1
|
McTavish D, Thornton J. Appetite stimulants for people with cystic fibrosis. Cochrane Database Syst Rev 2022; 9:CD008190. [PMID: 36149378 PMCID: PMC9504874 DOI: 10.1002/14651858.cd008190.pub3] [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: 12/14/2022]
Abstract
BACKGROUND Chronic loss of appetite in cystic fibrosis concerns both individuals and families. Appetite stimulants have been used to help cystic fibrosis patients with chronic anorexia attain optimal body mass index (BMI) and nutritional status. However, these may have adverse effects on clinical status. This is an updated version of the original review. OBJECTIVES To systematically search for and evaluate the evidence on the beneficial effects of appetite stimulants in the management of cystic fibrosis-related anorexia and synthesise reports of any side effects. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and online trials registries; handsearched reference lists; and contacted local and international experts to identify relevant trials. Last search of the Cystic Fibrosis Trials Register: 23 May 2022. Last search of online trial registries: 10 May 2022. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of appetite stimulants compared to placebo, control, no treatment or different appetite stimulants, or to the same appetite stimulants at different doses or regimens for at least one month in adults and children with cystic fibrosis. DATA COLLECTION AND ANALYSIS Review authors independently extracted data and assessed risk of bias of the included trials. We used the GRADE approach to assess the certainty of the evidence and performed meta-analyses. MAIN RESULTS We included four trials (70 participants) comparing appetite stimulants (cyproheptadine hydrochloride and megestrol acetate) to placebo; the numbers of adults or children within each trial were not always reported. We assessed the certainty of evidence as low due to the small number of participants, incomplete or selective outcome reporting, and unclear risk of selection bias. Regarding our primary outcomes, a meta-analysis of two trials (42 participants) showed that appetite stimulants may produce a larger increase in weight (kg) at three months (mean difference (MD) 1.25 kg, 95% confidence interval (Cl) 0.45 to 2.05), and one trial (17 participants) showed a similar result at six months (MD 3.80 kg, 95% CI 1.27 to 6.33) (both low-certainty evidence). Results also showed that weight z score may increase with appetite stimulants compared to placebo at three months (MD 0.61, 95% CI 0.29 to 0.93; 3 studies; 40 participants; P < 0.001) and at six months (MD 0.74, 95% CI 0.26 to 1.22; 1 trial; 17 participants). There was no evidence of a difference in effect between cyproheptadine hydrochloride and megestrol acetate for either outcome. Only one trial (25 participants) reported analysable data for body composition (BMI), with results favouring cyproheptadine hydrochloride compared to placebo; a further trial (16 participants) narratively agreed with this result. All four trials reported on lung function at durations ranging from two to nine months. Considering analysable data, two trials (42 participants) found that appetite stimulants may make little or no difference in forced expiratory volume at one second (FEV1) % predicted at three months, and one trial (17 participants) found similar results at six months. Two further three-month trials narratively agreed with these results. Limited information was reported for secondary outcomes. Two trials (23 participants) reported results showing that appetite stimulants may increase appetite compared to placebo at three months (odds ratio 45.25, 95% CI 3.57 to 573.33; low-certainty evidence). Only one study reported on quality of life, finding that cyproheptadine reduced fatigue in two participants compared with none with placebo. One study (25 participants) found no difference in energy intake between appetite stimulant or placebo at three months. Insufficient reporting of adverse effects prevented a full determination of their impact. Two studies (33 participants) narratively reported similar requirements for additional antibiotics between appetite stimulants and placebo at three months. AUTHORS' CONCLUSIONS: At six months in adults and children, appetite stimulants improved only two of the outcomes of this review: weight (or weight z score) and subjectively reported appetite. Insufficient reporting of side effects prevented a full determination of their impact. Whilst the data may suggest the potential use of appetite stimulants in treating anorexia in adults and children with cystic fibrosis, this is based upon low-certainty evidence from a small number of trials, therefore firm conclusions cannot be drawn. Clinicians need to be aware of the potential adverse effects of appetite stimulants and actively monitor any individuals prescribed these medications accordingly. Research is required to determine meaningful surrogate measures for appetite and to define what constitutes quality weight gain. Future trials of appetite stimulants should use a validated measure of symptoms including a disease-specific instrument for measuring poor appetite. This review highlights the need for multicentred, adequately powered, and well-designed trials to evaluate agents to safely increase appetite in people with cystic fibrosis and to establish the optimal mode of treatment.
Collapse
Affiliation(s)
- Diane McTavish
- Adult Cystic Fibrosis Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Judith Thornton
- Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK
| |
Collapse
|
2
|
Thaker V, Carter B, Putman M. Recombinant growth hormone therapy for cystic fibrosis in children and young adults. Cochrane Database Syst Rev 2021; 8:CD008901. [PMID: 34424546 PMCID: PMC8407505 DOI: 10.1002/14651858.cd008901.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is an inherited condition causing disease most noticeably in the lungs, digestive tract and pancreas. People with CF often have malnutrition and growth delay. Adequate nutritional supplementation does not improve growth optimally and hence an anabolic agent, recombinant human growth hormone (rhGH), has been proposed as a potential intervention. This is an update of a previously published review. OBJECTIVES To evaluate the effectiveness and safety of rhGH therapy in improving lung function, quality of life and clinical status of children and young adults with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of latest search: 12 January 2021. We also searched ongoing trials registers: clinicaltrials.gov from the United States - date of latest search 19 Jun 2021; WHO International Clinical Trials Registry Platform (ICTRP) - date of latest search 05 March 2018 (not available in 2021). We conducted a search of relevant endocrine journals and proceedings of the Endocrinology Society meetings using Web of Science, Scopus and Proceedings First. Date of latest search: 21 Jun 2021. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of all preparations of rhGH compared to either no treatment, or placebo, or each other at any dose (high-dose and low-dose) or route and for any duration, in children or young adults (aged up to 25 years) diagnosed with CF (by sweat test or genetic testing). DATA COLLECTION AND ANALYSIS Two authors independently screened papers, extracted trial details and assessed their risk of bias. We assessed the quality of the evidence using the GRADE system. MAIN RESULTS We included eight trials (291 participants, aged between five and 23 years) in the current version of the review. Seven trials compared standard-dose rhGH (approximately 0.3 mg/kg/week) to no treatment and one three-arm trial (63 participants) compared placebo, standard-dose rhGH (0.3 mg/kg/week) and high-dose rhGH (0.5 mg/kg/week). Six trials lasted for one year and two trials for six months. We found that rhGH treatment may improve some of the pulmonary function outcomes, but there was no difference between standard and high-dose levels (low-certainty evidence, limited by inconsistency across the trials, small number of participants and short duration of therapy). The trials show evidence of improvement in the anthropometric parameters (height, weight and lean body mass) with rhGH therapy, again no differences between dose levels. We found improvement in height for all comparisons (very low- to low-certainty evidence), but improvements in weight and lean body mass were only reported for standard-dose rhGH versus no treatment (very low-certainty evidence). There is some evidence indicating a change in the level of fasting blood glucose with rhGH therapy, however, it did not cross the clinical threshold for diagnosis of diabetes in the trials of short duration (low-certainty evidence). There is low- to very low-certainty evidence for improvement of pulmonary exacerbations with no further significant adverse effects, but this is limited by the short duration of trials and the small number of participants. One small trial provided inconsistent evidence on improvement in quality of life (very low-certainty evidence). There is limited evidence from three trials in improvements in exercise capacity (low-certainty evidence). None of the trials have systematically compared the expense of therapy on overall healthcare costs. AUTHORS' CONCLUSIONS When compared with no treatment, rhGH therapy is effective in improving the intermediate outcomes in height, weight and lean body mass. Some measures of pulmonary function showed moderate improvement, but no consistent benefit was seen across all trials. The significant change in blood glucose levels, although not causing diabetes, emphasizes the need for careful monitoring of this adverse effect with therapy in a population predisposed to CF-related diabetes. No significant changes in quality of life, clinical status or side-effects were observed in this review due to the small number of participants. Long-term, well-designed randomised controlled trials of rhGH in individuals with CF are required prior to routine clinical use of rhGH in CF.
Collapse
Affiliation(s)
- Vidhu Thaker
- Division of Molecular Genetics and Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Ben Carter
- Biostatistics and Health Informatics, King's College London; Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Melissa Putman
- Department of Endocrinology, Boston's Children's Hospital and Massachusetts General Hospital, Boston, USA
| |
Collapse
|
3
|
Le TN, Anabtawi A, Putman MS, Tangpricha V, Stalvey MS. Growth failure and treatment in cystic fibrosis. J Cyst Fibros 2020; 18 Suppl 2:S82-S87. [PMID: 31679733 DOI: 10.1016/j.jcf.2019.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 01/10/2023]
Abstract
Poor growth has long been a characteristic feature of cystic fibrosis (CF) and is significantly linked to lung function and overall health status. Improvements in pulmonary and nutrition care for patients with cystic fibrosis (CF) have resulted in better growth outcomes; however, height gains have not paralleled the improvements in weight in children with CF, and patients with more severe CF mutations remain significantly more affected. Many factors affect the growth hormone-IGF-1 axis and the growth plate of the long bones, including the chronic inflammatory state associated with CF. There are also increasing data on the direct effects of CFTR on bone and implications for CFTR modulators in attaining optimal growth. Treatments aimed at improving growth in CF are also reviewed here.
Collapse
Affiliation(s)
- Trang N Le
- Departments of Internal Medicine and Pediatrics, Division of Endocrinology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Abeer Anabtawi
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Melissa S Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Vin Tangpricha
- Atlanta VA Medical Center, Atlanta, GA, USA; Division of Endocrinology, Metabolism & Lipids, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael S Stalvey
- Atlanta VA Medical Center, Atlanta, GA, USA; Department of Pediatrics, University of Alabama at Birmingham, AL, USA
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is commonly associated with compromised growth especially in severe cases when the pulmonary function (PFT) deteriorates. As growth optimization is an important aspect of CF management, this review will summarize the current knowledge on the prevalence of growth failure in CF patients, and focus on the mechanisms leading to poor growth, on the association of poor linear growth with reduced PFT and on recombinant human growth hormone (rhGH) therapy in CF patients. RECENT FINDINGS Despite the improvement in CF care in the last 2 decades, compromised linear growth is still quite prevalent. The pathophysiology of growth failure in CF is multifactorial. Malnutrition due to decreased energy intake increased energy expenditure and malabsorption of ingested nutrients secondary to pancreatic insufficiency, all probably play a major role in growth restriction. In addition, chronic inflammation characteristic of CF may contribute to growth failure via alteration in the GH-insulin-like growth factor 1 signaling and other changes in the growth plate. rhGH and new CFTR modulators may improve some growth parameters. SUMMARY Beyond optimizing nutrition and malabsorption, and controlling chronic inflammation, children with CF may benefit from the anabolic effects of rhGH therapy to improve their anthropometric parameters. Whether this translates into better PFT and improved long-term outcomes is yet to be determined.
Collapse
Affiliation(s)
- Eran Lavi
- Division of Pediatric Endocrinology, Pediatric Endocrinology Unit
| | - Alex Gileles-Hillel
- Pediatric Pulmonology and CF Unit, Department of Pediatrics
- The Wohl Institute for Translational Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Zangen
- Division of Pediatric Endocrinology, Pediatric Endocrinology Unit
| |
Collapse
|
5
|
Thaker V, Carter B, Putman M. Recombinant growth hormone therapy for cystic fibrosis in children and young adults. Cochrane Database Syst Rev 2018; 12:CD008901. [PMID: 30557452 PMCID: PMC6517261 DOI: 10.1002/14651858.cd008901.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is an inherited condition causing disease most noticeably in the lungs, digestive tract and pancreas. People with CF often have malnutrition and growth delay. Adequate nutritional supplementation does not improve growth optimally and hence an anabolic agent, recombinant human growth hormone (rhGH), has been proposed as a potential intervention. This is an update of a previously published review. OBJECTIVES To evaluate the effectiveness and safety of rhGH therapy in improving lung function, quality of life and clinical status of children and young adults with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of latest search: 22 October 2018.We also searched ongoing trials registers in clinicaltrials.gov from the United States and WHO International Clinical Trials Registry Platform (ICTRP). Date of latest search: 05 March 2018.We conducted a search of relevant endocrine journals and proceedings of the Endocrinology Society meetings using Web of Science, Scopus and Proceedings First. Date of latest search: 04 March 2018. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of all preparations of rhGH compared to either no treatment, or placebo, or each other at any dose (high-dose and low-dose) or route and for any duration, in children or young adults (aged up to 25 years) diagnosed with CF (by sweat test or genetic testing). DATA COLLECTION AND ANALYSIS Two authors independently screened papers, extracted trial details and assessed their risk of bias. We assessed the quality of the evidence using the GRADE system. MAIN RESULTS We included eight trials (291 participants, aged between five and 23 years) in this revision of the review. Seven trials compared standard-dose rhGH (approximately 0.3 mg/kg/week) to no treatment and one three-arm trial (63 participants) compared placebo, standard-dose rhGH (0.3 mg/kg/week) and high-dose rhGH (0.5 mg/kg/week). Six trials lasted for one year and two trials for six months. We found that rhGH treatment may improve some of the pulmonary function outcomes but there was no difference between standard and high-dose levels (low-quality evidence, limited by inconsistency across the trials, small number of participants and short duration of therapy). The trials show evidence of improvement in the anthropometric parameters (height, weight and lean body mass) with rhGH therapy, again no differences between dose levels. We found improvement in height for all comparisons (very low- to low quality evidence), but improvements in weight and lean body mass were only reported for standard-dose rhGH versus no treatment (very low-quality evidence). There is some evidence indicating a change in the level of fasting blood glucose with rhGH therapy, however, it did not cross the clinical threshold for diagnosis of diabetes in the trials of short duration (low-quality evidence). There is low- to very low-quality evidence for improvement of pulmonary exacerbations with no further significant adverse effects, but this is limited by the short duration of trials and the small number of participants. One small trial provided inconsistent evidence on improvement in quality of life (very low-quality evidence). There is limited evidence from three trials in improvements in exercise capacity (low-quality evidence). None of the trials have systematically compared the expense of therapy on overall healthcare costs. AUTHORS' CONCLUSIONS When compared with no treatment, rhGH therapy is effective in improving the intermediate outcomes in height, weight and lean body mass. Some measures of pulmonary function showed moderate improvement, but no consistent benefit was seen across all trials. The significant change in blood glucose levels, although not causing diabetes, emphasizes the need for careful monitoring of this adverse effect with therapy in a population predisposed to CF-related diabetes. No significant changes in quality of life, clinical status or side-effects were observed in this review due to the small number of participants. Long-term, well-designed randomised controlled trials of rhGH in individuals with CF are required prior to routine clinical use of rhGH in CF.
Collapse
Affiliation(s)
- Vidhu Thaker
- Columbia University Medical CenterDivision of Molecular Genetics, Department of Pediatrics630 West 168th St.New YorkNYUSA10032
| | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & NeuroscienceBiostatistics and Health InformaticsDenmark HillLondonUK
| | - Melissa Putman
- Boston's Children's Hospital and Massachusetts General HospitalDepartment of Endocrinology333 Longwood Avenue, 6th FloorBostonUSAMA 02115
| | | |
Collapse
|
6
|
Strawhacker MT, Wellendorf J. Caring for Children With Cystic Fibrosis: A Collaborative Clinical and School Approach. J Sch Nurs 2016; 20:5-15. [PMID: 14731111 DOI: 10.1177/10598405040200010301] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Earlier diagnosis and more effective treatments have improved both morbidity and mortality associated with cystic fibrosis, making regular school attendance a reality. School nurses have a unique opportunity to assist students with cystic fibrosis successfully manage their disease. Medical treatment for cystic fibrosis can be complex, leaving students and families in need of health consultation and support. The clinic and school nurse each brings a unique perspective to cystic fibrosis care management. Working to understanding perspectives across settings and looking for ways to collaborate through mutual planning and goal setting is an ideal way to support families and promote achievement of optimal health status for students.
Collapse
|
7
|
Wong SC, Dobie R, Altowati MA, Werther GA, Farquharson C, Ahmed SF. Growth and the Growth Hormone-Insulin Like Growth Factor 1 Axis in Children With Chronic Inflammation: Current Evidence, Gaps in Knowledge, and Future Directions. Endocr Rev 2016; 37:62-110. [PMID: 26720129 DOI: 10.1210/er.2015-1026] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Growth failure is frequently encountered in children with chronic inflammatory conditions like juvenile idiopathic arthritis, inflammatory bowel disease, and cystic fibrosis. Delayed puberty and attenuated pubertal growth spurt are often seen during adolescence. The underlying inflammatory state mediated by proinflammatory cytokines, prolonged use of glucocorticoid, and suboptimal nutrition contribute to growth failure and pubertal abnormalities. These factors can impair growth by their effects on the GH-IGF axis and also directly at the level of the growth plate via alterations in chondrogenesis and local growth factor signaling. Recent studies on the impact of cytokines and glucocorticoid on the growth plate further advanced our understanding of growth failure in chronic disease and provided a biological rationale of growth promotion. Targeting cytokines using biological therapy may lead to improvement of growth in some of these children, but approximately one-third continue to grow slowly. There is increasing evidence that the use of relatively high-dose recombinant human GH may lead to partial catch-up growth in chronic inflammatory conditions, although long-term follow-up data are currently limited. In this review, we comprehensively review the growth abnormalities in children with juvenile idiopathic arthritis, inflammatory bowel disease, and cystic fibrosis, systemic abnormalities of the GH-IGF axis, and growth plate perturbations. We also systematically reviewed all the current published studies of recombinant human GH in these conditions and discussed the role of recombinant human IGF-1.
Collapse
Affiliation(s)
- S C Wong
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - R Dobie
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - M A Altowati
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - G A Werther
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - C Farquharson
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| | - S F Ahmed
- Developmental Endocrinology Research Group (S.C.W., M.A.A., S.F.A.), University of Glasgow, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom; Division of Developmental Biology (R.D., C.F.), Roslin Institute, University of Edinburgh, Midlothian EH25 9RG, United Kingdom; and Hormone Research (G.A.W.), Murdoch Children's Research Institute, Melbourne, VIC 3052, Australia
| |
Collapse
|
8
|
Bai W, Binkley TL, Wallace JW, Carver TW, Specker BL. Peripheral quantitative computed tomography (pQCT) bone measurements in children with cystic fibrosis. Pediatr Pulmonol 2016; 51:28-33. [PMID: 26551628 DOI: 10.1002/ppul.23323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 07/29/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) have low bone density and increased fracture risk. METHODS Cross-sectional study investigating whole body bone mineral content (WBBMC), bone geometry and strength in 12 children with CF compared to 23 age- and sex-matched controls with and without adjusting for age, height, and body composition. RESULTS CF group had lower WBBMC than controls (P = 0.007) with larger differences at older ages (age-by-group, P = 0.08). CF group had decreased height (P = 0.006), a trend of lower lean mass per height (P = 0.08), and no difference in relationship between WBBMC and lean mass compared to controls (P = 0.65). Periosteal and endosteal circumferences were smaller in CF (each, P = 0.02). Positive relationships of cortical area and bone strength with age were attenuated with CF (group-by-age; each, P < 0.01). CONCLUSION Children with CF have similar WBBMC relative to lean mass as controls. Cortical bone area and bone strength were less in CF group compared to controls, with greater differences in older children.
Collapse
Affiliation(s)
- Wei Bai
- EA Martin Program in Human Nutrition, SWC Box 506, South Dakota State University, South Dakota
| | - Teresa L Binkley
- EA Martin Program in Human Nutrition, SWC Box 506, South Dakota State University, South Dakota
| | - James W Wallace
- Sanford Children's Specialty Clinic, 1600 W. 22nd Street, Sioux Falls, South Dakota
| | - Terrence W Carver
- Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, Missouri
| | - Bonny L Specker
- EA Martin Program in Human Nutrition, SWC Box 506, South Dakota State University, South Dakota
| |
Collapse
|
9
|
Thaker V, Haagensen AL, Carter B, Fedorowicz Z, Houston BW. Recombinant growth hormone therapy for cystic fibrosis in children and young adults. Cochrane Database Syst Rev 2015:CD008901. [PMID: 25991406 DOI: 10.1002/14651858.cd008901.pub3] [Citation(s) in RCA: 9] [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: 12/24/2022]
Abstract
BACKGROUND Cystic fibrosis is an inherited condition causing disease most noticeably in the lungs, digestive tract and pancreas. People with cystic fibrosis often have malnutrition and growth delay. Adequate nutritional supplementation does not improve growth optimally and hence an anabolic agent, recombinant growth hormone, has been proposed as a potential intervention. OBJECTIVES To evaluate the effectiveness and safety of recombinant human growth hormone therapy in improving lung function, quality of life and clinical status of children and young adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of latest search: 11 February 2015.We conducted a search of relevant endocrine journals and proceedings of the Endocrinology Society meetings using Scopus and Proceedings First. Date of latest search: 04 March 2015. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of all preparations of recombinant growth hormone compared to either no treatment, or placebo, or each other at any dose (high-dose and low-dose) or route and for any duration, in children or young adults aged up to 25 years diagnosed with cystic fibrosis (by sweat test or genetic testing). DATA COLLECTION AND ANALYSIS Two authors independently screened papers, extracted trial details and assessed their risk of bias. MAIN RESULTS Four controlled trials were included in this review (with 161 participants in total), each with an unclear risk of bias. Analysis of data obtained from these trials shows improvement in height for all comparisons, but improvements in weight and lean tissue mass were only reported in the comparison of standard dose recombinant growth hormone versus no treatment. One study showed moderate improvement at one time point in one parameter of pulmonary function tests, forced vital capacity (per cent predicted) when comparing standard dose recombinant growth hormone and no treatment, but there was no consistent benefit in lung function across all studies. Little evidence was found for improvement in quality of life. An improvement in fasting blood glucose levels was reported when comparing rhGH to placebo only. Exercise capacity improved in participants receiving standard dose recombinant growth hormone versus no treatment, but not for any other comparison. There is insufficient evidence to conclude any changes in hospitalisations, antibiotic use or significant adverse effects. AUTHORS' CONCLUSIONS Recombinant growth hormone therapy is effective in improving the intermediate outcomes in height, weight and lean tissue mass when compared with no treatment. One measure of pulmonary function test showed moderate improvement at a single time point, but no consistent benefit was seen across all studies. No significant changes in quality of life, clinical status or side-effects were observed in this review. Long-term, well-designed randomised controlled trials of recombinant growth hormone therapy in people with cystic fibrosis are required prior to evaluation of human growth hormone treatment for routine use.
Collapse
Affiliation(s)
- Vidhu Thaker
- Department of Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, Massachusetts, USA, 02115
| | | | | | | | | |
Collapse
|
10
|
Abstract
BACKGROUND Chronic loss of appetite in cystic fibrosis concerns both individuals and families. Appetite stimulants have been used to help cystic fibrosis patients with chronic anorexia attain optimal body mass index and nutritional status. However, these may have adverse effects on clinical status. OBJECTIVES The aim of this review is to systematically search for and evaluate evidence on the beneficial effects of appetite stimulants in the management of CF-related anorexia and synthesize reports of any side-effects. SEARCH METHODS Trials were identified by searching the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register, MEDLINE, Embase, CINAHL, handsearching reference lists and contacting local and international experts.Last search of online databases: 01 April 2014.Last search of the Cystic Fibrosis Trials Register: 08 April 2014. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of appetite stimulants, compared to placebo or no treatment for at least one month in adults and children with cystic fibrosis. DATA COLLECTION AND ANALYSIS Authors independently extracted data and assessed the risk of bias within eligible trials. Meta-analyses were performed. MAIN RESULTS Three trials (total of 47 recruited patients) comparing appetite stimulants (cyproheptadine hydrochloride and megesterol acetate) to placebo were included; the numbers of adults or children within each trial were not always reported. The risk of bias of the included trials was graded as moderate.A meta-analysis of all three trials showed appetite stimulants produced a larger increase in weight z score at three months compared to placebo, mean difference 0.61 (95% confidence interval 0.29 to 0.93) (P < 0.001) (n = 40) with no evidence of a difference in effect between two different appetite stimulants. One of these trials also reported a significant weight increase with megesterol acetate compared to placebo at six months (n = 17). The three trials reported no significant differences in forced expiratory volume at one second (per cent predicted) between the appetite stimulant groups and placebo at follow up, with durations ranging from two to nine months. A meta-analysis of two trials showed a significantly higher proportion of patients reporting increased appetite, odds ratio 45.25 (95% confidence interval 3.57 to 573.33) (P = 0.003) (n = 23), but the frequency of reported side effects was undetermined. AUTHORS' CONCLUSIONS In the short term (six months) in adults and children, appetite stimulants improved only two of the outcomes in this review - weight (or weight z score) and appetite; and side effects were insufficiently reported to determine the full extent of their impact. Whilst the data may suggest the potential use of appetite stimulants in treating anorexia in adults and children with cystic fibrosis, this is based upon moderate quality data from a small number of trials and so this therapy cannot be conclusively recommended based upon the findings in the review. Clinicians need to be aware of the potential adverse effects of appetite stimulants and actively monitor any patients prescribed these medications accordingly.Research is needed to determine meaningful surrogate measures for appetite and define what constitutes quality weight gain. Future trials of appetite stimulants should use a validated measure of symptoms including a disease-specific instrument for measuring poor appetite. This review highlights the need for multicentred, adequately powered and well-designed trials to evaluate agents to safely increase appetite in people with cystic fibrosis and to establish the optimal mode of treatment.
Collapse
Affiliation(s)
- Ruth Chinuck
- Adult CF Unit, Department of Dietetics and Nutrition, Therapy Services, Nottingham University Hospitals, City Campus, Hucknall Road, Nottingham, UK, NG5 1PB
| | | | | | | |
Collapse
|
11
|
Thaker V, Haagensen AL, Carter B, Fedorowicz Z, Houston BW. Recombinant growth hormone therapy for cystic fibrosis in children and young adults. Cochrane Database Syst Rev 2013; 6:CD008901. [PMID: 23737090 PMCID: PMC4465600 DOI: 10.1002/14651858.cd008901.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cystic fibrosis is an inherited condition causing disease most noticeably in the lungs, digestive tract and pancreas. People with cystic fibrosis often have malnutrition and growth delay. Adequate nutritional supplementation does not improve growth optimally and hence an anabolic agent, recombinant growth hormone, has been proposed as a potential intervention. OBJECTIVES To evaluate the effectiveness and safety of recombinant human growth hormone therapy in improving lung function, quality of life and clinical status of children and young adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of latest search: 15 May 2013.We conducted a search of relevant endocrine journals and proceedings of the Endocrinology Society meetings using Scopus and Proceedings First. Date of latest search: 15 March 2012. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of all preparations of recombinant growth hormone compared to either no treatment, or placebo, or each other at any dose (high-dose and low-dose) or route and for any duration, in children or young adults aged up to 25 years diagnosed with cystic fibrosis (by sweat test or genetic testing). DATA COLLECTION AND ANALYSIS Two authors independently screened papers, extracted trial details and assessed their risk of bias. MAIN RESULTS Four controlled trials were included in this review (with 161 participants in total), each with an unclear risk of bias. Analysis of data obtained from these trials shows improvement in height for all comparisons, but improvements in weight and lean tissue mass were only reported in the comparison of standard dose recombinant growth hormone versus no treatment. There is moderate improvement in one parameter of pulmonary function tests, functional vital capacity (per cent predicted) when comparing standard dose recombinant growth hormone and no treatment. Little evidence was found for improvement in quality of life. An improvement in fasting blood glucose levels was reported when comparing rhGH to placebo only. Exercise capacity improved in participants receiving standard dose recombinant growth hormone versus no treatment, but not for any other comparison. There is insufficient evidence to conclude any changes in hospitalisations, antibiotic use or significant adverse effects. AUTHORS' CONCLUSIONS Recombinant growth hormone therapy is effective in improving the intermediate outcomes in height, weight and lean tissue mass when compared with no treatment. One measure of pulmonary function test showed moderate improvement. No significant changes in quality of life, clinical status or side-effects were observed in this review. Long-term, well-designed randomised controlled trials of recombinant growth hormone therapy in patients with cystic fibrosis are required prior to evaluation of human growth hormone treatment for routine use in patients.
Collapse
|
12
|
Pozzo AM, Kemp SF. Growth and growth hormone treatment in children with chronic diseases. Endocrinol Metab Clin North Am 2012; 41:747-59. [PMID: 23099268 DOI: 10.1016/j.ecl.2012.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Growth hormone has been available for treatment of various conditions for over 50 years. There have been a number of chronic disease states in which it has been used, such as chronic kidney disease, which became a US Food and Drug Administration (FDA)-approved indication in 1993. For other chronic disease states there have been clinical studies supporting its use, but they have not yet been approved as a indications by the FDA. Examples of such diseases are cystic fibrosis, chronic arthritis, short bowel syndrome, burn trauma, and hypophosphatemic rickets.
Collapse
Affiliation(s)
- Alba Morales Pozzo
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202-3591, USA.
| | | |
Collapse
|
13
|
|
14
|
Stalvey MS, Anbar RD, Konstan MW, Jacobs JR, Bakker B, Lippe B, Geller DE. A multi-center controlled trial of growth hormone treatment in children with cystic fibrosis. Pediatr Pulmonol 2012; 47:252-63. [PMID: 21905270 PMCID: PMC4166490 DOI: 10.1002/ppul.21546] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 08/08/2011] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We evaluated safety and efficacy of recombinant human growth hormone (rhGH) for improving growth, lean body mass (LBM), pulmonary function, and exercise tolerance in children with cystic fibrosis (CF) and growth restriction. STUDY DESIGN Multicenter, open-label, controlled clinical trial comparing outcomes in prepubertal children <14 years with CF, randomized in a 1:1 ratio to receive daily rhGH (Nutropin AQ) or no treatment (control) for 12 months, followed by a 6-month observation (month 18). Safety was monitored at each visit, including assessments of glucose tolerance. RESULTS Sixty-eight subjects were randomized (control n = 32; rhGH n = 36). Mean height standard deviation score (SDS) in the rhGH group increased by 0.5 ± 0.4 at 12 months (mean ± SD, P < 0.001); the control group height SDS remained unchanged. Weight increased by 3.8 ± 1.8 versus 2.8 ± 1.5 kg, (mean ± SD, P = 0.0356) and LBM increased by 3.8 ± 1.8 versus 2.1 ± 1.4 kg (P = 0.0002) in the rhGH group versus controls, respectively. Forced vital capacity increased by 325 ± 319 in the rhGH group compared with 178 ± 152 ml in controls (mean ± SD, P = 0.032). Forced expiratory volume in 1 sec improved in both groups with a significant difference between groups after adjustment for baseline severity (LS mean ± SE: rhGH, 224 ± 37, vs. controls, 108 ± 40 ml; P = 0.04). There was no difference between groups in exercise tolerance (6-min walk distance) at 1 year. Changes in glucose tolerance for the two groups were similar over the 12-month study period, with three subjects developing IGT and one CFRD in each group. One rhGH-treated patient developed increased intracranial pressure. CONCLUSIONS Treatment with rhGH in prepubertal children with CF was effective in promoting growth, weight, LBM, lung volume, and lung flows, and had an acceptable safety profile.
Collapse
Affiliation(s)
- Michael S Stalvey
- University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Amorim PG, Mendes TDB, Oliveira LSPD, Guerra-Júnior G, Ribeiro JD. [Growth hormone in children and adolescents with cystic fibrosis]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2011; 55:671-676. [PMID: 22231968 DOI: 10.1590/s0004-27302011000900001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 10/28/2011] [Indexed: 05/31/2023]
Abstract
The recombinant human growth hormone (rhGH) can improve weight gain, physical growth, clinical and lung in cystic fibrosis (CF). However, the routine use, although promising, is not established in the literature. The objective of this study was to assess the benefits of rhGH in children and adolescents with CF. We conducted a systematic review in the database PubMed, Lilacs, SciELO and Cochrane, in the period 2000-2010, using the keywords: "cystic fibrosis", "growth hormone", "children" and "adolescents". We found 77 articles and included 11 randomized controlled trials, with 290 children and adolescents with CF. The short-term use (1-24 months) of rhGH improved the height, weight, growth rate, bone mineral content and components of pulmonary function. Adverse effects, like diabetes, were not observed in the studies. The short-term use of rhGH improved growth and body composition in patients with CF.
Collapse
Affiliation(s)
- Pollyana Garcia Amorim
- Faculdade de Ciências Médicas (FCM), Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil.
| | | | | | | | | |
Collapse
|
16
|
Haupt ME, Kim EE, Prestridge AL. Successful prolonged use of recombinant human insulin-like growth factor-1 in a child with cystic fibrosis. Pediatr Pulmonol 2011; 46:1137-41. [PMID: 21618713 DOI: 10.1002/ppul.21478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 03/15/2011] [Accepted: 03/26/2011] [Indexed: 11/07/2022]
Abstract
Growth failure is a common and complicated process in children with cystic fibrosis (CF). Growth hormone, which is becoming a more commonly used agent in such patients, has demonstrated beneficial effects aside from increased growth velocity. Recently, insulin-like growth factor-1 has gained significant attention in the understanding of growth failure in children with CF. We report the successful prolonged use of recombinant human insulin-like growth factor-1 in an adolescent boy with CF, who demonstrated significant clinical benefits from the therapy.
Collapse
Affiliation(s)
- Mark E Haupt
- Division of Pulmonary Medicine, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60614, USA.
| | | | | |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW To review the contribution of various therapeutic interventions on both longevity and quality of life in cystic fibrosis patients. RECENT FINDINGS Long-term survival in cystic fibrosis has increased markedly in the past 25 years, largely due to a robust clinical trials program carried out at Cystic Fibrosis Foundation accredited clinical centers in the United States and similar organizations worldwide. Cystic fibrosis patients are recommended complex, time-intensive daily therapies that are often difficult for families and patients to sustain long-term. Recently, attention to the perceived value of a particular therapy on a patient's well being is recognized as important for individualizing therapeutic regimens that provide maximal clinical benefit and are more likely to be adhered to long-term by the patient. Cystic fibrosis care is in a new era in which patient-related outcomes (PROs) for the assessment of health-related quality of life (HRQOL) are regarded with equal importance to medically beneficial therapies. SUMMARY Numerous advances in the clinical care of cystic fibrosis have led to improved survival, although definitive correction of the abnormal cystic fibrosis transmembrane regulator protein function remains elusive. Patients struggle to maintain rigorous, time-intensive therapeutic regimens, whereas clinicians strive to identify which interventions preserve quality of life. Cystic fibrosis patients depend on their caregiver's ability to assess both the medical benefit and the contribution to quality of life that therapeutic regimes bring to their disease. Caregivers, in turn, need measures of HRQOL in order to prioritize the various therapeutic interventions that are at their disposal in order to provide not just longevity, but meaningful quality of life.
Collapse
|
18
|
Abstract
Growth hormone (GH) was first used to treat a patient in 1958. For the next 25 years it was available only from cadaver sources, which was of concern because of safety considerations and short supply. In 1985, GH produced by recombinant DNA techniques became available, expanding its possible uses. Since that time there have been three indications approved by the US Food and Drug Administration (FDA) for GH-deficiency states and nine indications approved for non-GH-deficiency states. In 2003 the FDA approved GH for use in idiopathic short stature (ISS), which may indirectly cover other diagnoses that have short stature as a feature. However, coverage for GH therapy is usually more reliably obtainable for a specific indication, rather than the ISS indication. Possible future uses for GH therapy could include the treatment of syndromes such as Russell-Silver syndrome or chondrodystrophy. Other non-short-stature indications could include wound healing and burns. Other uses that have been poorly studied include aging and physical performance, in spite of the interest already shown by elite athletes in using GH. The safety profile of GH developed over the past 25 years has shown it to be a very safe hormone with few adverse events associated with it. The challenge for the future is to follow these patients into adulthood to determine whether GH therapy poses any long-term risks.
Collapse
Affiliation(s)
- Stephen F Kemp
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202-3591, USA.
| | | |
Collapse
|
19
|
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.
Collapse
Affiliation(s)
- Dana S Hardin
- Ohio State University and Columbus Children's Hospital, Columbus, Ohio, USA
| |
Collapse
|
20
|
Wong SC, Kumar P, Galloway PJ, Blair JC, Didi M, Dalzell AM, Hassan K, McGrogan P, Ahmed SF. A preliminary trial of the effect of recombinant human growth hormone on short-term linear growth and glucose homeostasis in children with Crohn's disease. Clin Endocrinol (Oxf) 2011; 74:599-607. [PMID: 21470283 DOI: 10.1111/j.1365-2265.2011.03977.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is unclear whether recombinant human growth hormone (rhGH) improves linear growth in children with Crohn's disease (CD). AIMS To investigate the effects of rhGH on height velocity (HV) and glucose homeostasis over a 6-month period. DESIGN AND SETTING Randomized controlled trial in two tertiary children's hospitals in 22 children with inflammatory bowel disease amongst whom 21 had CD. Duration of disease from diagnosis and number of acute relapses requiring either exclusive enteral nutrition or therapeutic dose of oral prednisolone were similar in the treatment and control groups. INTERVENTION Either rhGH (0·067 mg/kg per day) as daily subcutaneous injections (rhGH group; n, 11) or no rhGH, (Ctrl; n, 11) for 6 months. MAIN OUTCOME MEASURE Percentage change in HV after 6 months in the two groups. Auxology, puberty, skeletal age, disease factors, treatment and glucose homeostasis were also assessed. RESULTS Median HV increased from 4·5 (range, 0·6, 8·9) at baseline to 10·8 (6·1, 15·0) cm/year at 6 month (P = 0·003) in the rhGH group, whereas in the Ctrl group, it was 3·8 (1·4, 6·7) and 3·5 cm/year (2·0, 9·6), respectively (P = 0·58). Median percentage increase in HV after 6 months in the rhGH group was 140% (16·7, 916·7) compared with 17·4% (-42·1%, 97·7%) in the Ctrl group (P < 0·001). There were no significant differences in disease activity and proinflammatory cytokines at baseline and 6 months in both groups and change in bone age for chronological age was also similar in the two groups. In the rhGH group, fasting insulin increased from 4·0 (2·0, 11·0) to 7·0 mU/l (2·0, 16·0) (P = 0·02), whereas in the Ctrl group, it was 3·0 (1·2, 12·7) and 3·8 mU/l (2·1, 7·0) (P = 0·72), respectively. CONCLUSIONS Although this pilot trial shows that rhGH can improve short-term linear growth in children with CD, the clinical efficacy of this therapy needs to be further studied in longer-term studies of growth, glucose homeostasis and disease status.
Collapse
Affiliation(s)
- S C Wong
- Developmental Endocrinology Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Phung OJ, Coleman CI, Baker EL, Scholle JM, Girotto JE, Makanji SS, Chen WT, Talati R, Kluger J, White CM. Recombinant human growth hormone in the treatment of patients with cystic fibrosis. Pediatrics 2010; 126:e1211-26. [PMID: 20921071 DOI: 10.1542/peds.2010-2007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Recombinant human growth hormone (rhGH) improves growth in patients with growth hormone deficiency or idiopathic short stature. Its role in patients with cystic fibrosis (CF) is unclear. OBJECTIVE To review the effectiveness of rhGH in the treatment of patients with CF. METHODS Medline and the Cochrane Central Register of Controlled Trials were searched from the earliest date through April 2010. Randomized controlled trials, observational studies, systematic reviews/meta-analyses, or case reports were included if rhGH therapy was administered to patients with CF and data on prespecified harms, intermediate outcomes, or final health outcomes were reported. When applicable, end points were pooled by using a random-effects model. The overall body of evidence was graded for each outcome as insufficient, low, moderate, or high. RESULTS Ten unique controlled trials (n = 312) and 8 observational studies (n = 58) were included. On quantitative synthesis of controlled trials, several markers of pulmonary function, anthropometrics, and bone mineralization were significantly improved versus control. Results of single-arm observational studies for the aforementioned outcomes were generally supportive of findings in clinical trials. There is insufficient evidence to determine the effect of rhGH on intravenous antibiotic use during therapy, pulmonary exacerbations, health-related quality-of-life, bone consequences, or total mortality, but moderate evidence suggests that rhGH therapy reduces the rate of hospitalization versus control. CONCLUSIONS rhGH improved almost all intermediate measures of pulmonary function, height, and weight in patients with CF. Improvements in bone mineral content are also promising. However, with the exception of hospitalizations, the benefits on final health outcomes cannot be directly determined at this time.
Collapse
Affiliation(s)
- Olivia J Phung
- University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT 06102-5037, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Ross J, Czernichow P, Biller BMK, Colao A, Reiter E, Kiess W. Growth hormone: health considerations beyond height gain. Pediatrics 2010; 125:e906-18. [PMID: 20308212 DOI: 10.1542/peds.2009-1783] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The therapeutic benefit of growth hormone (GH) therapy in improving height in short children is widely recognized; however, GH therapy is associated with other metabolic actions that may be of benefit in these children. Beneficial effects of GH on body composition have been documented in several different patient populations as well as improvements in lipid profile. Marked augmentation of bone mineral density also seems evident in many pediatric populations. Some of these benefits may require continued therapy past the acquisition of adult height. With long-term therapy of any kind, the adverse consequences of treatment should also be considered. Fortunately, long-term GH treatment seems to be safe and well-tolerated. This review describes the long-term metabolic effects of GH treatment in the pediatric population and considers how these may benefit children who are treated with GH.
Collapse
Affiliation(s)
- Judith Ross
- Department of Pediatrics, Thomas Jefferson University, 1025 Walnut St, Suite 726, Philadelphia, PA 19107, USA.
| | | | | | | | | | | | | |
Collapse
|
23
|
Oxandrolone Improves Height Velocity and BMI in Patients with Cystic Fibrosis. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2009:826895. [PMID: 20145725 PMCID: PMC2817396 DOI: 10.1155/2009/826895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 11/03/2009] [Indexed: 11/18/2022]
Abstract
Objective. To evaluate the effectiveness of oxandrolone in improving the nutritional status and linear growth of pediatric patients with cystic fibrosis (CF).
Methods. Medical records of patients with CF treated with oxandrolone were reviewed for height z score, height velocity (HV), BMI z score, weight velocity (WV), Tanner stage, pulmonary function, liver enzyme levels, and any reported adverse events. Data were compared before (pre-Ox) and after (Ox) oxandrolone using a paired t-test.
Results. 5 subjects (ages 8.5–14.5 years) were treated with oxandrolone 2.5 mg daily for 8–38 months. After 8–12 months of treatment, there was a statistically significant improvement in HV (pre-Ox = 5.3 ± 1.4 cm/yr, Ox = 8.3 ± 1.2 cm/yr, P < .01) and BMI z score (pre-Ox = −0.61 ± 1.04, Ox = −0.30 ± 0.86, P = .02). Both height z score (pre-Ox = −1.64 ± 0.63, Ox = −1.30 ± 0.49, P = .057) and WV (pre-Ox = 4.2 ± 3.7 kg/yr, Ox = 6.8 ± 1.0 kg/yr, P = .072) showed beneficial trends that did not reach statistical significance. No adverse events were reported.
Conclusions. In this brief clinical report, oxandrolone improved the HV and BMI z score in patients with CF. Larger studies are needed to determine if oxandrolone is an effective, safe, and affordable option to stimulate appetite, improve weight gain, and promote linear growth in patients with CF.
Collapse
|
24
|
Sparks AA, McGee SJ, Boone CE, Neuringer IP, Jones SK, Aris RM. 'Old' bones in young bodies: the tale of cystic fibrosis. Curr Opin Endocrinol Diabetes Obes 2009; 16:407-14. [PMID: 19816169 DOI: 10.1097/med.0b013e3283329b16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is the most common genetic disease within the white population and leads to premature respiratory failure. Approximately, 60 000 individuals are currently living with CF in North America and Europe, almost half of whom are adults. RECENT FINDINGS Dozens of studies across the globe indicate that CF adults have low bone density and increased rates of fractures. This genesis of the problem appears to be in late childhood to adolescence. SUMMARY Prevention and treatment of CF-related bone disease must address the myriad risk factors (decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic lung infection with increased serum levels of proinflammatory, bone-active cytokines, malnutrition and low body weight, physical inactivity and glucocorticoid therapy) for poor bone health. This review will address the pathogenesis, diagnosis and treatment of bone disease in CF. It will also discuss best practice guidelines for optimizing bone health in patients with CF.
Collapse
Affiliation(s)
- Amy A Sparks
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | | | | | | | | | | |
Collapse
|
25
|
Walvoord EC, de la Peña A, Park S, Silverman B, Cuttler L, Rose SR, Cutler G, Drop S, Chipman JJ. Inhaled growth hormone (GH) compared with subcutaneous GH in children with GH deficiency: pharmacokinetics, pharmacodynamics, and safety. J Clin Endocrinol Metab 2009; 94:2052-9. [PMID: 19336514 DOI: 10.1210/jc.2008-1897] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Delivery of GH via inhalation is a potential alternative to injection. Previous studies of inhaled GH in adults have demonstrated safety and tolerability. OBJECTIVE We sought to assess safety and tolerability of inhaled GH in children and to estimate relative bioavailability and biopotency between inhaled GH and sc GH. DESIGN/METHODS This pediatric multicenter, randomized, double-blind, placebo-controlled, crossover trial had two 7-d treatment phases. Patients received inhaled GH and sc GH in the alternate phase. Placebo was administered by the route opposite from active drug. GH and IGF-I levels were measured at multiple time points. Pharmacokinetics were assessed using noncompartmental methods. RESULTS Twenty-two GH-deficient children aged 6-16 yr were treated. Absorption of GH appeared to be faster after inhalation with maximum serum concentrations measured at 1-4 h compared with 2-8 h for sc GH. Mean relative bioavailability for inhaled GH was 3.5% (90% confidence interval 2.7-4.4%). Mean relative biopotency, based on IGF-I response, was 5.5% (confidence interval 5.2-5.8%). Similar dose-dependent increases in mean serum GH area under the curve and IGF-I changes from baseline were seen after inhaled and sc GH doses. Inhaled GH was well tolerated and preferred to injection. No significant changes in pulmonary function tests were seen. CONCLUSIONS In this first pediatric trial of GH delivered by inhalation, it was well tolerated and resulted in dose-dependent increases in serum GH and IGF-I levels. This study establishes that delivery of GH via the deep lung is feasible in children.
Collapse
Affiliation(s)
- Emily C Walvoord
- Department of Pediatrics (E.C.W.), Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Switzer M, Rice J, Rice M, Hardin DS. Insulin-like growth factor-I levels predict weight, height and protein catabolism in children and adolescents with cystic fibrosis. J Pediatr Endocrinol Metab 2009; 22:417-24. [PMID: 19618660 DOI: 10.1515/jpem.2009.22.5.417] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multiple reports have demonstrated the benefit of growth hormone (GH) treatment in children with cystic fibrosis (CF) and previous studies have demonstrated low to normal insulin-like growth factor-I (IGF-I) levels in these patients. Most biological effects of GH are mediated by IGF-I; however, the relationship between height, weight and rate of growth has not been systematically studied in CF. We conducted a retrospective analysis of 52 patients (including control volunteers with CF) who had participated in previous studies of GH treatment to determine the relationship between levels of IGF-I and growth in children with CF. In a subset of these patients, we also evaluated the relationship between protein catabolism and IGF-I. Baseline IGF-I levels and IGF-I z-scores were correlated with same day measures of height, weight, height and weight z-scores. In a subset of patients, IGF-I levels were also correlated with leucine rate of appearance (a measure of protein catabolism). IGF-I levels were obtained every six months during our studies and were correlated with same day height, weight and protein turnover. Height and weight velocity were calculated every six months from study baseline and were correlated with IGF-I levels. In all patients, whether treated with GH or controls, we found a positive linear correlation between IGF-I levels and height (r = 0.66, p < 0.0001) and weight (r = 0.61, p < 0.0001), as well as height and weight velocity. There was also a strong relationship between leucine rate of appearance and IGF-I. These results suggest a strong correlation between IGF-I and height, weight and protein catabolism and emphasize the need to normalize IGF-I levels in children with cystic fibrosis.
Collapse
Affiliation(s)
- Michael Switzer
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH 43205, USA
| | | | | | | |
Collapse
|
27
|
Varness T, Seffrood E, Connor E, Rock M, Allen D. Oxandrolone Improves Height Velocity and BMI in Patients with Cystic Fibrosis. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2009. [DOI: 10.1186/1687-9856-2009-826895] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
28
|
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]
|
29
|
Barreto AM, Bigolin MC, Ramos JCRR, Machado LPRR, Silva LDR, Silveira RBD, Boguszewski MCS. [Growth hormone therapy for children with chronic diseases]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2008; 52:774-782. [PMID: 18797584 DOI: 10.1590/s0004-27302008000500009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 05/20/2008] [Indexed: 05/26/2023]
Abstract
Growth disorders are commonly observed in children suffering from chronic diseases. The pathogenesis of growth failure is multifactorial. In chronic inflammatory diseases such as juvenile idiopathic arthritis and inflammatory bowel disease, growth is also affected by pro-inflammatory cytokines. Patients with chronic diseases might also become growth hormone (GH) deficient. However, normal or increased GH secretion with reduced plasma concentrations of insulin-like growth factor-I indicate a degree of GH insensitivity in some patients. Growth damage can increase with specific treatments, especially if glucocorticoids are used. GH therapy has been used to reduce the consequences of the disease and long-term steroid therapy in these patients. In this review, it is reported the encouraging results of GH treatment in growth-retarded children with chronic diseases, both in well defined indications as well in situations still under investigation.
Collapse
Affiliation(s)
- Alexandre M Barreto
- Unidade de Endocrinologia Pediátrica, Departamento de Pediatria, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease. It affects multiple body organs. The lungs and pancreas are the most affected which results in progressive lung damage and pancreatic insufficiency. Due to the disease process, CF patients require significantly higher caloric intake than recommended for other individuals. The nutritional goal for CF patients is to achieve normal growth and development and, once genetic potential is reached, to maintain good nutritional status throughout life. Evidence has shown that lung function is closely associated with nutritional status in CF and that nutritional status is an independent predictor of survival. Most CF patients are on a high calorie diet to help achieve normal growth and development and maintain good lung function. Inadequate caloric intake in CF can lead to malnutrition. Malnutrition in CF requires careful, multidisciplinary history taking, physical exam, and overall patient/family assessment. Only by determining the actual cause of the malnutrition can appropriate and safe therapies be used to treat it. Appetite stimulants, although efficacious in treating malnutrition in CF, should only be prescribed if decreased food intake secondary to inadequate appetite is the principal cause of the malnutrition and all other contributing factors have been assessed, ruled-out or treated. In this review, we attempted to summarize the use of several appetite stimulants used in CF and other diseases to improve appetite and maximize caloric intake.
Collapse
Affiliation(s)
- Samya Z Nasr
- Pediatric Pulmonology, University of Michigan Health System, Ann Arbor, Michigan 48109-5212, USA.
| | | |
Collapse
|
31
|
Abstract
In summary, there is a significant interplay between the pulmonary manifestations and nutritional status of CF patients. The advances in CF clinical care in the past 2 decades are mainly attributed to anti-infective therapy as well as aggressive nutritional management. Currently, there are multiple therapeutic agents that are in clinical trial that target either the underlying CFTR defect or the downstream effects of CFTR. The broad spectrum of therapeutic agents being studied as well as the advances in therapies that target the underlying CFTR defect are exciting, making it likely that at least one of the treatments will make a major difference in how we will treat CF in the future.
Collapse
Affiliation(s)
- Reshma Amin
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | | |
Collapse
|
32
|
Wong SC, Hassan K, McGrogan P, Weaver LT, Ahmed SF. The effects of recombinant human growth hormone on linear growth in children with Crohn's disease and short stature. J Pediatr Endocrinol Metab 2007; 20:1315-24. [PMID: 18341091 DOI: 10.1515/jpem.2007.20.12.1315] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS The efficacy of recombinant human growth hormone (rhGH) in treating the growth failure associated with Crohn's disease (CD) is unclear. METHODS Retrospective data analysis at 12 months before (T-12), 6 months before (T-6), at baseline (T+0), 6 months after (T+6) and 12 months after (T+12) rhGH treatment in seven patients with CD (five males). RESULTS Median chronological age (CA) and median difference between CA and bone age was 15.9 yr (range, 13.0 to 17.9) and 1.7 yr (-0.7 to 3.3), respectively. Median dose of rhGH at T+0 was 0.23 mg/wk (0.15 to 0.31). Pubertal status remained unchanged in 6/7 patients. Median albumin and C-reactive protein (CRP) were similar at T+0 and T+6. Median height SDS at T+0, T+6 and T+12 was -2.2 (-4.0 to -1.5), -1.9 (-4.1 to -0.8), -1.9 (-4.1 to -0.7), respectively (NS). Median height velocity (HV) SDS at T+0 and T+6 was -2.5 (-4.8 to 1.4) and -0.9 (-5.3 to 3.4), respectively (NS). There was a positive correlation between percentage change in HV SDS at T+6 and dose of rhGH at T+0 (r = 0.8, p = 0.03). CONCLUSION Introduction of rhGH therapy was associated with a cessation in the deterioration in linear growth. However, an improvement in height SDS was not observed over the period of the study. Future studies should explore the efficacy of a higher dose of rhGH in CD.
Collapse
Affiliation(s)
- S C Wong
- Bone and Endocrine Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | | | | | | | | |
Collapse
|
33
|
Mayer-Hamblett N, Ramsey BW, Kronmal RA. Advancing outcome measures for the new era of drug development in cystic fibrosis. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2007; 4:370-7. [PMID: 17652504 PMCID: PMC2647602 DOI: 10.1513/pats.200703-040br] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Accepted: 04/27/2007] [Indexed: 11/20/2022]
Abstract
The growing pipeline of candidate drugs for cystic fibrosis (CF) is challenging clinical trial research. There has been a shift from evaluating drugs aimed at treating the secondary manifestations of CF to evaluating drugs targeted toward the primary prevention of chronic lung disease. As CF is an orphan disease, there is a fundamental need to assess new therapies efficiently and accurately by mechanisms that best use the number of available patients. This need can be addressed with the continued advancement and refinement of CF outcome measures. We begin by presenting an overview of the outcome measures currently used in CF clinical studies, defined and categorized in terms of one of the three main classes of endpoints: clinical efficacy measures, surrogate endpoints, and biomarkers. To move forward efficiently, clinical research in CF is dependent on the development of new outcomes able to capture biologic and clinical response to novel therapeutic approaches. We conclude with a discussion of the criteria by which all new outcome measures should be evaluated. A systematic, rigorous approach to outcome measure development is needed to provide the tools necessary for evaluating new therapies and moving drugs out of the pipeline and into the CF clinic.
Collapse
|
34
|
Graham MR, Baker JS, Evans P, Kicman A, Cowan D, Hullin D, Davies B. Short-term recombinant human growth hormone administration improves respiratory function in abstinent anabolic-androgenic steroid users. Growth Horm IGF Res 2007; 17:328-335. [PMID: 17512232 DOI: 10.1016/j.ghir.2007.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/01/2007] [Accepted: 04/03/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To determine whether 6 days recombinant human growth hormone (rhGH) administration, in an abstinent anabolic-androgenic steroid (AAS) using group had any respiratory, endurance exercise and biochemical effects compared with an abstinent AAS control group. METHODS Male subjects (n=48) were randomly divided, using a single blind procedure into two groups: (1) control group (C) n=24, means+/-SD, age 32+/-11 years; height 1.8+/-0.06 m; (2) rhGH using group (0.019 mg kg(-1) day(-1)) (GH) n=24, means+/-SD, age 32+/-9 years; height 1.8+/-0.07 m. Anthropometry, respiratory muscle function and endurance exercise were investigated. Respiratory measurements examined, were forced expiratory volume in one second, forced vital capacity, maximum inspiratory pressure and maximum expiratory pressure. Endurance exercise was assessed by measuring peak oxygen uptake (VO(2)peak). Biochemical analysis included; haemoglobin, packed cell volume, glucose, sodium, urea, creatinine, total protein, albumin, testosterone and insulin like growth factor-I (IGF-I). RESULTS Forced expiratory volume in one second/forced vital capacity, maximum inspiratory pressure, maximum expiratory pressure, and IGF-I significantly increased compared with the control group (all P<0.05). Body mass index, fat free mass index, peak oxygen uptake, maximum inspiratory pressure, maximum expiratory pressure, IGF-I and serum sodium significantly increased, whilst body fat, total protein and albumin, significantly decreased within the GH group (all P<0.017). CONCLUSION The findings of this study indicated that short-term high dose rhGH increased aerobic performance and respiratory muscle strength in former AAS users.
Collapse
Affiliation(s)
- Michael R Graham
- Health and Exercise Science Research Unit, Faculty of Health Sport and Science, University of Glamorgan, Pontypridd, Wales, United Kingdom.
| | | | | | | | | | | | | |
Collapse
|
35
|
Schnabel D, Grasemann C, Staab D, Wollmann H, Ratjen F. A multicenter, randomized, double-blind, placebo-controlled trial to evaluate the metabolic and respiratory effects of growth hormone in children with cystic fibrosis. Pediatrics 2007; 119:e1230-8. [PMID: 17545356 DOI: 10.1542/peds.2006-2783] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Positive effects of growth hormone therapy on growth, nutritional status, and lung function have been observed in patients with cystic fibrosis, but the current evidence is based on unblinded studies that involved a small number of patients. This trial was designed as a multicenter, randomized, placebo-controlled, double-blind study to assess the efficacy and safety of 2 dosages of growth hormone in cystic fibrosis. METHODS Sixty-three dystrophic patients with cystic fibrosis were randomly assigned for 24 weeks to 1 of 3 treatment arms: growth hormone dosage of 0.11 IU/kg body weight per day, growth hormone dosage of 0.21 IU/kg body weight per day, or placebo. The 24-week double-blind period was followed by an open treatment period of 24 weeks. The primary outcome measure was the change in forced expiratory volume in 1 second in percentage predicted from baseline. Secondary outcome measures were changes in height, weight, and exercise tolerance. RESULTS Height, growth velocity, and growth factors (insulin-like growth factor 1 and insulin-like growth factor-binding protein 3) increased significantly in both treatment groups, whereas weight gain did not differ between the growth hormone groups and placebo. A trend toward improvement in absolute forced vital capacity was observed in patients who received the higher growth hormone dosage, whereas forced expiratory volume in 1 second did not change significantly with growth hormone treatment. Maximal oxygen uptake during peak exercise increased significantly in treated patients. There were no significant differences in the frequency or severity of adverse effects or in the incidence of abnormalities in glucose metabolism. CONCLUSIONS These data suggest that in the group investigated, growth hormone therapy was well tolerated and had positive metabolic effects but did not result in short-term improvement of lung function in patients with cystic fibrosis.
Collapse
Affiliation(s)
- Dirk Schnabel
- Department of Pediatric Endocrinology and Diabetology, Children's Hospital, Charite, Berlin, Germany
| | | | | | | | | |
Collapse
|
36
|
Abstract
Among patients who have cystic fibrosis (CF), lung disease is a significant contributor to morbidity. From a clinical perspective, the link between malnutrition and lung dysfunction in CF is well established; however, the causal relationship remains unclear. Nutritional intervention for CF patients is predicated on the hypothesis that improved nutritional status improves pulmonary function. Which interventions will be of most value and have sustained gains is not completely clear from the available data. Taking into account that several factors condition the deficits that lead to malnutrition in CF, multidisciplinary interventions are likely to give the best results. More research is needed to better dissect the nutritional factors involved in lung disease and to identify effective and safe interventions through systematic controlled trials.
Collapse
Affiliation(s)
- Carlos E Milla
- Department of Pediatrics, Center for Excellence in Pulmonary Biology, Stanford University, 770 Welch Road, Palo Alto, CA 94304, USA.
| |
Collapse
|
37
|
Hardin DS, Kemp SF, Allen DB. Twenty years of recombinant human growth hormone in children: relevance to pediatric care providers. Clin Pediatr (Phila) 2007; 46:279-86. [PMID: 17475983 DOI: 10.1177/0009922806293924] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recombinant human growth hormone has revolutionized the management of children and adolescents with growth hormone deficiency and other growth disorders, but clinical and ethical controversies remain regarding diagnostic approach, optimal recombinant human growth hormone dose and duration, and expected outcomes. Management of pubertal and transitioning patients with growth hormone deficiency has also commanded increased attention. Recent clinical studies that demonstrate the positive health benefits of recombinant human growth hormone in children with cystic fibrosis, inflammatory bowel disease, and juvenile rheumatoid arthritis have not yet clarified issues about patient selection and appropriate long-term use. An understanding of current recombinant human growth hormone indications and controversies can facilitate patient evaluation and expedite referral for potential treatment. This review summarizes current indications for recombinant human growth hormone use, discusses clinical challenges, and provides recommendations for pediatricians caring for children who may be appropriate candidates for recombinant human growth hormone therapy.
Collapse
Affiliation(s)
- Dana S Hardin
- Ohio State University and Columbus Children's Hospital, Columbus, OH 43205, USA.
| | | | | |
Collapse
|
38
|
Hardin DS, Adams-Huet B, Brown D, Chatfield B, Dyson M, Ferkol T, Howenstine M, Prestidge C, Royce F, Rice J, Seilheimer DK, Steelman J, Shepherds R. Growth hormone treatment improves growth and clinical status in prepubertal children with cystic fibrosis: results of a multicenter randomized controlled trial. J Clin Endocrinol Metab 2006; 91:4925-9. [PMID: 17018651 DOI: 10.1210/jc.2006-1101] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT This multicenter, randomized, controlled, crossover trial of prepubertal children with cystic fibrosis (CF) tests the hypotheses that recombinant human GH (rhGH) treatment 1) improves height, weight, lean mass, and bone content irrespective of baseline measures; 2) improves clinical status and quality of life; and 3) has continued effect after cessation after 1 yr of treatment. METHODS Sixty-one prepubertal subjects (<or=25th percentile for height and weight) were randomized into two groups: daily rhGH treatment or no treatment groups for 1 yr. In yr 2, treatments were crossed over. Outcome measures included serial standardized height and weight, number of hospitalizations and antibiotic courses, random blood glucose levels, lean mass, bone mineral content, pulmonary function, nutritional intake, and CF quality of life questionnaires. RESULTS Groups were similar at baseline and prepubertal during the entire study. After 1 yr, GH showed significantly greater gain in height, weight, lean mass, and bone mineral content. Gain in height was similar regardless of baseline. There were fewer hospitalizations in the rhGH-treated group and improvement in CF quality of life questionnaires measures of weight and body image. There was no difference in pulmonary function between groups. Results were similar in those treated with rhGH the second year. After cessation of rhGH treatment, there was sustained effect for increased height and weight velocity, as well as accrual of bone mineral. CONCLUSION rhGH therapy improves height and weight, decreases the number of hospitalizations, and improves quality of life in prepubertal children with CF. These effects are sustained after rhGH is discontinued.
Collapse
Affiliation(s)
- Dana S Hardin
- Department of Pediatrics, University of Texas Southwestern Medical School, Texas 75390, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
UNLABELLED Children with cystic fibrosis (CF) have a high incidence of delayed puberty and poor growth. We retrospectively reviewed pubertal maturation data from 105 children with CF who had participated in studies on growth hormone (GH). As part of the GH study, participants were randomized into two cohorts, one of which was treated with GH for 1 year, and then followed off GH, and the other group was first followed off GH, and then treated with GH for 1 year. Pubertal staging was obtained throughout these studies and we have retrospectively analyzed the data. RESULTS In prepubertal females, GH treatment resulted in a normalized onset of breast development as compared to delayed onset in non-treated females. Females treated during puberty had a normal tempo of breast development. In prepubertal males, GH treatment resulted in a normalized onset of testicular volume compared to non-treated males. Testicular size progression was not accelerated in pubertal boys treated with GH. CONCLUSION GH treatment normalizes pubertal onset in prepubertal children with CF.
Collapse
Affiliation(s)
- Mark Vanderwel
- University of Texas Southwestern Medical School, Division of Pediatric Endocrinology, Dallas, USA
| | | |
Collapse
|
40
|
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease that results in lung failure and premature death. A long recognized symptom of CF is growth failure, which is clinically relevant because it correlates with the severity of lung disease. We describe growth retardation in a mouse model of CF and discuss its potential for modeling certain aspects of human growth retardation. Mice with a null mutation in Cftr (cystic fibrosis transmembrance conductance regulator) were compared with wild-type (WT) mice at 31, 45, and 84 d of age. CF mice were severely growth retarded in weight and length compared with wild-type controls. Serum insulin like growth factor I (Igf-1) was lower in CF mice by 31-55% (depending on age and sex) and it significantly correlated with the size of mice after controlling for gender, age, and Cftr genotype. There was a marginally significant deficiency of serum growth hormone (Gh) in CF females, but not males. Our findings were consistent with models of an energy deficit in rodents. We, therefore, assessed food intake and found no difference between CF and WT mice, suggesting that CF mice had a malabsorption-mediated energy deficit. We argue that CF mice are suited to study the effects of intestinal disease on growth as well as other proposed growth-modulating processes.
Collapse
Affiliation(s)
- Lewis A Rosenberg
- Department of Genetics, Case Western Reserve University, Cleveland, OH 44106, USA
| | | | | | | |
Collapse
|
41
|
Abstract
Life expectancy for patients with Cystic Fibrosis (CF) has steadily improved during the last three decades, and death in childhood is now uncommon. Nutrition is a critical component of the management of CF, and nutritional status is directly associated with both pulmonary status and survival. Expert dietetic care is necessary, and attention must be given to ensuring an adequate energy intake in the face of demands which may be increased by inadequately controlled malabsorption, chronic broncho-pulmonary colonisation by bacteria and fungi, exacerbations of acute lung infection, impaired lung function, and the need for rehabilitation, repair and growth. Pancreatic enzyme replacement therapy (PERT) is needed by up to 90% of CF patients in Northern Europe, where the 'severe' mutation deltaF508 predominates, but a smaller proportion in Mediterranean countries and elsewhere, because pancreatic insufficiency is one of few features of CF which correlate with genotype. Complications of CF including liver disease and CF-related diabetes pose further challenges. In addition, deficiency of specific nutrients including fat soluble vitamins (particularly A, E and K) essential fatty acids and occasionally minerals occur for a variety of reasons. Osteopenia is common and poorly understood. Liver disease increases the likelihood of vitamin D deficiency. Glucose intolerance and diabetes affect at least 25% of CF adults, and the diabetes differs from both types 1 and 2 diabetes mellitus, but it inversely correlates with prognosis. Management consists of anticipating problems and addressing them vigorously as soon as they appear. Supplements of vitamins are routinely given. Energy supplements can be oral, enteral or, rarely, parenteral. All supplements, including PERT, are adjusted to individual needs.
Collapse
Affiliation(s)
- John A Dodge
- Singleton Hospital, University of Wales Swansea, Swansea SA2 8QA, UK.
| | | |
Collapse
|
42
|
Hardin DS, Ferkol T, Ahn C, Dreimane D, Dyson M, Morse M, Prestidge C, Rice J, Seilheimer DK. A retrospective study of growth hormone use in adolescents with cystic fibrosis. Clin Endocrinol (Oxf) 2005; 62:560-6. [PMID: 15853825 DOI: 10.1111/j.1365-2265.2005.02259.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Studies of growth hormone (GH) effectiveness in prepubertal children with cystic fibrosis (CF) have been published previously. We present a retrospective study of GH treatment in adolescents with CF. STUDY DESIGN We performed a retrospective evaluation of data from 25 pubertal adolescents (ages 13 years 4 months to 16 years 11 months, Tanner stage III or IV). Thirteen (4 F) were followed for 1 year, then received 1 year of treatment with GH (GHTX). We compared the results with a 'control' group of 12 (4 F) whose growth was followed for 1 year (NonTX) but who were not treated with GH at the time of this review. Anthropometric data included: height, weight, lean tissue mass (LTM) and bone mineral content (BMC). Pulmonary function, number of hospitalizations, glycosylated haemoglobin (HbA1c), random blood glucose levels, IGF-I, oestradiol and testosterone levels are also reported. RESULTS There was no difference between the groups at baseline. After 1 year, GHTX had significantly greater height and weight velocity, height and weight Z-scores, body mass index (BMI), LTM and BMC. Absolute pulmonary function was better and hospitalizations were fewer in the GHTX. No subject developed glucose intolerance or had any other side-effects. CONCLUSION These results suggest that GH use in pubertal adolescents with CF safely improves height, body weight, bone mineralization and clinical status.
Collapse
Affiliation(s)
- Dana S Hardin
- Department of Pediatrics, University of Texas South-Western Medical School, Dallas, TX 75390-9063, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
|
44
|
Hardin DS, Rice J, Ahn C, Ferkol T, Howenstine M, Spears S, Prestidge C, Seilheimer DK, Shepherd R. Growth hormone treatment enhances nutrition and growth in children with cystic fibrosis receiving enteral nutrition. J Pediatr 2005; 146:324-8. [PMID: 15756212 DOI: 10.1016/j.jpeds.2004.10.037] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Impaired longitudinal growth and poor weight gain are common and important problems in children with cystic fibrosis. This study evaluates the hypothesis that adjunctive growth hormone (GH) therapy augments the growth response to nutritional supplementation. STUDY DESIGN We recruited 18 prepubertal children who received enteral nutritional supplementation for at least 2 years before enrollment. Nine were randomly assigned to receive no GH for 1 year, followed by 1 year of GH. Nine were randomly assigned to receive 1 year of GH followed by a second year of GH. Measurements included height, weight, pulmonary function, lean tissue mass, bone mineral content, hospitalizations, outpatient antibiotic use, and caloric intake. RESULTS Growth hormone resulted in significant improvement in height, weight, bone mineral content, lean tissue mass, and number of hospitalizations. Pulmonary function was similar at baseline. Absolute forced vital capacity and forced expiratory volume in 1 minute significantly increased in GH treatment, but there was no significant change in percent predicted pulmonary function. Caloric intake was similar in both groups during both years. CONCLUSIONS These results suggest that GH is a useful for enhancing growth in children with cystic fibrosis receiving enteral nutritional supplementation.
Collapse
Affiliation(s)
- Dana S Hardin
- University of Texas-Southwestern Medical School, Department of Pediatrics, Dallas 75390-9063, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
IGF-I mediates some, but not all of the metabolic actions of GH and it has both GH-like and insulin-like actions in vivo. GH and IGF-I both have a net anabolic effect in man enhancing whole body protein synthesis over a period of weeks and perhaps months. Both hormones favorably improve body composition in GH deficient subjects with an increase in lean body mass and decreased adiposity. This is also observed when IGF-I is given to patients with GH-receptor mutations. These compounds, however, have divergent effects on carbohydrate metabolism. A potent glucose lowering effect is typically observed after IGF-I administration, with improved insulin sensitivity with marked lowering of circulating insulin concentrations, whereas GH therapy is associated with mild compensatory hyperinsulinemia, a reflection of relative insulin resistance. The latter observation makes IGF-I a potentially more convenient anabolic agent to use in conditions where carbohydrate metabolism is more likely to be impaired. GH increases lipolysis as a direct effect of GH on the adipocyte, as well as lipid oxidation by increasing substrate availability. However IGF-I increases lipid oxidation only when given chronically, most likely as a result of chronic insulinopenia. These compounds have been tried in a variety of catabolic conditions in man and both hormones have been effective in reducing the protein wasting effects of glucocorticosteroids and mitigate some of the catabolic effects of severe hypogonadism in males. A comparison of these and other effects of these hormones is provided in this brief review. Subsequent studies are still needed to fully elucidate the safety and efficacy of IGF-I for use in humans.
Collapse
Affiliation(s)
- Nelly Mauras
- Division of Endocrinology, The Department of Pediatrics at the Nemours Children's Clinic, 807 Children's Way, Jacksonville, FL 32207, USA.
| | | |
Collapse
|
46
|
Abstract
PURPOSE OF REVIEW Multiple studies have shown that nutritional status is a strong predictor of morbidity and mortality in patients with cystic fibrosis (CF). Since CF is characterized by progressive lung disease, it could be argued that the underlying lung disease is what determines the nutritional failure seen in most patients. This review will summarize the data available from studies that have attempted to better define this relation and also present a review of the possible mechanisms involved taken from both observational and interventional studies. RECENT FINDINGS Longitudinal studies with sufficiently large follow-up times have demonstrated that young underweight patients have worst pulmonary function outcomes. More importantly, these studies concur in that the yearly change in growth parameters has a significant effect on the rate at which pulmonary function develops. Although the mechanisms behind this important association are yet unclear, there is some suggestion from interventional studies that the accrual of lean body mass is the factor that is involved in the preservation of lung function. SUMMARY Nutritional status strongly influences pulmonary health among CF patients. Therefore, aggressive nutritional support aiming at achieving normal growth patterns should lead to adequate development of lung function and maintenance of pulmonary health. However, more research is required with long-term longitudinal studies to better identify the most critical nutritional characteristics influencing this process as well as the most effective nutritional interventions.
Collapse
Affiliation(s)
- Carlos E Milla
- The Minnesota CF Center, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA.
| |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW As individuals with cystic fibrosis (CF) have experienced marked improvements in longevity over the last three decades, bone disease has emerged as a new problem. Bone disease in CF has not been previously reviewed in this journal. Therefore, this review will give a brief overview of bone disease in CF and then concentrate on treatment options. RECENT FINDINGS In some series, as many as three fourths of adults with CF have low bone density. Decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic inflammation, physical inactivity, and glucocorticoid treatment are some of the factors that contribute to this problem. Vitamin D depletion most likely contributes to bone disease, but identifying the safest and most efficacious vitamin D supplementation has yet to be resolved. Calcium and vitamin K supplementations are important if the diet contains less than the recommended amounts. Treatment of delayed puberty and adult hypogonadism with hormone replacement is recommended to achieve peak bone mass and maintain bone density. Bisphosphonates, including pamidronate and alendronate, are beneficial in improving bone mineral density before and after transplantation in CF adults. Bisphosphonates have not been studied in CF children. SUMMARY Although much progress has been made in our understanding of the pathogenesis, natural history, and clinical manifestations of bone disease in CF, treatment options are still evolving. More attention to nutrition, in terms of the maintenance of lean body mass and vitamin D and calcium supplementation, is likely to decrease bone complications. Bisphosphonates can be of value in CF adults with low bone density. Several clinical trials are under way to help optimize the treatment of CF bone disease.
Collapse
Affiliation(s)
- Robert Aris
- Division of Pulmonary Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | | | | |
Collapse
|
48
|
Sinaasappel M, Stern M, Littlewood J, Wolfe S, Steinkamp G, Heijerman HGM, Robberecht E, Döring G. Nutrition in patients with cystic fibrosis: a European Consensus. J Cyst Fibros 2004; 1:51-75. [PMID: 15463811 DOI: 10.1016/s1569-1993(02)00032-2] [Citation(s) in RCA: 255] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This document is the result of an European Consensus conference which took place in Artimino, Tuscany, Italy, in March 2001 involving 33 experts on nutrition in patients with cystic fibrosis, organised by the European Cystic Fibrosis Society, and sponsored by Axcan-Scandipharm, Baxter, Dr Falk Pharma, Fresenius, Nutricia, SHS International, Solvay Pharmaceuticals (major sponsor). The purpose of the conference was to develop a consensus document on nutrition in patients with cystic fibrosis based on current evidence.
Collapse
Affiliation(s)
- M Sinaasappel
- Department of Paediatric Gastroenterology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Suman OE, Mlcak RP, Herndon DN. Effects of exogenous growth hormone on resting pulmonary function in children with thermal injury. ACTA ACUST UNITED AC 2004; 25:287-93. [PMID: 15273470 DOI: 10.1097/01.bcr.0000124792.22931.d7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Burned children living beyond the acute phase of injury often have extensive physical functional limitations, such as impaired spirometry pulmonary function (PF). In patients with both lung disease and nutritional compromise, such as cystic fibrosis, studies suggest that growth hormone (GH) therapy improves PF. However, whether GH will improve PF in burned children is presently unknown. We therefore evaluated whether GH administration of 0.05 mg/kg/day for 1 year would improve PF in burned children. Thirty children, aged 7 to 18, with a 40% or more total body surface area burned were randomized into two groups and studied. One group received GH (n = 17) and the other received saline (n = 13). No differences were noted at hospital discharge between groups in age, % total body surface area, height, and weight. At 12 months after burn, both groups had similar height and weight. Baseline PF were below normal in both groups, but no statistical differences were noted between groups. At 1 year, there was a significant increase in PF in both groups; however, this increase in PF was similar in both groups. We conclude that the response in PF in burned children from the administration of GH prescribed for up to 1 year is limited.
Collapse
Affiliation(s)
- Oscar E Suman
- Medical Staff Administration, Shriners Hospitals for Children and Department of Surgery, The University of Texas Medical Branch, Galveston, Texas 77550, USA
| | | | | |
Collapse
|
50
|
Abstract
Since the advent of growth hormone (GH), the pediatric applications of GH therapy have expanded. Children with a wide variety of growth disorders have received GH treatment. The therapeutic effects and safety profile of GH in a number of pediatric conditions are reviewed, including GH deficiency (GHD), Turner syndrome, chronic renal failure, children born small for gestational age, Prader-Willi syndrome, juvenile chronic arthritis, and cystic fibrosis. GH therapy has been clearly shown to improve height velocity during childhood in a variety of pediatric conditions in which growth is compromised. There is now data that confirms GH treatment also improves final height in a number of diagnostic subgroups. Early initiation and individualization of GH treatment has the potential to normalize childhood growth in children with idiopathic GHD and enable them to achieve their genetic target height in a cost-effective manner. In children in whom GHD is not the main factor compromising growth, supra-physiological doses of GH have been shown to increase height velocity during childhood and final height. The development of predictive models for these conditions may allow further improvements in height outcome while maintaining an acceptable safety profile. Survivors of childhood malignancy, particularly those who have had craniospinal irradiation, represent a particularly challenging group. They appear to be less responsive to GH than children with idiopathic GHD and have a tendency to enter puberty at an earlier age. Both of these factors have a negative impact on their final height. Strategies that combine GH treatment with suppression of puberty using a gonadotropin releasing hormone analog may result in improved height outcomes. When children with GHD are treated with standard doses of GH there is a strong safety record. Adverse events during GH therapy are uncommon and often not drug related. Continued surveillance into adult life is crucial however, particularly in children receiving supra-physiological doses of GH or whose underlying condition increases their risk of adverse effects.
Collapse
Affiliation(s)
- Mark Harris
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | | | | |
Collapse
|