endocrinology, Sophia Children's Hospital/Erasmus University Medical Centre, 3015 GJ Rotterdam, The Netherlands
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Svensson J, Sjögren K, Fäldt J, Andersson N, Isaksson O, Jansson JO, Ohlsson C. Liver-derived IGF-I regulates mean life span in mice. PLoS One 2011; 6:e22640. [PMID: 21799924 PMCID: PMC3143189 DOI: 10.1371/journal.pone.0022640] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 07/02/2011] [Indexed: 01/14/2023] Open
Abstract
Background Transgenic mice with low levels of global insulin-like growth factor-I (IGF-I) throughout their life span, including pre- and postnatal development, have increased longevity. This study investigated whether specific deficiency of liver-derived, endocrine IGF-I is of importance for life span. Methods and Findings Serum IGF-I was reduced by approximately 80% in mice with adult, liver-specific IGF-I inactivation (LI-IGF-I-/- mice), and body weight decreased due to reduced body fat. The mean life span of LI-IGF-I-/- mice (n = 84) increased 10% vs. control mice (n = 137) (Cox's test, p<0.01), mainly due to increased life span (16%) of female mice [LI-IGF-I-/- mice (n = 31): 26.7±1.1 vs. control (n = 67): 23.0±0.7 months, p<0.001]. Male LI-IGF-I-/- mice showed only a tendency for increased longevity (p = 0.10). Energy expenditure, measured as oxygen consumption during and after submaximal exercise, was increased in the LI-IGF-I-/- mice. Moreover, microarray and RT-PCR analyses showed consistent regulation of three genes (heat shock protein 1A and 1B and connective tissue growth factor) in several body organs in the LI-IGF-I-/- mice. Conclusions Adult inactivation of liver-derived, endocrine IGF-I resulted in moderately increased mean life span. Body weight and body fat decreased in LI-IGF-I-/- mice, possibly due to increased energy expenditure during exercise. Genes earlier reported to modulate stress response and collagen aging showed consistent regulation, providing mechanisms that could underlie the increased mean life span in the LI-IGF-I-/- mice.
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Affiliation(s)
- Johan Svensson
- Department of Internal Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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Hardin DS. Treatment of short stature and growth hormone deficiency in children with somatotropin (rDNA origin). Biologics 2011; 2:655-61. [PMID: 19707446 PMCID: PMC2727887 DOI: 10.2147/btt.s2252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Somatotropin (growth hormone, GH) of recombinant DNA origin has provided a readily available and safe drug that has greatly improved management of children and adolescents with GH deficiency (GHD) and other disorders of growth. In the US and Europe, regulatory agencies have given approval for the use of GH in children and adults who meet specific criteria. However, clinical and ethical controversies remain regarding the diagnosis of GHD, dosing of GH, duration of therapy and expected outcomes. Areas which also require consensus include management of pubertal patients, transitioning pediatric patients to adulthood, management of children with idiopathic short stature and the role of recombinant IGF-1 in treatment. Additionally, studies have demonstrated anabolic benefits of GH in children who have inflammatory-based underlying disease and efficacy of GH in overcoming growth delays in people treated chronically with corticosteroids. These areas are open for possible new uses of this drug. This review summarizes current indications for GH use in children and discusses areas of clinical debate and potential anabolic uses in chronic illness.
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Affiliation(s)
- Dana S Hardin
- Ohio State University and Columbus Children's Hospital, Columbus, Ohio, USA
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McArthur S, Robinson IC, Gillies GE. Novel ontogenetic patterns of sexual differentiation in arcuate nucleus GHRH neurons revealed in GHRH-enhanced green fluorescent protein transgenic mice. Endocrinology 2011; 152:607-17. [PMID: 21159856 DOI: 10.1210/en.2010-0798] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
GH secretion and growth rates are developmentally regulated and sexually dimorphic, but the neuroregulatory mechanisms between birth and puberty are unclear. Using the GHRH-enhanced green fluorescent protein (eGFP) transgenic mouse, in which eGFP provides a strong surrogate signal for identifying GHRH neurons, we showed that numbers in the male arcuate nucleus were double those seen in females at x postnatal day (P)1 and P10, during which time numbers increased 2- to 3-fold. Thereafter (P20, P30, P60, P365) there was a significant trend for numbers to decrease in males and increase in females, such that sex differences were, surprisingly, absent in young and late adulthood. Conversely, we identified the emergence of male-dominant sex differences in the number of processes extended per GHRH perikarya across puberty. Intriguingly, prepubertal gonadectomy (P28), unlike adult gonadectomy, caused a dramatic 40% loss of GHRH cells in both sexes in adulthood and a significant (30%) increase in processes emanating from cell bodies only in females. These findings establish a novel ontogenetic profile for GHRH neurons and suggest previously undiscovered roles for peripubertal gonadal factors in establishing population size in both sexes. They also provide the first demonstration of emergent sex-specific GHRH architecture, which may signal the onset of sex-dependent regulation of activity reported for adult GHRH-eGFP neurons, and its differential regulation by gonadal factors in males and females. This information adds to our knowledge of processes that underpin the emergence of sex-specific GH secretory dynamics and hence biological activity of this pleiotropic hormone.
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Affiliation(s)
- Simon McArthur
- Division of Experimental Medicine, Imperial College, London W12 0NN, United Kingdom
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Kaltsas G, Vgontzas A, Chrousos G. Fatigue, endocrinopathies, and metabolic disorders. PM R 2010; 2:393-8. [PMID: 20656620 DOI: 10.1016/j.pmrj.2010.04.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
Fatigue is a frequent reason for seeking medical attention. Endocrine dysfunction is a common etiology of fatigue. In fact, thyroid function is usually one of the first explanations on the list of possible diagnoses. The symptoms associated with endocrinopathies are frequently "nonspecific," and psychiatric disease or psychological disorders need to be differentiated. Often, this can be accomplished using biological measures of hormone function, such as measures of thyroid, pituitary, parathyroid, and adrenal hormone levels. The field of endocrinology is highly dependent on an algorithmic approach to differential diagnosis using hormone levels as the guide. The use of self-reports helps identify at-risk patients, and raises suspicions about whether there is an abnormality, but diagnosis is dependent on laboratory values. Metabolic abnormalities, such as hyper- or hypoglycemia, dyslipidemia, and gonadal dysfunction can also contribute to fatigue. A better understanding of the interactions among hormones, their releasing factors, and regulation of inflammation will help identify abnormalities early and help distinguish endocrinopathies from other causes of fatigue. Early identification of these abnormalities may reduce end-organ damage and improve treatment strategies.
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Affiliation(s)
- Gregory Kaltsas
- Department of Pathophysiology, National University of Athens, Athens, Greece
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Fernández-Pérez L, Nóvoa J, Ståhlberg N, Santana-Farré R, Boronat M, Marrero D, Henríquez-Hernández L, Norstedt G, Flores-Morales A. The effect of in vivo growth hormone treatment on blood gene expression in adults with growth hormone deficiency reveals potential biomarkers to monitor growth hormone therapy. Clin Endocrinol (Oxf) 2010; 72:800-6. [PMID: 19849699 DOI: 10.1111/j.1365-2265.2009.03732.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Growth hormone (GH) replacement therapy is presently utilized in the treatment of adult GH deficiency (AGHD). Adult responses to GH treatment are highly variable and, apart from measurement of IGF-I, few tools are currently available for monitoring GH treatment progress. As GH receptors are expressed in certain blood cell types, changes in gene expression in peripheral blood can reflect perturbations induced as a result of GH therapy. DESIGN/PATIENTS We have carried out a pilot study to identify GH-responsive genes in blood, and have assessed the utility of GH-responsive genes in monitoring GH therapy in AGHD. Blood was collected from ten women diagnosed with AGHD syndrome both before and 4 weeks after initiation of GH substitutive therapy. RNA was extracted from peripheral blood mononuclear cells (PBMCs) and changes in response to GH were detected using microarray-based gene analysis. RESULTS All patients responded to GH replacement therapy, with serum levels of IGF-I increasing by an average of 307% (P = 0.0003) while IGFBP-3 increased by an average of 182% (P = 0.0002). Serum levels of triglycerides, LDL-C, HDL-C, APOA1 or APOB did not change after 1 month of GH treatment. By contrast, we detected an increase in Lp(a) serum levels (P = 0.0149). Using a stringent selection cutoff of P <or= 0.05, paired analysis identified a set of transcripts that correlated with GH administration. We applied the multivariate statistical technique PLS-DA to the changes in gene expression, demonstrating their utility in differentiating untreated patients and those undergoing GH replacement therapy. CONCLUSION This study shows that GH-dependent effects on gene expression in PBMCs can be detected by microarray-based gene analysis, and our results establish a foundation for the further exploration of peripheral blood as a surrogate to detect exposure to GH therapy.
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Affiliation(s)
- L Fernández-Pérez
- Department of Clinical Sciences, Molecular and Translational Endocrinology Group, University of Las Palmas de GC, Canary Islands, Spain.
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Moyes VJ, Walker DM, Owusu-Antwi S, Maher KT, Metherell L, Akker SA, Monson JP, Clark AJL, Drake WM. d3-GHR genotype does not explain heterogeneity in GH responsiveness in hypopituitary adults. Clin Endocrinol (Oxf) 2010; 72:807-13. [PMID: 20039885 DOI: 10.1111/j.1365-2265.2009.03768.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Heterogeneity in growth hormone (GH) responsiveness in adult hypopituitary patients receiving recombinant human GH (rhGH) is poorly understood; doses vary up to fourfold between individuals. Deletion of exon 3 in the GH receptor (d3-GHR) has been linked to enhanced rhGH responsiveness in children. We investigated the role of the d3-GHR polymorphism in determining adult rhGH responsiveness. METHODS One hundred and ninety-four patients treated with an identical rhGH dosing protocol in a single centre were genotyped for the d3-GHR, and the results correlated with changes in serum IGF-I and clinical parameters of GH responsiveness after 6 and 12 months of GH replacement therapy. RESULTS Allele frequencies for homozygous full length (fl/fl), heterozygous d3 (fl/d3) and homozygous d3 (d3/d3) were 52%, 38.7% and 9.3%, respectively, and were in Hardy-Weinberg equilibrium. Baseline IGF-I and DeltaIGF-I at 6 months were comparable between groups. DeltaIGF-I at 12 months was significantly greater in the d3/d3 group (P = 0.028). No difference was detected between fl/d3 and fl/fl groups. Regression analyses of DeltaIGF-I at 12 months and DeltaIGF-I/rhGH dose confirmed a significant relationship of d3/d3 genotype on rhGH response. There was no difference between groups in maintenance rhGH dose between genotypes. CONCLUSION Homozygosity for d3-GHR confers a marginal increase in GH responsiveness at 12 months but without a detectable change in maintenance rhGH dose required. Both d3 alleles are required to achieve this response; given that only 10% of the population are d3 homozygotes, the d3GHR does not explain the marked heterogeneity of GH responsiveness in hypopituitary adults.
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Affiliation(s)
- V J Moyes
- Department of Endocrinology, St. Bartholomew's Hospital, London, UK
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Movérare-Skrtic S, Svensson J, Karlsson MK, Orwoll E, Ljunggren O, Mellström D, Ohlsson C. Serum insulin-like growth factor-I concentration is associated with leukocyte telomere length in a population-based cohort of elderly men. J Clin Endocrinol Metab 2009; 94:5078-84. [PMID: 19846733 DOI: 10.1210/jc.2009-1450] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Both leukocyte telomere length and IGF-I are associated with the aging process. A previous in vitro study suggested that IGF-I may modulate telomerase activity in white blood cells, but little is known whether these two systems interact in vivo. PATIENTS AND METHODS Leukocyte telomere length was determined using a quantitative PCR assay in 2744 elderly men (mean age 75.5 yr, range 69-81 yr) included in the population-based Osteoporotic Fractures in Men-Sweden study. Serum IGF-I concentration was measured using RIA. RESULTS Subjects with a leukocyte telomere length in the lowest tertile group had lower serum IGF-I concentration than subjects in the two tertile groups with longer telomere lengths (P = 0.005). Logistic regression analyses showed that a higher serum IGF-I concentration was associated with a significantly reduced risk of having a leukocyte telomere length in the lowest tertile group and also after adjustment for multiple covariates (P < 0.01). Multivariate linear regression analyses demonstrated that tertile of leukocyte telomere length was positively, whereas age was negatively, associated with serum IGF-I concentration in elderly men. CONCLUSIONS In this large population-based, cross-sectional study, leukocyte telomere length was positively associated with serum IGF-I concentration in elderly men. The mechanisms underlying the association between serum IGF-I concentration and leukocyte telomere length remain to be determined.
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Affiliation(s)
- Sofia Movérare-Skrtic
- Center for Bone Research, Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
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Abe S, Okumura A, Mukae T, Nakazawa T, Niijima SI, Yamashiro Y, Shimizu T. Depressive tendency in children with growth hormone deficiency. J Paediatr Child Health 2009; 45:636-40. [PMID: 19845844 DOI: 10.1111/j.1440-1754.2009.01586.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM This study assessed changes in depressive tendency of children with growth hormone deficiency. METHODS The 41 children with growth hormone deficiency were assessed using the Depression Self-Rating Scale for Children. A score of 16 or more indicated a depressive tendency. The first assessment was carried out before growth hormone treatment, and the second one was carried out at 6 months or longer after the beginning of growth hormone treatment. RESULTS The Depression Self-Rating Scale for Children improved significantly from 9.7 +/- 6.1 points before treatment to 6.9 +/- 4.6 points after treatment (P= 0.0013). A depressive tendency was observed in six patients (15%) before growth hormone treatment, and in two patients (5%) after treatment. No significant relationship was observed between the decrease in the score and the length of the treatment. A significant improvement was observed for 6 of the 18 items in the Depression Self-Rating Scale for Children. CONCLUSION A depressive tendency was relatively common in children with growth hormone deficiency, and the Depression Self-Rating Scale for Children was decreased after growth hormone treatment. These results suggest that growth hormone treatment may have positive effects on the psychosocial aspects in children with growth hormone deficiency.
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Affiliation(s)
- Shinpei Abe
- Department of Pediatrics, Juntendo University School of Medicine, Tokyo 113-8421, Japan.
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Sıklar Z, Öcal G, Berberoğlu M, Bilir P. Combined evaluation of IGF-1 and IGFBP-3 as an index of efficacy and safety in growth hormone treated patients. J Clin Res Pediatr Endocrinol 2009; 1:240-3. [PMID: 21274301 PMCID: PMC3005747 DOI: 10.4274/jcrpe.v1i5.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Accepted: 07/29/2009] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Measurement of serum insulin-like growth factor-1 (IGF-1) and IGF binding protein-3 (IGFBP-3) levels has been recommended as a useful index for monitoring of growth hormone (GH) therapy in GH deficient children. In this study we aimed to evaluate IGF-1/IGFBP-3 molar ratio during GH treatment as an index of safety and efficacy. METHODS Serum IGF-1 and IGFBP-3 levels and molar ratio of IGF-1/IGFBP-3 were evaluated in 50 GH deficienct children, during 3 years of GH therapy and these parameters were compared with the growth response. RESULTS All patients completed the first year, 38 the second year and 26 the third year of therapy. Although 15 patients in the first year, 5 patients in the second year, and 5 patients in the third year had high IGF-1 SDS values, height increments were similar in the low IGF-1 group and in the normal or high IGF-1 level groups. Molar ratios were also not statistically different between the groups. Molar ratio of IGF-1/IGFBP-3 seemed to be more reliable in evaluating the efficacy than basal IGF-1 level. CONCLUSIONS Evaluation of the molar ratio of IGF-1/IGFBP-3 may be recommended as a tool to monitor GH treatment and it may be possible to individualize GH treatment accordingly.
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Affiliation(s)
- Zeynep Sıklar
- Ankara University School of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey.
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Ohlsson C, Mohan S, Sjögren K, Tivesten A, Isgaard J, Isaksson O, Jansson JO, Svensson J. The role of liver-derived insulin-like growth factor-I. Endocr Rev 2009; 30:494-535. [PMID: 19589948 PMCID: PMC2759708 DOI: 10.1210/er.2009-0010] [Citation(s) in RCA: 291] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
IGF-I is expressed in virtually every tissue of the body, but with much higher expression in the liver than in any other tissue. Studies using mice with liver-specific IGF-I knockout have demonstrated that liver-derived IGF-I, constituting a major part of circulating IGF-I, is an important endocrine factor involved in a variety of physiological and pathological processes. Detailed studies comparing the impact of liver-derived IGF-I and local bone-derived IGF-I demonstrate that both sources of IGF-I can stimulate longitudinal bone growth. We propose here that liver-derived circulating IGF-I and local bone-derived IGF-I to some extent have overlapping growth-promoting effects and might have the capacity to replace each other (= redundancy) in the maintenance of normal longitudinal bone growth. Importantly, and in contrast to the regulation of longitudinal bone growth, locally derived IGF-I cannot replace (= lack of redundancy) liver-derived IGF-I for the regulation of a large number of other parameters including GH secretion, cortical bone mass, kidney size, prostate size, peripheral vascular resistance, spatial memory, sodium retention, insulin sensitivity, liver size, sexually dimorphic liver functions, and progression of some tumors. It is clear that a major role of liver-derived IGF-I is to regulate GH secretion and that some, but not all, of the phenotypes in the liver-specific IGF-I knockout mice are indirect, mediated via the elevated GH levels. All of the described multiple endocrine effects of liver-derived IGF-I should be considered in the development of possible novel treatment strategies aimed at increasing or reducing endocrine IGF-I activity.
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Affiliation(s)
- Claes Ohlsson
- Division of Endocrinology, Institute of Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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User trial of Easypod™, an electronic autoinjector for growth hormone. ANNALES D'ENDOCRINOLOGIE 2008; 69:511-6. [DOI: 10.1016/j.ando.2008.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 04/23/2008] [Accepted: 04/30/2008] [Indexed: 11/21/2022]
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Denson LA. Growth hormone therapy in children and adolescents: pharmacokinetic/pharmacodynamic considerations and emerging indications. Expert Opin Drug Metab Toxicol 2008; 4:1569-80. [DOI: 10.1517/17425250802465347] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gondoni LA, Vismara L, Marzullo P, Vettor R, Liuzzi A, Grugni G. Growth hormone therapy improves exercise capacity in adult patients with Prader-Willi syndrome. J Endocrinol Invest 2008; 31:765-72. [PMID: 18997487 DOI: 10.1007/bf03349255] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prader-Willi syndrome (PWS) is associated with an inappropriate proportion of fat mass (FM) to non-FM compared to simple obesity. Altered body composition in PWS resembles that seen in subjects with GH deficiency, in which a reduction of lean body mass (LBM) is observed. The low LBM may contribute to the reduced motor skills seen in PWS patients. AIM The objective of the study was to investigate the effects of GH therapy on exercise capacity and body composition in a group of adult subjects with PWS. SUBJECTS AND METHODS Twelve PWS adults (7 males and 5 females, aged 26.4+/-4.4 yr, body mass index 44.3+/-4.6 kg/m2) participated in the study. Body composition analysis and exercise stress test were carried out throughout the 12 months GH therapy. Body composition was measured by Dual Energy X-ray Absorptiometry. Physical performance was evaluated using treadmill exercise test. Exercise intensity was expressed as metabolic equivalents (MET, 1 MET= 3.5 ml O2 kg(-1) min(-1)). Statistical analysis was performed by repeated-measures analysis of variance followed by post-hoc analysis with t test for paired data for comparisons among the different follow ups. RESULTS Compared to baseline GH therapy increased LBM at 6 (p<0.0001) and 12 months (p<0.005) (45.3+/-7.7 kg vs 48.6+/-6.7 kg vs 48.2+/-7.5 kg). FM% was significantly reduced both after 6 and 12 months (p<0.02) (56.1+/-4.8% vs 53.7+/-4.2% vs 53.3+/-4.8%). Attained MET were found to be improved by 16% after 6 months and by 19% after 12 months of GH (p<0.001), while the small further rise between 6 and 12 months was not significant. CONCLUSIONS Our findings seem to support the view that GH therapy has beneficial effects on physical activity and agility as well as on body composition of adult patients with PWS.
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Affiliation(s)
- L A Gondoni
- Division of Cardiac Rehabilitation, S. Giuseppe Hospital, Research Institute, Istituto Auxologico Italiano, Verbania, Italy
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Norrman LL, Johannsson G, Sunnerhagen KS, Svensson J. Baseline characteristics and the effects of two years of growth hormone (GH) replacement therapy in adults with GH deficiency previously treated for acromegaly. J Clin Endocrinol Metab 2008; 93:2531-8. [PMID: 18397981 DOI: 10.1210/jc.2007-2673] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The effects of GH replacement in GH-deficient (GHD) adults previously treated for acromegaly are not well known. OBJECTIVE, DESIGN, AND PATIENTS: In this single-center, open-labeled, prospective study, 10 consecutive GHD adults with cured acromegaly (A group) and 10 matched GHD adults with previous nonfunctioning hypopituitary disease (NF group) were included. Comparisons were made at baseline and in the responses in body composition, muscle strength, bone mass, and metabolic indices during 2 yr of GH replacement. RESULTS At baseline, upper leg local muscle endurance and serum low-density lipoprotein-cholesterol concentration were more impaired in the A group. The A group contained three patients with hypertension, one with diabetes mellitus type 2, and one with hyperlipidemia. The NF group had only one patient with hypertension. There were no significant between-group differences in the responses to the GH therapy. Body composition and serum lipid pattern improved in both groups without any deterioration of glucose homeostasis. At study end, no difference remained between the two groups in any variable. During the 2-yr treatment, one patient had a myocardial infarction and two had cerebral infarctions in the A group, whereas no vascular event occurred in the NF group. CONCLUSIONS GHD patients with previous acromegaly have an impaired cardiovascular risk profile and decreased local muscle endurance as compared with other GHD patients. Two-year GH replacement eliminated these differences, but vascular events occurred more frequently in the A group. Therefore, GHD patients with cured acromegaly will benefit from GH replacement, but careful monitoring of cardiovascular status is needed.
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Affiliation(s)
- Lise-Lott Norrman
- Research Centre for Endocrinology and Metabolism, Department of Internal Medicine, Gröna Stråket 8, Sahlgrenska University Hospital, Göteborg, Sweden
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Shariat N, Holladay CD, Cleary RK, Phillips JA, Patton JG. Isolated growth hormone deficiency type II caused by a point mutation that alters both splice site strength and splicing enhancer function. Clin Genet 2008; 74:539-45. [PMID: 18554279 DOI: 10.1111/j.1399-0004.2008.01042.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A heterozygous single base mutation in the human growth hormone (GH) gene (GH-1) was identified in a family presenting with isolated GH deficiency type II (IGHD II). Affected individuals have a guanine to adenine transition at the first nucleotide of exon 3 (E3+1 G-->A) that results in exon skipping and production of a dominant-negative 17.5-kDa isoform. We show that the mechanistic basis for exon skipping is due to the unique position of this mutation because it weakens the 3' splice site and simultaneously disrupts a splicing enhancer located within the first seven bases of exon 3. A G-->T mutation at this same position not only affects splicing but also results in a premature stop codon for those transcripts that include exon 3. Thus, mutations that alter the first nucleotide of exon 3 illustrate the various mechanisms by which changes in sequence can cause disease: splice site selection, splicing enhancer function, messenger RNA decay, missense mutations, and nonsense mutations. For IGHD II, only exon skipping leads to production of the dominant-negative isoform, with increasing skipping correlating with increasing disease severity.
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Affiliation(s)
- N Shariat
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA
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di Iorgi N, Secco A, Napoli F, Tinelli C, Calcagno A, Fratangeli N, Ambrosini L, Rossi A, Lorini R, Maghnie M. Deterioration of growth hormone (GH) response and anterior pituitary function in young adults with childhood-onset GH deficiency and ectopic posterior pituitary: a two-year prospective follow-up study. J Clin Endocrinol Metab 2007; 92:3875-84. [PMID: 17666476 DOI: 10.1210/jc.2007-1081] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The current criteria for definition of partial GHD in young adults are still a subject of debate. OBJECTIVES The objective of the study was to reinvestigate anterior pituitary function in young adults with congenital childhood-onset GHD associated with structural hypothalamic-pituitary abnormalities and normal GH response at the time of first reassessment of GH secretion. DESIGN AND SETTING This was a prospective explorative study conducted in a university research hospital. PATIENTS AND METHODS Thirteen subjects with a mean age of 17.2 +/- 0.7 yr and a peak GH after insulin tolerance test (ITT) higher than 5 microg/liter were recruited from a cohort of 42 patients with childhood-onset GHD and ectopic posterior pituitary at magnetic resonance imaging. GH secretion after ITT and GHRH plus arginine, IGF-I concentration, and body mass index, waist circumference, blood pressure, total cholesterol, and fibrinogen were evaluated at baseline and at 2-yr follow-up. RESULTS At mean age of 19.2 +/- 0.7 yr, the mean peak GH response decreased significantly after ITT (P = 0.00001) and GHRH plus arginine (P = 0.0001). GH peak values after ITT and GHRH plus arginine were less than 5 and 9 microg/liter in 10 and eight patients, respectively. Additional pituitary defects were documented in eight patients. Significant changes were found in the values of IGF-I sd score (P = 0.0026), waist circumference (P = 0.00001), serum total cholesterol (P = 0.00001), and serum fibrinogen (P = 0.0004). CONCLUSIONS The results of this study underline the importance of further reassessment of pituitary function in young adults with GHD of childhood-onset and poststimulation GH responses suggestive of partial GHD.
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Affiliation(s)
- Natascia di Iorgi
- AssociateDepartment of Pediatrics Istituto di Ricovero e Cura a Carattere Scientifico G. Gaslini, University of Genova, Largo Gerolamo Gaslini, 5, 16147 Genova, Italy.
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Dahlgren J, Veimo D, Johansson L, Bech I. Patient acceptance of a novel electronic auto-injector device to administer recombinant human growth hormone: results from an open-label, user survey of everyday use. Curr Med Res Opin 2007; 23:1649-55. [PMID: 17559757 DOI: 10.1185/030079907x210589] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To measure the user acceptance of a electronic auto-injector device (easypod) for recombinant human growth hormone (r-hGH) administration. STUDY DESIGN AND METHODS This was an open-label, uncontrolled study in which participants (n = 61) were trained to use the device to administer subcutaneous recombinant human growth hormone (r-hGH). Participants' opinions on the device were recorded by questionnaire and/or telephone interview during training and after 15 and 60 days of use. Opinions on the device were also collected from nurses or physicians who trained the participants in device use. RESULTS After 60 days, 98% (54/55) of responders reported a 'good' or 'very good' overall impression of the device. The pre-programmed dose feature, skin sensor, on-screen instructions, display of remaining dose, confirmation of injected dose and automatic needle attachment were identified by the majority of participants as 'very useful'. Participants were reported to have easily understood the injection process, and 87% (48/55) expressed a preference to continue use of the device. The device had a good safety profile, and no adverse events were reported during the study or follow-up periods. CONCLUSIONS Participants had a good overall impression of the device and the majority expressed a preference to continue its use. The combination of features offered by the device make it user-friendly, and such ease of use may facilitate greater adherence to treatment, in turn improving therapy outcomes.
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Affiliation(s)
- J Dahlgren
- Queen Silvia Children's Hospital, Göteborg, Sweden.
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Götherström G, Bengtsson BA, Bosaeus I, Johannsson G, Svensson J. A 10-year, prospective study of the metabolic effects of growth hormone replacement in adults. J Clin Endocrinol Metab 2007; 92:1442-5. [PMID: 17284638 DOI: 10.1210/jc.2006-1487] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Only a few studies have investigated the effects of GH replacement in adults for more than 5 yr. OBJECTIVE/DESIGN/PATIENTS In a prospective, open-label, single-center study, the effects of 10-yr GH replacement were determined. Eighty-seven consecutive patients (52 men and 35 women), with a mean age of 44.1 (range 22-74) yr with adult-onset GH deficiency (GHD) were included. RESULTS The initial mean dose of GH (0.98 mg/d) was reduced during the study and at yr 10 was 0.47 mg/d. The mean IGF-I sd score increased from -1.81 at baseline to 1.29 at study end. The absolute reduction in total body fat was transient. However, after correction for age and sex using a four-compartment model, the reduction in body fat was sustained during the 10-yr study period. There was a sustained improvement in serum lipid profile and after 10 yr, and blood glycosylated hemoglobin level was reduced. The treatment responses in IGF-I sd score, serum high-density lipoprotein cholesterol level, and body composition as measured using dual-energy x-ray absorptiometry were more marked in men, whereas women had a more marked reduction in blood glycosylated hemoglobin level. CONCLUSION The effect on the absolute amount of body fat was seen early and was transient, which could be due to the normal aging of the patients. The effects on metabolic indices were detected later, but they were sustained and even progressive throughout the study period.
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Affiliation(s)
- G Götherström
- Research Centre for Endocrinology and Metabolism, Department of Clinical Nutrition, Gröna Stråket 8, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Burger AG, Monson JP, Colao AM, Klibanski A. Cardiovascular risk in patients with growth hormone deficiency: effects of growth hormone substitution. Endocr Pract 2007; 12:682-9. [PMID: 17229667 DOI: 10.4158/ep.12.6.682] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review the literature on the increased cardiovascular risk in patients with growth hormone (GH) deficiency and the positive effects of GH replacement. METHODS We analyze the factors that contribute to cardiovascular risk in GH deficiency, including body composition and lipid profile, and summarize GH treatment strategies and results described in the literature. RESULTS The prominent clinical finding in patients with GH deficiency is the increased abdominal fat, even in patients with normal weight. Cardiac ejection volume tends to be decreased, and arterial distensibility is diminished. The lipid status is also worsened, accompanied by increased inflammatory markers, such as highly sensitive C-reactive protein. Typically, GH treatment reduces visceral fat and increases muscle mass, changes that diminish cardiovascular risk. Because of direct effects as well as increased hemodynamic performance and increased blood volume, cardiac performance is improved. With GH therapy, total cholesterol and low-density lipoprotein levels decrease by 10% to 20%, and inflammatory markers such as C-reactive protein decline. Carbohydrate metabolism during moderate to long-term treatment is minimally affected, although obese patients with GH deficiency on rare occasion may have hyperglycemia or even diabetes. CONCLUSION The relevance of the beneficial effects of GH on the cardiovascular system is strongly suggested but not fully proved. The results in a large cohort of GH-treated patients (the KIMS or Pharmacia and Upjohn International Metabolic Surveillance database) demonstrated no difference in cardiovascular risk in comparison with that in a control population after a mean of 3 years of treatment.
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Affiliation(s)
- Albert G Burger
- Department of Medicine, University of Geneva, Cologny (Geneva), Switzerland
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Abstract
Growth hormone replacement therapy has been used regularly in adult Growth hormone deficiency since the availability of recombinant GH in the 1980's. GH replacement improves quality of life, bone turnover markers, cardiovascular risk markers and adverse body composition. Originally, GH doses in replacement regimes were determined by weight and surface area and dose increases based on body composition outcomes analogous to pediatric practice. These regimens led to significant side effects related to excess GH, arthralgias, headaches and peripheral edema and IGF-I levels above the upper limit of the reference range. Newer treatment regimes therefore account for known factors affecting serum GH and IGF-I levels, i.e. age, gender, estrogen replacement and pre-treatment IGF-I levels. Monitoring is now via clinical symptomatology combined with serum total IGF-I levels, potentially this avoids excessive GH exposure and allows monitoring of compliance and dose titration. There is a lack of data relating IGF-I to biological endpoints, but analysis suggests that dose titration of IGF-I to the upper half of the age and gender related reference range is acceptable. The use of reliable IGF-I assays and extensive age and gender related reference ranges is necessary and centralized monitoring is preferable. Free IGF-I and bioavailable IGF-I measurements are available but their use in the monitoring of GH replacement remains to be determined.
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Affiliation(s)
- Claire E Higham
- Department of Endocrinology, Christie Hospital, Manchester M20 4BX, UK
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Abstract
This clinical review summarizes current approaches to diagnosis and treatment of anterior pituitary hormone deficiency. The diagnostic value of endocrine function tests and replacement strategies for hydrocortisone, thyroxine, sex steroids, and growth hormone replacement are reviewed. Female androgen deficiency syndrome and the current role of DHEA and testosterone replacement in women are also discussed.
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Affiliation(s)
- Christoph J Auernhammer
- Department of Internal Medicine II, Klinikum der Ludwig-Maximilians-Universität München, Standort Grosshadern, Marchioninistr. 15, Munich 81377, Germany.
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Abstract
Growth hormone release and IGF-I synthesis decrease with increasing age. The regulation of the GH/IGF-I system is dependent on the integrity of the hypothalamus, pituitary and liver. During aging there are several changes which contribute to the decline in GH/IGF-I including changes in signal to the somatotrophs from growth hormone releasing hormone, somatostatin and other factors such as body composition, exercise, diet and sleep. All of these factors are discussed in detail within this review. The phenotypic similarities between aging and adult growth hormone deficiency syndrome combined with this decrease in GH/IGF-I with aging have prompted the question whether aging is a GH deficient state. The advent of recombinant growth hormone has led to a number of studies treating elderly patients with GH alone or in combination with sex steroids or exercise. The results of these studies would not back up the use of GH in elderly non-hypopituitary patients as they did not show efficacy, showed high rates of adverse events and there is also some evidence associating GH/IGF-I and risk of neoplasia. If GH therapy is to be used in this cohort of patients further long term efficacy and safety studies are required.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Division of Medical Sciences, University of Birmingham, Edgbaston B15 2TT, England
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Franco C, Johannsson G, Bengtsson BA, Svensson J. Baseline characteristics and effects of growth hormone therapy over two years in younger and elderly adults with adult onset GH deficiency. J Clin Endocrinol Metab 2006; 91:4408-14. [PMID: 16940452 DOI: 10.1210/jc.2006-0887] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The effects of GH replacement in elderly GH-deficient (GHD) adults are not well known. OBJECTIVE/DESIGN/PATIENTS In this prospective, single-center, open-label study, baseline characteristics and the effects of 2-yr GH replacement were determined in 24 GHD adults above 65 yr of age and in 24 younger GHD patients (mean age, 37 yr; range, 27-46 yr). All patients had adult onset disease, and both groups were comparable in terms of the number of pituitary hormonal deficiencies, gender, body mass index, and waist/hip ratio. Duration of hypopituitarism was, however, longer in the elderly patients. RESULTS The mean maintenance dose of GH was 0.31 (sem, 0.03) mg/d in the elderly GHD patients and 0.44 (0.04) mg/d in the younger patients. The less marked response in IGF-I sd score, total body fat, and extracellular water in the elderly patients lost significance when the dose of GH was accounted for in the statistical analyses. Despite the lower dose in the elderly GHD group, these patients had a more marked reduction in waist/hip ratio and serum low-density lipoprotein-cholesterol level, and these differences remained also after correction for duration of hypopituitarism. There was no difference at baseline or in responsiveness in lean mass, bone mineral density, and glucose homeostasis. CONCLUSIONS This study identifies elderly GHD adults as a GH-sensitive group in whom a low dose of GH can improve body composition and serum lipid profile without any significant impairment of glucose metabolism. GH replacement should therefore be considered in elderly GHD adults.
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Affiliation(s)
- Celina Franco
- Research Centre for Endocrinology and Metabolism, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden
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Itoh E, Hizuka N, Fukuda I, Takano K. Metabolic disorders in adult growth hormone deficiency: A study of 110 patients at a single institute in Japan. Endocr J 2006; 53:539-45. [PMID: 16829702 DOI: 10.1507/endocrj.k03-115] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study carried out at a single institute in Japan was to investigate the clinical characteristics and complications of patients with adult growth hormone deficiency (GHD). Clinical and biochemical data of 110 patients (50 males, 60 females; mean age 42 +/- 17 yr) with adult GHD who attended Tokyo Women's Medical University between 1990 and 1999 were analyzed retrospectively from medical records. This retrospective analysis demonstrated that 109 patients had multiple pituitary hormone deficiencies, with 98 patients having a deficiency of more than three hormones. Sixty-one patients had childhood onset GHD (COGHD) while the remaining 49 patients had adulthood onset GHD (AOGHD). Body mass index (BMI) ranged from 16.9 to 35.9 with a mean of 23.9 +/- 4.1 (kg/m2), with BMI being > or = 25 kg/m2 in 38 patients (31% of COGHD and 38% of AOGHD). Forty-one percent of the patients had hypercholesterolemia, 41% had hypertriglyceridemia, 47% had decreased levels of HDL cholesterol and 48% had increased levels of LDL cholesterol. Intima-media thickness (IMT) of the carotid arteries was investigated in 33 patients, with abnormal findings including increased IMT or plaque being observed in 4 of 18 COGHD patients and 4 of 15 AOGHD patients. Diabetes mellitus and impaired glucose tolerance was found in 4 COGHD patients and 16 AOGHD patients. Insulin resistance was assessed in 36 patients by the homeostasis model insulin resistance index (HOMA-R) and ranged from 0.65 to 10.58 with a mean of 2.80 +/- 0.37. This mean value of HOMA-R was significantly greater than that measured in normal subjects (1.58 +/- 0.05: P < 0.05). These data suggest that abnormal lipid and glucose metabolism, and atherosclerotic changes occur frequently in adult patients with GHD. Insulin resistance may play a role in glucose and lipid metabolism disorders associated with GHD.
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Affiliation(s)
- Emina Itoh
- Department of Medicine, Institute of Clinical Endocrinology, Tokyo Women's Medical University, Tokyo, Japan
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50
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Woodhouse LJ, Mukherjee A, Shalet SM, Ezzat S. The influence of growth hormone status on physical impairments, functional limitations, and health-related quality of life in adults. Endocr Rev 2006; 27:287-317. [PMID: 16543384 DOI: 10.1210/er.2004-0022] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The availability of recombinant human GH and somatostatin analogs has resulted in widespread treatment for adults with GH deficiency (GHD) and those with GH excess (acromegaly). Despite being at opposite ends of the spectrum in terms of their GH/IGF-I axis, both of these populations experience overlapping somatic impairments. Adults with untreated GHD have low circulating levels of IGF-I that manifest as altered body composition with increased fat and reduced lean body and skeletal muscle mass. At the other end of the spectrum, adults with GH excess, who have elevated levels of IGF-I, also have altered body composition. Impairments that result from disorders of either GHD or GH excess are both associated with increased functional limitations, such as reduced ability to walk quickly for prolonged periods, and poorer health-related quality of life (HR-QoL). Adults with untreated GHD and GH excess both commonly complain of excessive fatigue that seems to be associated more with impaired aerobic than muscular performance. Several studies have documented that administration of GH or somatostatin analogs to adults with GHD or GH excess, respectively, ameliorates abnormal biochemical profile and the associated somatic impairments. However, whether these improvements translate into improved physical function in adults with GHD or GH excess remains largely unknown, and their impact on HR-QoL controversial. Review of placebo-controlled trials to date suggests that GH and somatostatin analogs have greater effects on gas exchange and aerobic performance than as anabolic agents on skeletal muscle mass and function. Future investigations should include dose-response studies to establish the optimal combination of pharmacological agents plus exercise required to improve not only biochemical markers but also physical function and HR-QoL in adults with GHD or GH excess.
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Affiliation(s)
- Linda J Woodhouse
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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