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Olwi D, Day F, Ong K. Effect of Growth Hormone Therapy on Pubertal Timing: Systematic Review and Meta-Analysis. Horm Res Paediatr 2023; 97:1-10. [PMID: 37075730 DOI: 10.1159/000530578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/01/2023] [Indexed: 04/21/2023] Open
Abstract
INTRODUCTION Recombinant human growth hormone (rhGH) therapy effectively increases height in various disorders of childhood growth. However, whether rhGH affects pubertal timing is unclear. We aimed to review systematically published evidence on the effect of rhGH on pubertal timing. METHODS Embase, MEDLINE, and Cochrane Library databases were searched until December 2021 on randomized and non-randomized controlled studies of rhGH in children. RESULTS Twenty-five articles (n = 1,433 children) were identified, describing 12 randomized and 13 non-randomized controlled studies in children with idiopathic short stature (ISS; 15 studies), small for gestational age (n = 6 studies), chronic renal failure (n = 3), Noonan syndrome (n = 1), and growth hormone deficiency (n = 1). Significant differences in the effects of rhGH on pubertal timing were found by clinical indication. Only among children with ISS, rhGH promoted earlier age at pubertal timing (mean difference = -0.46 years; 95% CI, -0.90 to -0.03; 9 studies; n total = 397) or higher relative risk for pubertal onset during study follow-up (1.26; 95% CI, 1.03 to 1.54; 6 studies; n total = 284). CONCLUSIONS Treatment with rhGH appears to promote earlier pubertal timing among children with ISS. Evidence was lacking in children with growth hormone deficiency due to the absence of studies with untreated controls.
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Affiliation(s)
- Duaa Olwi
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK,
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia,
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia,
| | - Felix Day
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ken Ong
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Kızılcan Çetin S, Ramoğlu MG, Şıklar Z, Özsu E, Aycan Z, Tutar HE, Berberoğlu M. The Effect of Growth Hormone Therapy on Cardiac Outcomes in Noonan Syndrome: Long Term Follow-up Results. J Clin Res Pediatr Endocrinol 2022; 14:422-432. [PMID: 35859537 PMCID: PMC9724055 DOI: 10.4274/jcrpe.galenos.2022.2022-12-13] [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] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Cardiac involvement is common in Noonan syndrome (NS). Concerns have been raised regarding the effect of recombinant growth hormone (rGH) use on ventricular wall thickness and a possible increased risk of cardiac side effects. This study aimed to investigate the effect of rGH on the development of hypertrophic cardiomyopathy and other cardiac findings in NS. METHODS Patients under the age of 18 years and diagnosed with NS according to the Van der Burgt criteria, were included. Patients were divided into two groups according to those receiving rGH or not at the time of obtaining cardiac measurements. Before and after the treatment, electrocardiographic and echocardiographic (ECHO) assessments were made, including interventricular septal thickness, left ventricular internal diameter, and left ventricular posterior thickness. Results were expressed as Z scores. RESULTS Twenty-four NS subjects (16 boys, eight girls) were included. At the beginning of the follow up, the overall height standard deviation score was -2.56±0.94. Sixteen were on rGH. The mean rGH treatment duration was 8.3±3.8 years, and the mean dose was 0.22±0.04 mg/kg/week. The final height was 169±8.2 cm, and 10 of 11 patients who reached the final height received rGH. There was no difference between the rGH and non-rGH groups in terms of ECHO parameters pre-and post-treatment. CONCLUSION In this cohort, there was no change in ECHO parameters on rGH and during follow-up. These results suggest that rGH is safe in NS patients with cardiac pathology under close follow-up.
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Affiliation(s)
- Sirmen Kızılcan Çetin
- 1Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey,* Address for Correspondence: Sirmen Kızılcan Çetin MD, Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey Phone: +90 312 595 66 35 E-mail:
| | - Mehmet Gökhan Ramoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Cardiology, Ankara, Turkey
| | - Zeynep Şıklar
- 1Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Elif Özsu
- 1Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zehra Aycan
- 1Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Hasan Ercan Tutar
- Ankara University Faculty of Medicine, Department of Pediatric Cardiology, Ankara, Turkey
| | - Merih Berberoğlu
- 1Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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3
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Dahlgren J, Noordam C. Growth, Endocrine Features, and Growth Hormone Treatment in Noonan Syndrome. J Clin Med 2022; 11:jcm11072034. [PMID: 35407641 PMCID: PMC8999676 DOI: 10.3390/jcm11072034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 12/23/2022] Open
Abstract
Noonan syndrome is a heterogeneous congenital disorder. The main features are typical facial features, short stature and cardiac defects. The diagnosis is clinical: in 80% of patients with Noonan syndrome a genetic defect can be shown. Inheritance is predominantly autosomal dominant and seldom autosomal recessive. In 2001, PTPN11 was the first gene connected to Noonan syndrome, and until now, at least 20 other genes have been discovered. All genes code for proteins involved in the RAS-MAP-kinase pathway, and therefore, Noonan syndrome is one of the known RASopathies. Other RASopathies include neurofibromatosis and CFC syndrome. Short stature is one of the defining features of Noonan syndrome. The cause is not fully understood but is multifactorial. Other endocrinological features are confined to delayed puberty and hypogonadism in boys and males. To increase adult height, children with Noonan syndrome have been treated with human growth hormone since the 1990s. This seems to be beneficial in most of the children treated. In this narrative review, we describe the current knowledge on growth, endocrinological features and growth hormone treatment in patients with Noonan syndrome.
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Affiliation(s)
- Jovanna Dahlgren
- Department of Pediatrics, University of Gothenburg, 41685 Gothenburg, Sweden;
| | - Cees Noordam
- Centre for Paediatric Endocrinology Zurich (PEZZ), 8006 Zurich, Switzerland
- Department of Pediatrics, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
- Correspondence: ; Tel.: +41-4-4364-3700
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4
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Stagi S, Ferrari V, Ferrari M, Priolo M, Tartaglia M. Inside the Noonan "universe": Literature review on growth, GH/IGF axis and rhGH treatment: Facts and concerns. Front Endocrinol (Lausanne) 2022; 13:951331. [PMID: 36060964 PMCID: PMC9434367 DOI: 10.3389/fendo.2022.951331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/18/2022] [Indexed: 12/21/2022] Open
Abstract
Noonan syndrome (NS) is a disorder characterized by a typical facial gestalt, congenital heart defects, variable cognitive deficits, skeletal defects, and short stature. NS is caused by germline pathogenic variants in genes coding proteins with a role in the RAS/mitogen-activated protein kinase signaling pathway, and it is typically associated with substantial genetic and clinical complexity and variability. Short stature is a cardinal feature in NS, with evidence indicating that growth hormone (GH) deficiency, partial GH insensitivity, and altered response to insulin-like growth factor I (IGF-1) are contributing events for growth failure in these patients. Decreased IGF-I, together with low/normal responses to GH pharmacological provocation tests, indicating a variable presence of GH deficiency/resistance, in particular in subjects with pathogenic PTPN11 variants, are frequently reported. Nonetheless, short- and long-term studies have demonstrated a consistent and significant increase in height velocity (HV) in NS children and adolescents treated with recombinant human GH (rhGH). While the overall experience with rhGH treatment in NS patients with short stature is reassuring, it is difficult to systematically compare published data due to heterogeneous protocols, potential enrolment bias, the small size of cohorts in many studies, different cohort selection criteria and varying durations of therapy. Furthermore, in most studies, the genetic information is lacking. NS is associated with a higher risk of benign and malignant proliferative disorders and hypertrophic cardiomyopathy, and rhGH treatment may further increase risk in these patients, especially as dosages vary widely. Herein we provide an updated review of aspects related to growth, altered function of the GH/IGF axis and cell response to GH/IGF stimulation, rhGH treatment and its possible adverse events. Given the clinical variability and genetic heterogeneity of NS, treatment with rhGH should be personalized and a conservative approach with judicious surveillance is recommended. Depending on the genotype, an individualized follow-up and close monitoring during rhGH treatments, also focusing on screening for neoplasms, should be considered.
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Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
- *Correspondence: Stefano Stagi,
| | - Vittorio Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Marta Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Manuela Priolo
- Medical Genetics Unit, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
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Fowlkes JL, Thrailkill KM, Bunn RC. RASopathies: The musculoskeletal consequences and their etiology and pathogenesis. Bone 2021; 152:116060. [PMID: 34144233 PMCID: PMC8316423 DOI: 10.1016/j.bone.2021.116060] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 01/07/2023]
Abstract
The RASopathies comprise an ever-growing number of clinical syndromes resulting from germline mutations in components of the RAS/MAPK signaling pathway. While multiple organs and tissues may be affected by these mutations, this review will focus on how these mutations specifically impact the musculoskeletal system. Herein, we review the genetics and musculoskeletal phenotypes of these syndromes in humans. We discuss how mutations in the RASopathy syndromes have been studied in translational mouse models. Finally, we discuss how signaling molecules within the RAS/MAPK pathway are involved in normal and abnormal bone biology in the context of osteoblasts, osteoclasts and chondrocytes.
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Affiliation(s)
- John L Fowlkes
- University of Kentucky Barnstable Brown Diabetes Center, Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY 40536, United States of America.
| | - Kathryn M Thrailkill
- University of Kentucky Barnstable Brown Diabetes Center, Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY 40536, United States of America
| | - R Clay Bunn
- University of Kentucky Barnstable Brown Diabetes Center, Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY 40536, United States of America
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Rodríguez F, Gaete X, Cassorla F. Etiology and Treatment of Growth Delay in Noonan Syndrome. Front Endocrinol (Lausanne) 2021; 12:691240. [PMID: 34149626 PMCID: PMC8212989 DOI: 10.3389/fendo.2021.691240] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/12/2021] [Indexed: 12/05/2022] Open
Abstract
Noonan syndrome is characterized by multiple phenotypic features, including growth retardation, which represents the main cause of consultation to the clinician. Longitudinal growth during childhood and adolescence depends on several factors, among them an intact somatotrophic axis, which is characterized by an adequate growth hormone (GH) secretion by the pituitary, subsequent binding to its receptor, proper function of the post-receptor signaling pathway for this hormone (JAK-STAT5b and RAS/MAPK), and ultimately by the production of its main effector, insulin like growth factor 1 (IGF-1). Several studies regarding the function of the somatotrophic axis in patients with Noonan syndrome and data from murine models, suggest that partial GH insensitivity at a post-receptor level, as well as possible derangements in the RAS/MAPK pathway, are the most likely causes for the growth failure in these patients. Treatment with recombinant human growth hormone (rhGH) has been used extensively to promote linear growth in these patients. Numerous treatment protocols have been employed so far, but the published studies are quite heterogeneous regarding patient selection, length of treatment, and dose of rhGH utilized, so the true benefit of GH therapy is somewhat difficult to establish. This review will discuss the possible etiologies for the growth delay, as well as the outcomes following rhGH treatment in patients with Noonan syndrome.
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Affiliation(s)
- Fernando Rodríguez
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
| | - Ximena Gaete
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
- Pediatrics Department, Hospital Clínico San Borja – Arriarán, Santiago, Chile
| | - Fernando Cassorla
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
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7
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Libraro A, D’Ascanio V, Cappa M, Chiarito M, Digilio MC, Einaudi S, Grandone A, Maghnie M, Mazzanti L, Mussa A, Patti G, Scarano E, Spinuzza A, Vannelli S, Wasniewska MG, Ferrero GB, Faienza MF. Growth in Children With Noonan Syndrome and Effects of Growth Hormone Treatment on Adult Height. Front Endocrinol (Lausanne) 2021; 12:761171. [PMID: 35002956 PMCID: PMC8730290 DOI: 10.3389/fendo.2021.761171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Growth impairment is a common manifestation in Noonan syndrome (NS). Recombinant human GH (rhGH) treatment has been shown to increase growth and adult height (AH) in a few studies. We aimed to evaluate the growth trajectory towards the AH, and the effects of rhGH treatment in a large cohort of NS children. METHODS Retrospective, multicenter, cohort study including subjects with genetic diagnosis of NS. A total of 228 NS patients, 154 with PTPN11 mutations, 94 who reached AH, were recruited. Auxological data were collected at 2, 5, and 10 years, at pubertal onset, at AH. Sixty-eight NS subjects affected with GH deficiency (GHD) were treated with rhGH at a mean dose of 0.24 mg/kg per week until AH achievement. RESULTS ANOVA analysis showed a significant difference between birth length and height standard deviation scores (HSDS) at the different key ages (p<0.001), while no significant differences were found between HSDS measurements at 2, 5, and 10 years, at pubertal onset, and at AH. HSDS increased from -3.10 ± 0.84 to -2.31 ± 0.99 during rhGH treatment, with a total height gain of 0.79 ± 0.74, and no significant difference between untreated and treated NS at AH. CONCLUSIONS rhGH treatment at the standard dose used for children with GH idiopathic deficiency is effective in improving growth and AH in NS with GHD. Further studies are needed to assess genotype-specific response to rhGH treatment in the different pathogenic variants of PTPN11 gene and in the less common genotypes.
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Affiliation(s)
- Annachiara Libraro
- Department of Biomedical Sciences and Human Oncology, Pediatric Unit, University of Bari “A. Moro”, Bari, Italy
| | - Vito D’Ascanio
- National Research Council–Institute of Sciences of Food Production (CNR-ISPA), Bari, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Mariangela Chiarito
- Department of Biomedical Sciences and Human Oncology, Pediatric Unit, University of Bari “A. Moro”, Bari, Italy
| | - Maria Cristina Digilio
- Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Silvia Einaudi
- Department of Pediatric Endocrinology and Diabetology, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Anna Grandone
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health–University of Genova, Genoa, Italy
| | - Laura Mazzanti
- Pediatric Rare Diseases Unit, Department of Pediatrics, St. Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Mussa
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Giuseppa Patti
- Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health–University of Genova, Genoa, Italy
| | - Emanuela Scarano
- Pediatric Rare Diseases Unit, Department of Pediatrics, St. Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Antonietta Spinuzza
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | - Silvia Vannelli
- Department of Pediatric Endocrinology and Diabetology, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Malgorzata Gabriela Wasniewska
- Department of Human Pathology of Adulthood and Childhood Gaetano Barresi, Gaetano Martino University Hospital, University of Messina, Messina, Italy
| | | | - Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, Pediatric Unit, University of Bari “A. Moro”, Bari, Italy
- *Correspondence: Maria Felicia Faienza,
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Apperley LJ, Ramakrishnan R, Dharmaraj P, Das U, Didi M, Blair J, Senniappan S. Effect of Growth Hormone Therapy in Patients with Noonan Syndrome: A Retrospective Study. Int J Endocrinol Metab 2020; 18:e107292. [PMID: 33613679 PMCID: PMC7887459 DOI: 10.5812/ijem.107292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Noonan syndrome is an autosomal dominant condition with an incidence of 1:1000 to 1:2500. The disorder is associated with distinct dysmorphic features, cardiac anomalies, developmental delay and delayed puberty. Short stature is a recognised feature of Noonan syndrome. OBJECTIVES The aim of this study is to assess the effect of growth hormone treatment in patients with Noonan syndrome. METHODS Retrospective data was collected from patients with Noonan syndrome treated with growth hormone. The results were analysed with variables expressed as mean values and standard deviation scores. RESULTS Twelve Noonan syndrome patients (M: F = 10:2) treated with growth hormone were identified. The mean age of starting growth hormone was 8 years, with baseline height standard deviation score of -2.96 (range: -1.64 to -5.54). The height standard deviation score significantly improved to -2.50 (P = 0.0035) and then -2.22 (P = 0.0025), following one and two years of treatment, respectively. The average height velocity for the patients prior to starting treatment was 5.16cm/year (range: 2.4 - 8.2 cm/year), which significantly improved to 7.76cm/year (ranging from 4.1 to 12.8 cm/year) after one year of growth hormone treatment (P = 0.020) and to 6.51cm/year at the end of two years. CONCLUSIONS Our study has shown that growth hormone treatment significantly improves the height standard deviation score of patients with Noonan syndrome over a two-year course of growth hormone therapy without any side effects. Further research is required to analyse the long-term effect of growth hormone therapy in patients with Noonan syndrome, including the impact on final adult height.
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Affiliation(s)
- Louise Jayne Apperley
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Renuka Ramakrishnan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Poonam Dharmaraj
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Urmi Das
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Mohammed Didi
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Jo Blair
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
- Corresponding Author: Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK.
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Seo GH, Yoo HW. Growth hormone therapy in patients with Noonan syndrome. Ann Pediatr Endocrinol Metab 2018; 23:176-181. [PMID: 30599478 PMCID: PMC6312920 DOI: 10.6065/apem.2018.23.4.176] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/09/2018] [Indexed: 12/31/2022] Open
Abstract
Noonan syndrome (NS) is an autosomal dominant disorder that involves multiple organ systems, with short stature as the most common presentation (>70%). Possible mechanisms of short stature in NS include growth hormone (GH) deficiency, neurosecretory dysfunction, and GH resistance. Accordingly, GH therapy has been carried out for NS patients over the last three decades, and multiple studies have reported acceleration of growth velocity (GV) and increase of height standard deviation score (SDS) in both prepubertal and pubertal NS patients upon GH therapy. One year of GH therapy resulted in almost doubling of GV compared with baseline; afterwards, the increase in GV gradually decreased in the following years, showing that the effect of GH therapy wanes over time. After four years of GH therapy, ~70% of NS patients reached normal height considering their age and sex. Early initiation, long duration of GH therapy, and higher height SDS at the onset of puberty were associated with improved final height, whereas gender, dosage of GH, and the clinical severity did not show significant association with final height. Studies have reported no significant adverse events of GH therapy regarding progression of hypertrophic cardiomyopathy, alteration of metabolism, and tumor development. Therefore, GH therapy is effective for improving height and GV of NS patients; nevertheless, concerns on possible malignancy remains, which necessitates continuous monitoring of NS patients receiving GH therapy.
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Affiliation(s)
| | - Han-Wook Yoo
- Address for correspondence: Han-Wook Yoo, MD, PhD Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505 Korea Tel: +82-2-3010-3374 Fax: +82-2-473-3725 E-mail:
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Şıklar Z, Genens M, Poyrazoğlu Ş, Baş F, Darendeliler F, Bundak R, Aycan Z, Savaş Erdeve Ş, Çetinkaya S, Güven A, Abalı S, Atay Z, Turan S, Kara C, Can Yılmaz G, Akyürek N, Abacı A, Çelmeli G, Sarı E, Bolu S, Korkmaz HA, Şimşek E, Çatlı G, Büyükinan M, Çayır A, Evliyaoğlu O, İşgüven P, Özgen T, Hatipoğlu N, Elhan AH, Berberoğlu M. The Growth Characteristics of Patients with Noonan Syndrome: Results of Three Years of Growth Hormone Treatment: A Nationwide Multicenter Study. J Clin Res Pediatr Endocrinol 2016; 8:305-12. [PMID: 27125300 PMCID: PMC5096494 DOI: 10.4274/jcrpe.3013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Noonan syndrome (NS) is a multisystem disorder, and short stature is its most striking manifestation. Optimal growth hormone (GH) treatment for NS is still controversial. In this study, using a nationwide registration system, we aimed to evaluate the growth characteristics and the clinical features of NS patients in Turkey and their growth response to GH treatment. METHODS Children and adolescents with a diagnosis of NS were included inthe study. Laboratory assessment including standard GH stimulation test results were evaluated. Height increment of patients with or without GH treatment were analyzed after three years of therapy. RESULTS A total of 124 NS patients from different centers were entered in the web-based system. Short stature and typical face appearance were the most frequently encountered diagnostic features of our patients. Of the 84 patients who were followed long-term, 47 hadreceived recombinant human GH (rhGH). In this group of 47 patients, height standard deviation score (HSDS) increased from -3.62±1.14 to -2.85±0.96 after three years of therapy, indicating significant differences from the patients who did not receive GH treatment. PTPN11 gene was analyzed in 61 patients, and 64% of these patients were found to have a mutation. HSDS at admission was similar in patients with or without PTPN11 gene mutation. CONCLUSION A diagnosis of NS should be kept in mind in all patients with short stature showing systemic clinical findings. GH therapy is effective for improvement of short stature especially in the first two years of treatment. Further studies are needed for optimisation of GH therapy and evaluation of final height data in NS patients.
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Affiliation(s)
- Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey, Phone: +90 312 595 66 35 E-mail:
| | - Mikayir Genens
- İstanbul University Istanbul Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Şükran Poyrazoğlu
- İstanbul University Istanbul Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Firdevs Baş
- İstanbul University Istanbul Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Feyza Darendeliler
- İstanbul University Istanbul Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Rüveyde Bundak
- İstanbul University Istanbul Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Zehra Aycan
- Dr. Sami Ulus Child Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Şenay Savaş Erdeve
- Dr. Sami Ulus Child Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Semra Çetinkaya
- Dr. Sami Ulus Child Health and Disease Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Ayla Güven
- Göztepe Training and Research Hospital, Clinic of Pediatric Endocrinology, İstanbul, Turkey
| | - Saygın Abalı
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Zeynep Atay
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Serap Turan
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Cengiz Kara
- Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Endocrinology, Samsun, Turkey
| | - Gülay Can Yılmaz
- Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Endocrinology, Samsun, Turkey
| | - Nesibe Akyürek
- Konya Training and Research Hospital, Clinic of Pediatric Endocrinology, Konya, Turkey
| | - Ayhan Abacı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Gamze Çelmeli
- Akdeniz University Faculty of Medicine, Department of Pediatric Endocrinology, Antalya, Turkey
| | - Erkan Sarı
- Gülhane Military Medical Academy, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Semih Bolu
- Düzce University Faculty of Medicine, Department of Pediatric Endocrinology, Düzce, Turkey
| | - Hüseyin Anıl Korkmaz
- Dr. Behçet Uz Children Disease and Surgery Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey
| | - Enver Şimşek
- Osmangazi University Faculty of Medicine, Department of Pediatric Endocrinology, Eskişehir, Turkey
| | - Gönül Çatlı
- Tepecik Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey
| | - Muammer Büyükinan
- Konya Training and Research Hospital, Clinic of Pediatric Endocrinology, Konya, Turkey
| | - Atilla Çayır
- Erzurum Regional Training and Research Hospital, Clinic of Pediatric Endocrinology, Erzurum, Turkey
| | - Olcay Evliyaoğlu
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Pınar İşgüven
- Sakarya University Faculty of Medicine, Department of Pediatric Endocrinology, Sakarya, Turkey
| | - Tolga Özgen
- Bezmialem University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Nihal Hatipoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Atilla Halil Elhan
- Ankara University Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Jeong I, Kang E, Cho JH, Kim GH, Lee BH, Choi JH, Yoo HW. Long-term efficacy of recombinant human growth hormone therapy in short-statured patients with Noonan syndrome. Ann Pediatr Endocrinol Metab 2016; 21:26-30. [PMID: 27104176 PMCID: PMC4835558 DOI: 10.6065/apem.2016.21.1.26] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/12/2015] [Accepted: 11/26/2015] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Noonan syndrome (NS) is characterized by short stature, heart anomalies, developmental delays, dysmorphic features, cryptorchidism, and coagulation defects. Several studies reported the short-term effects of recombinant human growth hormone (rhGH) treatment on the improvement of height. This study was performed to evaluate the long-term efficacy of rhGH in children with NS in Korea. METHODS This study included 15 prepubertal NS children who received rhGH subcutaneously at a dose of 50-75 µg/kg/day for 6 days a week for at least >3 years. Preand posttreatment data, such as height, weight, bone age, insulin-like growth factor 1 (IGF-1), and IGF binding protein 3 (IGFBP-3) levels, were collected every 6 months. RESULTS Chronologic age and bone age at the start of treatment were 7.97±1.81 and 5.09±2.12 years, respectively. Height standard deviation score (SDS) was increased from -2.64±0.64 to -1.54±1.24 years after 3 years (P<0.001). Serum IGF-1 SDS levels were elevated from -1.28±1.03 to -0.10±0.94 (P<0.001). Height SDS was more increased in subjects without PTPN11 mutations compared to those with mutations after 3 years (P=0.012). However, the other parameters, including bone age, IGF-1 SDS, and IGFBP-3 SDS, were not significantly different between patients with and without PTPN11 mutations. CONCLUSION Although this study included a relatively small number of patients, long-term rhGH therapy in NS patients was safe and effective at improving height, growth velocity, and serum IGF-1 levels, in accordance with previous studies. However, the meticulous monitoring of potential adverse events is still needed because of high dose of rhGH and preexisting hyperactivity of RAS-MAPK pathway. Patients with PTPN11 mutations demonstrated a decreased response to rhGH therapy compared to those without mutations.
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Affiliation(s)
- Insook Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Eungu Kang
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Hyang Cho
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gu-Hwan Kim
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Hee Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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12
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Noonan JA, Kappelgaard AM. The efficacy and safety of growth hormone therapy in children with noonan syndrome: a review of the evidence. Horm Res Paediatr 2016; 83:157-66. [PMID: 25503994 DOI: 10.1159/000369012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/13/2014] [Indexed: 11/19/2022] Open
Abstract
Noonan syndrome is a genetic disorder associated with short stature. We reviewed 15 studies in which growth hormone (GH) therapy was used in children with Noonan syndrome. Data show consistent increases in mean height standard deviation score (SDS), with first-year changes of up to 1.26 SDS. Among studies reporting adult or near-adult height, GH therapy over 5-7 years resulted in adult height SDS from -0.6 to -2.1, with up to 60% of subjects in some studies achieving adult height within 1 SDS of mid-parental height. GH treatment results in an acceleration of bone age, likely reflecting normalization from the retarded bone age common in Noonan syndrome patients at the start of therapy. BMI is not affected by GH treatment, but favorable changes in fat mass and body composition are achievable. Longer-term studies and observational studies suggest a waning of the effect of GH therapy over time, as is seen in other GH-treated conditions, and early initiation of therapy and prepubertal status are important predictors of response. GH treatment does not appear to be associated with adverse cardiac or metabolic effects, and data on malignancy during GH treatment give no cause for concern, although they are limited.
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Affiliation(s)
- Jacqueline A Noonan
- Kentucky Children's Heart Center, Division of Pediatric Cardiology, University of Kentucky, Lexington, Ky., USA
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13
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Giacomozzi C, Deodati A, Shaikh MG, Ahmed SF, Cianfarani S. The impact of growth hormone therapy on adult height in noonan syndrome: a systematic review. Horm Res Paediatr 2016; 83:167-76. [PMID: 25721697 DOI: 10.1159/000371635] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recombinant human growth hormone (rhGH) is being used to promote linear growth in short children with Noonan syndrome. However, its efficacy is still controversial. AIMS To systematically determine the impact of rhGH therapy on adult height in children with Noonan syndrome. METHODS We searched the Cochrane Central Register of Controlled Trials, ISI Web of Science, MEDLINE, and the bibliographic references from all retrieved articles published until April 2014. Studies reporting adult/near-adult height in children with Noonan syndrome treated with rhGH or reporting at least a 3-year follow-up were analysed. Quality and strength of recommendation were assessed according to the Endocrine Society criteria. RESULTS No controlled trials reporting adult height were available. Five studies were identified reporting adult height or near adult height. Data comparison showed inter-individual variability in the response to rhGH, mean height gain standard deviation score ranging between 0.6 and 1.4 according to national standards, and between 0.6 and 2 according to Noonan standards. Significant biases affected all the studies. CONCLUSIONS High-quality controlled trials on the impact of rhGH therapy on adult height are lacking, and the robustness of available data is not sufficient to recommend such therapy in children with Noonan syndrome.
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Affiliation(s)
- Claudio Giacomozzi
- Dipartimento di Medicina Pediatrica, Bambino Gesù Children's Hospital, Rome, Italy
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Zavras N, Meazza C, Pilotta A, Gertosio C, Pagani S, Tinelli C, Bozzola M. Five-year response to growth hormone in children with Noonan syndrome and growth hormone deficiency. Ital J Pediatr 2015; 41:71. [PMID: 26444854 PMCID: PMC4595189 DOI: 10.1186/s13052-015-0183-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022] Open
Abstract
Background Noonan syndrome (NS) is an autosomal dominant disorder characterized by specific features including short stature, distinctive facial dysmorphic features, congenital heart defects, hypertrophic cardiomyopathy, skeletal anomalies and webbing of the neck. Molecular screening has shown that the majority of individuals with NS have a mutation in the PTPN11 gene. Noonan syndrome children may show an impaired growth hormone (GH)/insulin-like growth factor axis. Moreover, recombinant human GH (rhGH) has been shown to improve growth rate in patients with NS, although data are still limited. Methods In the present study, we assessed growth response following GH therapy (0.25 mg/Kg/week) in 5 (2 M and 3 F) GH-deficient NS patients (NSGHD, mean age 8.5 years) and in 5 (2 M and 3 F) idiopathic GH deficient (IGHD, mean age 8.6 years) patients. We also evaluated the safety of rhGH therapy in NS patients with GHD. Results At the beginning of GH treatment, height and growth rate were statistically lower in NSGHD children than in IGHD ones. During the first three years of rhGH therapy, NSGHD patients showed a slight improvement in height (from −2.71 SDS to −2.44 SDS) and growth rate (from −2.42 SDS to −0.23 SDS), although the values were always significantly lower than in IGHD children. After five years of rhGH treatment, height gain was higher in IGHD children (mean 28.3 cm) than in NSGHD patients (mean 23.6 cm). During the first five years of rhGH therapy, regular cardiological and haematological check-ups were performed, leading to the conclusion that rhGH therapy was safe. Conclusions In conclusion, pre-pubertal NS children with GHD slightly increased their height and growth rate during the first years of GH therapy, although the response to rhGH treatment was significantly lower than IGHD children. Furthermore, the therapy appeared to be safe since no severe adverse effects were reported, at least during the first five years. However, a close follow-up of these patients is mandatory, especially to monitor cardiac function.
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Affiliation(s)
| | - Cristina Meazza
- Internal Medicine and Therapeutics Department, University of Pavia, Auxology Research Centre, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, 2 27100, Pavia, Italy.
| | - Alba Pilotta
- Auxoendocrinology Center, Pediatric Department, University of Brescia, Spedali Civili, Brescia, Italy.
| | | | - Sara Pagani
- Internal Medicine and Therapeutics Department, University of Pavia, Auxology Research Centre, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, 2 27100, Pavia, Italy.
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS San Matteo, Pavia, Italy.
| | - Mauro Bozzola
- Internal Medicine and Therapeutics Department, University of Pavia, Auxology Research Centre, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, 2 27100, Pavia, Italy.
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15
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Lee PA, Ross JL, Pedersen BT, Kotnik P, Germak JA, Christesen HT. Noonan syndrome and Turner syndrome patients respond similarly to 4 years' growth-hormone therapy: longitudinal analysis of growth-hormone-naïve patients enrolled in the NordiNet® International Outcome Study and the ANSWER Program. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:17. [PMID: 26351466 PMCID: PMC4562101 DOI: 10.1186/s13633-015-0015-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/05/2015] [Indexed: 11/12/2022]
Abstract
Background Turner syndrome (TS) and Noonan syndrome (NS) are distinct syndromes associated with short stature and other similar phenotypic features. We compared the responses to growth hormone (GH) therapy of TS and NS patients enrolled in the NordiNet® International Outcome Study (IOS) or the American Norditropin Studies: Web-Enabled Research (ANSWER) Program, which collect information on GH therapy in clinical practice. Methods Repeated-measures regression analysis was performed on change in height standard deviation score (HSDS) and target-height-corrected HSDS, based on national normal references and treatment-naïve disease-specific references. Models were adjusted for baseline age and HSDS, and average GH dose. The study population was paediatric patients with TS and NS in the NordiNet® IOS and ANSWER Program. Longitudinal growth responses over 4 years were evaluated. Results In 30 NS patients (24 males; baseline age 8.39 ± 3.45 years) and 294 TS patients (7.81 ± 3.22 years), 4-year adjusted ΔHSDS were +1.14 ± 0.13 and +1.03 ± 0.04, respectively (national references). Based on untreated, disease-specific references, 4-year adjusted ΔHSDS for NS and TS were +1.48 ± 0.10 and +1.79 ± 0.04. The analyses showed a significant increase in HSDS over time for both NS and TS (P < 0.0001). ΔHSDS in NS was higher with younger baseline age; ΔHSDS in TS was higher for patients with younger baseline age and higher GH dose. Conclusions NS and TS patients responded well and similarly over 4 years of GH treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13633-015-0015-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, The Milton S. Hershey Medical Center, 500 University Dr., MC-H085, Hershey, PA 17033-0850 USA
| | - Judith L Ross
- Thomas Jefferson University, Philadelphia, PA USA ; DuPont Hospital for Children, Wilmington, DE USA
| | | | - Primoz Kotnik
- Department of Pediatric Endocrinology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
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16
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Lee PA, Ross J, Germak JA, Gut R. Effect of 4 years of growth hormone therapy in children with Noonan syndrome in the American Norditropin Studies: Web-Enabled Research (ANSWER) Program® registry. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2012; 2012:15. [PMID: 22682146 PMCID: PMC3477766 DOI: 10.1186/1687-9856-2012-15] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 06/08/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Noonan syndrome (NS) is a genetic disorder characterized by phenotypic features, including facial dysmorphology, cardiovascular anomalies, and short stature. Growth hormone (GH) has been approved by the United States Food and Drug Administration for short stature in children with NS. The objective of this analysis was to assess the height standard deviation score (HSDS) and change in HSDS (ΔHSDS) for up to 4 years (Y4) of GH therapy in children with NS. METHODS The American Norditropin Studies: Web-Enabled Research (ANSWER) Program®, a US-based registry, collects long-term efficacy and safety information on patients treated with Norditropin® (somatropin rDNA origin, Novo Nordisk A/S) at the discretion of participating physicians. A total of 120 children (90 boys, 30 girls) with NS, naïve to previous GH treatment, were included in this analysis. RESULTS The mean (SD) baseline age of subjects (n = 120) was 9.2 (3.8) years. Mean (SD) HSDS increased from -2.65 (0.73) at baseline to -1.32 (1.11) at Y4 (n = 17). Subjects showed continued increase in HSDS from baseline to Y4 without significant differences between genders at Y1 or Y2. The mean (SD) GH dose was 47 (11) mcg/kg/day at baseline and 59 (16) mcg/kg/day at Y4. There was a negative correlation between baseline age and ΔHSDS at Y1 (R = -0.3156; P = 0.0055) and Y2 (R = -0.3394; P = 0.017). ΔHSDS at Y1 was significantly correlated with ΔHSDS at Y2 (n = 37; R = 0.8527, P < 0.0001) and Y3 (n = 20; R = 0.5145; P = 0.0203), but not Y4 (n = 12; R = 0.4066, P = 0.1896). CONCLUSIONS GH treatment-naïve patients with NS showed continued increases in HSDS during 4 years of treatment with GH with no significant differences between genders up to 2 years. Baseline age was negatively correlated with ΔHSDS at Y1 and Y2. Whether long-term therapy in NS results in continued increase in HSDS to adult height remains to be investigated. TRIAL REGISTRATION ClinicalTrials.gov NCT01009905.
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Affiliation(s)
- Peter A Lee
- Department of Pediatrics, The Milton S, Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA.
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17
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Tartaglia M, Zampino G, Gelb BD. Noonan syndrome: clinical aspects and molecular pathogenesis. Mol Syndromol 2010; 1:2-26. [PMID: 20648242 DOI: 10.1159/000276766] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 10/30/2009] [Indexed: 01/20/2023] Open
Abstract
Noonan syndrome (NS) is a relatively common, clinically variable and genetically heterogeneous developmental disorder characterized by postnatally reduced growth, distinctive facial dysmorphism, cardiac defects and variable cognitive deficits. Other associated features include ectodermal and skeletal defects, cryptorchidism, lymphatic dysplasias, bleeding tendency, and, rarely, predisposition to hematologic malignancies during childhood. NS is caused by mutations in the PTPN11, SOS1, KRAS, RAF1, BRAF and MEK1 (MAP2K1) genes, accounting for approximately 70% of affected individuals. SHP2 (encoded by PTPN11), SOS1, BRAF, RAF1 and MEK1 positively contribute to RAS-MAPK signaling, and possess complex autoinhibitory mechanisms that are impaired by mutations. Similarly, reduced GTPase activity or increased guanine nucleotide release underlie the aberrant signal flow through the MAPK cascade promoted by most KRAS mutations. More recently, a single missense mutation in SHOC2, which encodes a cytoplasmic scaffold positively controlling RAF1 activation, has been discovered to cause a closely related phenotype previously termed Noonan-like syndrome with loose anagen hair. This mutation promotes aberrantly acquired N-myristoylation of the protein, resulting in its constitutive targeting to the plasma membrane and dysregulated function. PTPN11, BRAF and RAF1 mutations also account for approximately 95% of LEOPARD syndrome, a condition which resembles NS phenotypically but is characterized by multiple lentigines dispersed throughout the body, café-au-lait spots, and a higher prevalence of electrocardiographic conduction abnormalities, obstructive cardiomyopathy and sensorineural hearing deficits. These recent discoveries demonstrate that the substantial phenotypic variation characterizing NS and related conditions can be ascribed, in part, to the gene mutated and even the specific molecular lesion involved.
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Affiliation(s)
- M Tartaglia
- Dipartimento di Ematologia, Oncologia e Medicina Molecolare, Istituto Superiore di Sanità, Rome, Italy
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18
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Polgreen LE, Miller BS. Growth patterns and the use of growth hormone in the mucopolysaccharidoses. J Pediatr Rehabil Med 2010; 3:25-38. [PMID: 20563263 PMCID: PMC2886985 DOI: 10.3233/prm-2010-0106] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Short stature is characteristic of patients with mucopolysaccharidosis (MPS) diseases. For children with skeletal dysplasias, such as MPS, it is important to know the natural history of growth. An understanding of the natural growth pattern in each MPS disease provides a measurement to which treatments can be compared, as well as data which can help families and providers make individualized decisions about growth promoting treatments. Multiple advancements have been made in the treatment of MPS with both hematopoietic cell transplantation (HCT) and enzyme replacement therapy (ERT). The long term benefit of these treatments on growth is unknown. This article will review the published data on growth in children with MPS, and describe preliminary data on the use of human growth hormone (hGH) in children with MPS.
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Affiliation(s)
- L E Polgreen
- University of Minnesota, Department of Pediatrics, Division of Endocrinology, Minneapolis, MN, USA
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Walton-Betancourth S, Martinelli CE, Thalange NK, Dyke MP, Acerini CL, White S, Camacho-Hübner C, Savage MO. Excellent growth response to growth hormone therapy in a child with PTPN11-negative Noonan syndrome and features of growth hormone resistance. J Endocrinol Invest 2007; 30:439-41. [PMID: 17598979 DOI: 10.1007/bf03346324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report a child with Noonan syndrome, referred with severe short stature (height--5.4 SD) and biochemical features of GH resistance. The Noonan syndrome phenotype was confirmed by a clinical geneticist, however analysis of the protein tyrosine phosphatase nonreceptor type 11 (PTPN11) gene showed no mutation. Baseline serum IGF-I, IGFbinding protein 3 (IGFBP-3) and acid-labile subunit (ALS) were low, and in an IGF-I generation test, IGF-I did not increase into the normal range and IGFBP-3 and ALS did not change. These results are consistent with GH resistance. Treatment with human GH (hGH) was given in a dose of 0.05 mg/kg/day and height velocity increased from 5.6 to 10.7 cm/yr during the first year, and 8.9 cm/yr during the second year of therapy. Height standard deviation score has increased by 1.85 after 2 and a half yr of therapy. Serum IGF-I, IGFBP-3 and ALS values increased well into the normal range. This case shows that the potential value of GH therapy must be evaluated in each patient individually and that an excellent response may occur in a child with a PTPN11-negative genotype.
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Affiliation(s)
- S Walton-Betancourth
- Department of Endocrinology, St Bartholomew's and the Royal London Hospitals, London, UK
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Abstract
Noonan syndrome is a relatively common multiple malformation syndrome with characteristic facies, short stature and congenital heart disease, most commonly pulmonary stenosis (Noonan, Clin Pediatr, 33:548-555, 1994). Recently, a mutation in the PTPN11 gene (Tartaglia, Mehler, Goldberg, Zampino, Brunner, Kremer et al., Nat Genet, 29:465-468, 2001) was found to be present in about 50% of individuals with Noonan syndrome. The phenotype noted in Noonan syndrome is also found in a number of other syndromes which include LEOPARD (Gorlin, Anderson, Blaw, Am J Dis Child, 17:652-662, 1969), Cardio-facio-cutaneous syndrome (Reynolds, Neri, Hermann, Blumberg, Coldwell, Miles et al., Am J Med Genet, 28:413-427, 1986) and Costello syndrome (Hennekam, Am J Med Genet, 117C(1):42-48, 2003). All three of these syndromes share similar cardiac defects and all have postnatal short stature. Very recently, HRAS mutations (Aoki, Niihori, Kawame, Kurosawa, Ohashi, Tanaka et al., Nat Genet, 37:1038-1040, 2005) have been found in the Costello syndrome and germline mutations in KRAS and BRAF genes (Rodriguez-Viciana, Tetsu, Tidyman, Estep, Conger, Santa Cruz et al., Nat Genet, 2006; Niihori, Aoki, Narumi, Neri, Cave, Verloes et al., Nat Genet, 38:294-296, 2006) in the Cardio-facio-cutaneous syndrome. Phenotypic overlap between these genetic disorders can now be explained since each is caused by germline mutations that are major components of the RAS-MAPK pathway. This pathway plays an important role in growth factor and cytokine signaling as well as cancer pathogenesis.
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Affiliation(s)
- Jacqueline A Noonan
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA.
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Strehl J, Schepke M, Wardelmann E, Caselmann WH, Sauerbruch T. [Chronic diarrhea in a 43-year-old patient]. Internist (Berl) 2003; 44:626-30. [PMID: 12966790 DOI: 10.1007/s00108-003-0856-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 43-year old patient came to our clinic with chronic diarrhea. Determination of the faecal alpha 1-antitrypsin-clearance led to the diagnosis of exsudative enteropathy. Blood counts showed pronounced lymphocytopenia. Histopathological findings from intestinal and colorectal biopsies showed diffuse lymphangiectasis. Following exclusion of secondary types, our diagnosis was primary intestinal lymphangiectasis. Additional distinctive morphological and anamnestic features strongly suggested presence of Noonan's syndrome. Characteristic manifestations of Noonan's syndrome include changes in the lymphatic vessels in accordance with primary lymphangiectasis. Frequently, these changes are localized in the lungs. To date, only rare cases of intestinal lymphangiectasia in Noonan's syndrome have been reported. Treatment consisted of a protein-rich diet, with reduced fat content enriched by middle-chain fatty acids, as well as twice-daily injections of 200 micrograms octreotide. With this therapy, the symptoms improved.
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Affiliation(s)
- J Strehl
- Medizinische Klinik und Poliklinik I, Universitätsklinik Bonn.
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