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Ranieri M, Angelini I, D'Agostino M, Di Mise A, Centrone M, Venneri M, Ferrulli A, Mastrodonato M, Tamma G, Endo I, Fukumoto S, Matsumoto T, Valenti G. In vivo treatment with calcilytic of CaSR knock-in mice ameliorates renal phenotype reversing downregulation of the vasopressin-AQP2 pathway. J Physiol 2024; 602:3207-3224. [PMID: 38367250 DOI: 10.1113/jp284233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/30/2024] [Indexed: 02/19/2024] Open
Abstract
High concentrations of urinary calcium counteract vasopressin action via the activation of the Calcium-Sensing Receptor (CaSR) expressed in the luminal membrane of the collecting duct cells, which impairs the trafficking of aquaporin-2 (AQP2). In line with these findings, we provide evidence that, with respect to wild-type mice, CaSR knock-in (KI) mice mimicking autosomal dominant hypocalcaemia, display a significant decrease in the total content of AQP2 associated with significantly higher levels of AQP2 phosphorylation at Ser261, a phosphorylation site involved in AQP2 degradation. Interestingly, KI mice also had significantly higher levels of phosphorylated p38MAPK, a downstream effector of CaSR and known to phosphorylate AQP2 at Ser261. Moreover, ATF1 phosphorylated at Ser63, a transcription factor downstream of p38MAPK, was significantly higher in KI. In addition, KI mice had significantly higher levels of AQP2-targeting miRNA137 consistent with a post-transcriptional downregulation of AQP2. In vivo treatment of KI mice with the calcilytic JTT-305, a CaSR antagonist, increased AQP2 expression and reduced AQP2-targeting miRNA137 levels in KI mice. Together, these results provide direct evidence for a critical role of CaSR in impairing both short-term vasopressin response by increasing AQP2-pS261, as well as AQP2 abundance, via the p38MAPK-ATF1-miR137 pathway. KEY POINTS: Calcium-Sensing Receptor (CaSR) activating mutations are the main cause of autosomal dominant hypocalcaemia (ADH) characterized by inappropriate renal calcium excretion leading to hypocalcaemia and hypercalciuria. Current treatments of ADH patients with parathyroid hormone, although improving hypocalcaemia, do not improve hypercalciuria or nephrocalcinosis. In vivo treatment with calcilytic JTT-305/MK-5442 ameliorates most of the ADH phenotypes of the CaSR knock-in mice including hypercalciuria or nephrocalcinosis and reverses the downregulation of the vasopressin-sensitive aquaporin-2 (AQP2) expression, providing direct evidence for a critical role of CaSR in impairing vasopressin response. The beneficial effect of calcilytic in reducing the risk of renal calcification may occur in a parathyroid hormone-independent action through vasopressin-dependent inhibition of cAMP synthesis in the thick ascending limb and in the collecting duct. The amelioration of most of the abnormalities in calcium metabolism including hypercalciuria, renal calcification, and AQP2-mediated osmotic water reabsorption makes calcilytic a good candidate as a novel therapeutic agent for ADH.
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Affiliation(s)
- Marianna Ranieri
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Ines Angelini
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | | | - Annarita Di Mise
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Mariangela Centrone
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Maria Venneri
- Istituti Clinici Scientifici Maugeri SPA SB IRCCS, Bari, Italy
| | - Angela Ferrulli
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Maria Mastrodonato
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Grazia Tamma
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
| | - Itsuro Endo
- Department of Bioregulatory Sciences, Tokushima University, Tokushima, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, Tokushima, Japan
| | - Toshio Matsumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, Tokushima, Japan
| | - Giovanna Valenti
- Department of Biosciences, Biotechnologies and Environment, University of Bari, Italy
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Dinoi E, Pierotti L, Mazoni L, Citro F, Della Valentina S, Sardella C, Borsari S, Michelucci A, Caligo MA, Marcocci C, Cetani F. Clinical and molecular characteristics of two Italian kindreds with hypoparathyroidism, deafness and renal dysplasia (HDR) syndrome. J Endocrinol Invest 2024; 47:469-478. [PMID: 37561279 DOI: 10.1007/s40618-023-02171-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE Hypoparathyroidism, deafness, and renal dysplasia (HDR) syndrome, also known as Barakat syndrome, is a rare autosomal dominant disease characterized by the triad of hypoparathyroidism, deafness, and renal abnormalities. The disorder is caused by the haploinsufficiency of the zinc finger transcription factor GATA3 and exhibits a great clinical variability with an age-dependent penetrance of each feature. We report two unrelated kindreds whose probands were referred to our outpatient clinic for further evaluation of hypoparathyroidism. METHODS The proband of family 1, a 17-year-old boy, was referred for severe hypocalcemia (5.9 mg/dL) incidentally detected at routine blood tests. Abdomen ultrasound showed bilateral renal cysts. The audiometric evaluation revealed the presence of bilateral moderate hearing loss although the patient could communicate without any problem. Conversely, the proband of family 2, a 19-year-old man, had severe symptomatic hypocalcemia complicated by epileptic seizure at the age of 14 years; his past medical history was remarkable for right nephrectomy at the age of 4 months due to multicystic renal disease and bilateral hearing loss diagnosed at the age of 18 years. RESULTS Based on clinical, biochemical, and radiologic data, HDR syndrome was suspected and genetic analysis of the GATA3 gene revealed the presence of two pathogenetic variants in exon 3, c.404dupC and c.431dupG, in the proband of family 1 and 2, respectively. CONCLUSION HDR syndrome is a rare cause of hypoparathyroidism and must be excluded in all patients with apparently idiopathic hypoparathyroidism. A correct diagnosis is of great importance for early detection of other HDR-related features and genetic counseling.
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Affiliation(s)
- E Dinoi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - L Pierotti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - L Mazoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - F Citro
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - S Della Valentina
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - C Sardella
- Endocrine Unit 2, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - S Borsari
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Michelucci
- Laboratory of Molecular Genetics, University Hospital of Pisa, Pisa, Italy
| | - M A Caligo
- Laboratory of Molecular Genetics, University Hospital of Pisa, Pisa, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Endocrine Unit 2, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Cetani
- Endocrine Unit 2, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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van Dijk Christiansen P, Sikjær T, Andreasen CM, Thomsen JS, Brüel A, Hauge EM, Delaisse J, Rejnmark L, Andersen TL. Transitory Activation and Improved Transition from Erosion to Formation within Intracortical Bone Remodeling in Hypoparathyroid Patients Treated with rhPTH(1-84). JBMR Plus 2023; 7:e10829. [PMID: 38130746 PMCID: PMC10731115 DOI: 10.1002/jbm4.10829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 12/23/2023] Open
Abstract
In hypoparathyroidism, lack of parathyroid hormone (PTH) leads to low calcium levels and decreased bone remodeling. Treatment with recombinant human PTH (rhPTH) may normalize bone turnover. This study aimed to investigate whether rhPTH(1-84) continued to activate intracortical bone remodeling after 30 months and promoted the transition from erosion to formation and whether this effect was transitory when rhPTH(1-84) was discontinued. Cortical histomorphometry was performed on 60 bone biopsies from patients (aged 31 to 78 years) with chronic hypoparathyroidism randomized to either 100 μg rhPTH(1-84) a day (n = 21) (PTH) or similar placebo (n = 21) (PLB) for 6 months as add-on to conventional therapy. This was followed by an open-label extension, where patients extended their rhPTH(1-84) (PTH) (n = 5), continued conventional treatment (CON) (n = 5), or withdrew from rhPTH(1-84) and resumed conventional therapy (PTHw) for an additional 24 months (n = 8). Bone biopsies were collected at months 6 (n = 42) and 30 (n = 18). After 6 and 30 months, the overall cortical microarchitecture (cortical porosity, thickness, pore density, and mean pore diameter) in the PTH group did not differ from that of the PLB/CON and PTHw groups. Still, the PTH group had a significantly and persistently higher percentage of pores undergoing remodeling than the PLB/CON groups. A significantly higher percentage of these pores was undergoing bone formation in the PTH compared with the PLB/CON groups, whereas the percentage of pores with erosion only was not different. This resulted in a shift in the ratio between formative and eroded pores, reflecting a faster transition from erosion to formation in the PTH-treated patients. In the rhPTH(1-84) withdrawal group PTHw, the latter effects of PTH were completely reversed in comparison to those of the PLB/CON groups. In conclusion, rhPTH(1-84) replacement therapy in hypoparathyroidism patients promotes intracortical remodeling and its transition from erosion to formation without affecting the overall cortical microstructure. The effect persists for at least 30 months and is reversible when treatment is withdrawn. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Pernille van Dijk Christiansen
- Department of PathologyOdense University HospitalOdenseDenmark
- Molecular Bone Histology (MBH) Lab, Research Unit of Pathology, Department of Clinical Research and Department of Molecular MedicineUniversity of Southern DenmarkOdenseDenmark
| | - Tanja Sikjær
- Department of Endocrinology and Internal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Christina Møller Andreasen
- Department of PathologyOdense University HospitalOdenseDenmark
- Molecular Bone Histology (MBH) Lab, Research Unit of Pathology, Department of Clinical Research and Department of Molecular MedicineUniversity of Southern DenmarkOdenseDenmark
| | | | | | - Ellen Margrethe Hauge
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of RheumatologyAarhus University HospitalAarhusDenmark
| | - Jean‐Marie Delaisse
- Department of PathologyOdense University HospitalOdenseDenmark
- Molecular Bone Histology (MBH) Lab, Research Unit of Pathology, Department of Clinical Research and Department of Molecular MedicineUniversity of Southern DenmarkOdenseDenmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Thomas Levin Andersen
- Department of PathologyOdense University HospitalOdenseDenmark
- Molecular Bone Histology (MBH) Lab, Research Unit of Pathology, Department of Clinical Research and Department of Molecular MedicineUniversity of Southern DenmarkOdenseDenmark
- Molecular Bone Histology (MBH) Lab, Department of Forensic MedicineAarhus UniversityAarhusDenmark
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Santa Rosa RG, Polonine S, Pichone A, Gomes CP, Lima LFC, de Paula Paranhos Neto F, de Mendonça LMC, Farias MLF, Madeira M. Chronic hypoparathyroidism is associated with increased cortical bone density evaluated using high-resolution peripheral quantitative computed tomography. Endocrine 2023; 82:673-680. [PMID: 37624475 DOI: 10.1007/s12020-023-03495-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE This cross-sectional study aimed to assess bone mineral density (BMD), bone microarchitecture and fracture prevalence in women with chronic postsurgical hypoparathyroidism (hypoPT). METHODS Twenty-seven women with postsurgical hypoPT and 44 age-matched healthy women were included. Dual-energy X-ray absorptiometry was used to evaluate areal BMD and vertebral fracture assessment. High-resolution peripheral quantitative computed tomography assessed microarchitecture and volumetric BMD at the distal radius and tibia. Biochemical parameters, including fibroblast growth factor 23, C-terminal cross-linking telopeptide of type I collagen (ICTP), and procollagen type I N-terminal propeptide (P1NP), were also measured. Previous low-impact fractures were assessed and the 10-year fracture risk was estimated using the FRAX tool for the Brazilian population. RESULTS No participant had prevalent clinical fractures, and both groups showed low risk for major and hip based on FRAX tool, but two hypoPT patients had moderate to severe morphometric vertebral fractures. Women with hypoPT had increased aBMD in the lumbar spine, femoral neck and total hip (p < 0.05) and higher cortical vBMD in the radius (p = 0.020) and tibia (p < 0.001). Trabecular bone was not affected. Both P1NP and ICTP suggested low bone turnover rates, but no significant correlation was observed between bone density or microstructure and any of the biochemical parameters. CONCLUSIONS The prevalence of fragility fractures was low in HypoPT women and compatible with low fracture risk estimated by the FRAX tool. Patients had a higher aBMD and cortical vBMD than those of healthy control women, but the association with decreased bone turnover remains unclear.
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Affiliation(s)
- Renata Gervais Santa Rosa
- Endocrinology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Nephrology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Simone Polonine
- Endocrinology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alinie Pichone
- Nephrology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Carlos Perez Gomes
- Nephrology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | - Miguel Madeira
- Endocrinology Division, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Watts NB, Bilezikian JP, Bone HG, Clarke BL, Denham D, Levine MA, Mannstadt M, Peacock M, Rothman JG, Vokes TJ, Warren ML, Yin S, Sherry N, Shoback DM. Long-Term Safety and Efficacy of Recombinant Human Parathyroid Hormone (1-84) in Adults With Chronic Hypoparathyroidism. J Endocr Soc 2023; 7:bvad043. [PMID: 37091306 PMCID: PMC10119703 DOI: 10.1210/jendso/bvad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Indexed: 04/07/2023] Open
Abstract
Context Chronic hypoparathyroidism is conventionally treated with oral calcium and active vitamin D to reach and maintain targeted serum calcium and phosphorus levels, but some patients remain inadequately controlled. Objective To assess long-term safety and efficacy of recombinant human parathyroid hormone (1-84) (rhPTH(1-84)) treatment. Methods This was an open-label extension study at 12 US centers. Adults (n = 49) with chronic hypoparathyroidism were included. The intervention was rhPTH(1-84) for 6 years. The main outcome measures were safety, biochemical measures, oral supplement doses, bone indices. Results Thirty-eight patients (77.6%) completed the study. Throughout 72 months, mean albumin-adjusted serum calcium was within 2.00 to 2.25 mmol/L (8.0-9.0 mg/dL). At baseline, 65% of patients with measurements (n = 24/37) were hypercalciuric; of these, 54% (n = 13/24) were normocalciuric at month 72. Mean serum phosphorus declined from 1.6 ± 0.19 mmol/L at baseline (n = 49) to 1.3 ± 0.20 mmol/L at month 72 (n = 36). Mean estimated glomerular filtration rate was stable. rhPTH(1-84)-related adverse events were reported in 51.0% of patients (n = 25/49); all but 1 event were mild/moderate in severity. Mean oral calcium supplementation reduced by 45% ± 113.6% and calcitriol by 74% ± 39.3%. Bone turnover markers declined by month 32 to a plateau above pretreatment values; only aminoterminal propeptide of type 1 collagen remained outside the reference range. Mean bone mineral density z score fell at one-third radius and was stable at other sites. Conclusion 6 years of rhPTH(1-84) treatment was associated with sustained improvements in biochemical parameters, a reduction in the percentage of patients with hypercalciuria, stable renal function, and decreased supplement requirements. rhPTH(1-84) was well tolerated; no new safety signals were identified.
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Affiliation(s)
- Nelson B Watts
- Osteoporosis and Bone Health Services, Mercy Health, Cincinnati, OH 45236, USA
| | - John P Bilezikian
- Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Henry G Bone
- Michigan Bone and Mineral Clinic, PC, Detroit, MI 48236, USA
| | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Douglas Denham
- Clinical Trials of Texas, Inc., San Antonio, TX 78229, USA
| | - Michael A Levine
- Division of Endocrinology and Diabetes and Center for Bone Health, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Munro Peacock
- Department of Medicine, Division of Endocrinology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Tamara J Vokes
- Section of Endocrinology, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Mark L Warren
- Endocrinology and Metabolism, Physicians East, PA, Greenville, NC 27834, USA
| | - Shaoming Yin
- Takeda Pharmaceuticals USA, Inc., Lexington, MA 02421, USA
| | - Nicole Sherry
- Takeda Pharmaceuticals USA, Inc., Lexington, MA 02421, USA
| | - Dolores M Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA
- Department of Medicine, University of California, San Francisco, CA 94143, USA
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Sakane EN, Vieira MCC, Vieira GMM, Maeda SS. Treatment options in hypoparathyroidism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:651-657. [PMID: 36382754 PMCID: PMC10118816 DOI: 10.20945/2359-3997000000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypoparathyroidism remains the single endocrine deficiency disease that is not habitually treated with the missing hormone. In this article, we aim to provide a review of the conventional approach and the novel therapies as well as an overview of the perspectives on the treatment of this rare condition. We conducted a literature review on the conventional therapy using vitamin D analogs and calcium salts, indications for thiazide diuretics and phosphorus binders, PTH analogs history and usage, and the drugs that are currently being tested in clinical trials. Conventional treatment involves calcium salts and vitamin D analogs. Thiazide diuretics can be used to reduce hypercalciuria in some cases. A low-phosphate diet is recommended, and phosphate binders are rarely needed. During pregnancy, a careful approach is necessary. The use of PTH analogs is a new approach despite the limitation of high cost. Studies have included modified PTH molecules, calcilytics, microencapsulation of human parathyroid cells, and allotransplantation.
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Saha S, Mannar V, Kandasamy D, Sreenivas V, Goswami R. Vertebral fractures, trabecular bone score and their determinants in chronic hypoparathyroidism. J Endocrinol Invest 2022; 45:1777-1786. [PMID: 35585296 DOI: 10.1007/s40618-022-01818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/03/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Patients with hypoparathyroidism are at risk of vertebral fractures (VFs) despite high bone mineral density (BMD). We investigated this paradox by assessing trabecular bone score (TBS) and hip structural analysis (HSA) in non-surgical chronic hypoparathyroidism (cHypoPT) with and without VFs. METHODS 152 cHypoPT patients (age 40.2 ± 13.4 years, M: F = 81:71) with a median follow-up of 8 (2-13) years were assessed for BMD, VFs, TBS, and HSA and compared with 152 healthy controls. VFs at T7-L4 were assessed by Genant's method. Average serum total calcium and phosphorus during follow-up were assessed. RESULTS The lumbar spine and hip BMD were higher by 25.4 and 13.4% in cHypoPT than controls (P < 0.001). Paradoxically, VFs (30.9 vs.7.9%), including multiple (12.5 vs. 2.6%) were higher in cHypoPT (P < 0.001). Though overall average TBS (1.411 ± 0.091) was normal in cHypoPT, 25.4% of the females had subnormal TBS, more in post than pre-menopausal women (52.3 vs. 14%, P = 0.002) and as compared to males (6.1%, P = 0.001). TBS correlated with menopausal status and follow-up serum calcium-phosphorus product. For every gm/cm2 rise in BMD, TBS increase was only 0.227 in cHypoPT compared to 0.513 in controls. Frequency of VFs increased with declining TBS (P = 0.004). HSA was comparable between cHypoPT with and without VFs. 23.4% of cHypoPT with VFs had subnormal TBS. CONCLUSION 31% of cHypoPT patients had VFs. TBS indicated degraded bone microarchitecture in 50% of the post-menopausal cHypoPT women. However, TBS has limitations to detect abnormal bone microarchitecture in cHypoPT as only one-fourth of patients with VFs showed low TBS.
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Affiliation(s)
- S Saha
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - V Mannar
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - D Kandasamy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - V Sreenivas
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - R Goswami
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Puliani G, Hasenmajer V, Simonelli I, Sada V, Pofi R, Minnetti M, Cozzolino A, Napoli N, Pasqualetti P, Gianfrilli D, Isidori AM. Safety and Efficacy of PTH 1-34 and 1-84 Therapy in Chronic Hypoparathyroidism: A Meta-Analysis of Prospective Trials. J Bone Miner Res 2022; 37:1233-1250. [PMID: 35485213 PMCID: PMC9545848 DOI: 10.1002/jbmr.4566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/12/2022]
Abstract
Hypoparathyroidism is the only endocrine deficiency for which hormone replacement therapy is not the standard of care. Although conventional treatments may control hypocalcaemia, other complications such as hyperphosphatemia, kidney stones, peripheral calcifications, and bone disease remain unmet needs. This meta-analysis (PROSPERO registration number CRD42019126881) aims to evaluate and compare the efficacy and safety of PTH1-34 and PTH1-84 in restoring calcium metabolism in chronic hypoparathyroidism. EMBASE, PubMed, and CENTRAL databases were searched for randomized clinical trials or prospective studies published between January 1996 and March 2021. English-language trials reporting data on replacement with PTH1-34 or PTH1-84 in chronic hypoparathyroidism were selected. Three authors extracted outcomes, one author performed quality control, all assessed the risk of biases. Overall, data from 25 studies on 588 patients were analyzed. PTH therapy had a neutral effect on calcium levels, while lowering serum phosphate (-0.21 mmol/L; 95% confidence interval [CI], -0.31 to -0.11 mmol/L; p < 0.001) and urinary calcium excretion (-1.21 mmol/24 h; 95% CI, -2.03 to -0.41 mmol/24 h; p = 0.003). Calcium phosphate product decreased under PTH1-84 therapy only. Both treatments enabled a significant reduction in calcium and calcitriol supplementation. PTH therapy increased bone turnover markers and lumbar spine mineral density. Quality of life improved and there was no difference in the safety profile between PTH and conventionally treated patients. Results for most outcomes were similar for the two treatments. Limitations of the study included considerable population overlap between the reports, incomplete data, and heterogeneity in the protocol design. In conclusion, the meta-analysis of data from the largest collection to date of hypoparathyroid patients shows that PTH therapy is safe, well-tolerated, and effective in normalizing serum phosphate and urinary calcium excretion, as well as enabling a reduction in calcium and vitamin D use and improving quality of life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.,Oncological Endocrinology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Simonelli
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation of Health Research and Education, Rome, Italy.,Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Sada
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Nicola Napoli
- Operative Research Unit of Osteo-metabolic and thyroid diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.,Division of Bone and Mineral Diseases, Washington University in St. Louis, St. Louis, MO, USA
| | - Patrizio Pasqualetti
- Department of Public Health and Infectious Diseases, Section of Medical Statistics, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Ish-Shalom S, Caraco Y, Khazen NS, Gershinsky M, Szalat A, Schwartz P, Arbit E, Galitzer H, Tang JC, Burshtein G, Rothner A, Raskin A, Blum M, Fraser WD. Safety and Efficacy of Oral Human Parathyroid Hormone (1-34) in Hypoparathyroidism: An Open-Label Study. J Bone Miner Res 2021; 36:1060-1068. [PMID: 33666947 PMCID: PMC8252608 DOI: 10.1002/jbmr.4274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/12/2022]
Abstract
The standard treatment of primary hypoparathyroidism (hypoPT) with oral calcium supplementation and calcitriol (or an analog), intended to control hypocalcemia and hyperphosphatemia and avoid hypercalciuria, remains challenging for both patients and clinicians. In 2015, human parathyroid hormone (hPTH) (1-84) administered as a daily subcutaneous injection was approved as an adjunctive treatment in patients who cannot be well controlled on the standard treatments alone. This open-label study aimed to assess the safety and efficacy of an oral hPTH(1-34) formulation as an adjunct to standard treatment in adult subjects with hypoparathyroidism. Oral hPTH(1-34) tablets (0.75 mg human hPTH(1-34) acetate) were administered four times daily for 16 consecutive weeks, and changes in calcium supplementation and alfacalcidol use, albumin-adjusted serum calcium (ACa), serum phosphate, urinary calcium excretion, and quality of life throughout the study were monitored. Of the 19 enrolled subjects, 15 completed the trial per protocol. A median 42% reduction from baseline in exogenous calcium dose was recorded (p = .001), whereas median serum ACa levels remained above the lower target ACa levels for hypoPT patients (>7.5 mg/dL) throughout the study. Median serum phosphate levels rapidly decreased (23%, p = .0003) 2 hours after the first dose and were maintained within the normal range for the duration of the study. A notable, but not statistically significant, median decrease (21%, p = .07) in 24-hour urine calcium excretion was observed between the first and last treatment days. Only four possible drug-related, non-serious adverse events were reported over the 16-week study, all by the same patient. A small but statistically significant increase from baseline quality of life (5%, p = .03) was reported by the end of the treatment period. Oral hPTH(1-34) treatment was generally safe and well tolerated and allowed for a reduction in exogenous calcium supplementation, while maintaining normocalcemia in adult patients with hypoparathyroidism. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Sofia Ish-Shalom
- Endocrine Research Center, Lin Medical Center, Clalit Health Services, Haifa, Israel
| | - Yoseph Caraco
- Hadassah Medical Center, Hebrew University Medical School, Jerusalem, Israel
| | - Nariman Saba Khazen
- Endocrine Research Center, Lin Medical Center, Clalit Health Services, Haifa, Israel
| | - Michal Gershinsky
- Endocrine Research Center, Lin Medical Center, Clalit Health Services, Haifa, Israel
| | - Auryan Szalat
- Hadassah Medical Center, Hebrew University Medical School, Jerusalem, Israel
| | | | - Ehud Arbit
- Entera Bio Ltd, Jerusalem Bio Park, Jerusalem, Israel
| | | | - Jonathan Cy Tang
- Bioanalytical Facility, Biomedical Research Centre, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | | | - Ariel Rothner
- Entera Bio Ltd, Jerusalem Bio Park, Jerusalem, Israel
| | - Arthur Raskin
- Entera Bio Ltd, Jerusalem Bio Park, Jerusalem, Israel
| | - Miriam Blum
- Entera Bio Ltd, Jerusalem Bio Park, Jerusalem, Israel
| | - William D Fraser
- Bioanalytical Facility, Biomedical Research Centre, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.,Departments of Endocrinology and Clinical Biochemistry, Norfolk and Norwich University Hospital, Norwich, UK
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10
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Tay YKD, Tabacco G, Bilezikian JP. Bone quality in hypoparathyroidism. Minerva Endocrinol (Torino) 2021; 46:325-334. [PMID: 34014065 DOI: 10.23736/s2724-6507.21.03527-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hypoparathyroidism is a rare disorder characterized by hypocalcemia and deficient or absent levels of parathyroid hormone. The consequences of chronic hypoparathyroidism involve classic target organs of parathyroid hormone, namely the skeleton and the kidneys. In this article, we focus on the abnormalities in bone quality that are associated with hypoparathyroidism. As assessed by several modalities, bone quality is compromised. The evidence for abnormal bone quality includes findings from bone histomorphometry, bone material properties, and high-resolution peripheral computed tomography. These abnormalities include low bone turnover, altered skeletal microarchitecture and bone material properties. How these abnormalities relate to fracture risk are under investigation. In this study, we also reviewed the therapeutic effects of parathyroid hormone as replacement therapy in this disease.
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Affiliation(s)
- Yu-Kwang D Tay
- Department of General Medicine, Sengkang General Hospital, Singhealth, Singapore
| | - Gaia Tabacco
- Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - John P Bilezikian
- Unit of Metabolic Bone Disease, Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA -
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11
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Laurer E, Grünberger J, Naidoo U, Lanzersdorfer R, Wimleitner M, Tischlinger K, Högler W. Recombinant human parathyroid hormone (1-84) replacement therapy in a child with hypoparathyroidism. Bone 2021; 144:115834. [PMID: 33359892 DOI: 10.1016/j.bone.2020.115834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
First line conventional therapy of hypoparathyroidism comprises oral calcium and active vitamin D analogues. This approach may fail to correct hypocalcemia and hyperphosphatemia caused by the absence of parathyroid hormone and carries the risk of long-term complications including ectopic calcifications and renal damage. Full-length recombinant human parathyroid hormone (rhPTH[1-84]) is approved for the treatment of hypoparathyroidism in adults refractory to conventional therapy. To date, there is no data in children. Here, we report the successful use of rhPTH(1-84) in a 5-year old girl with hypoparathyroidism and concomitant chronic diarrhea manifesting as part of the autoimmune polyglandular syndrome type 1. Prior to starting rhPTH(1-84), the patient had been on conventional and later on rhPTH(1-34) continuous pump therapy. Conventional therapy failed to meet serum and urinary calcium target levels, whilst the pump therapy wasn't well tolerated and posed handling difficulties. Dose optimization for rhPTH(1-84) was informed by serum ionized calcium, spot urinary calcium-to-creatinine ratio and 24-hour urinary calcium excretion. Twice-daily subcutaneous injections of rhPTH(1-84) with a total dose of 3.35 μg/kg/d was well-tolerated, raised serum ionized calcium to target range (1.05-1.15 mmol/L) and normalized serum phosphate levels. Urinary calcium excretion was slightly above the recommended limit of 4 mg/kg/24 h, but improved compared to conventional therapy, with no evidence of nephrocalcinosis. Twice-daily administration stabilized serum calcium and phosphate levels compared to once-daily injections. rhPTH(1-84) treatment was well tolerated and the girl did not manifest any acute clinical complications of hypoparathyroidism throughout the entire observation period. Our experience with this case indicates that rhPTH(1-84) may be a physiological hormone replacement for managing hypoparathyroidism in children.
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Affiliation(s)
- Elisabeth Laurer
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria.
| | - Johanna Grünberger
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Uvistra Naidoo
- South African Tuberculosis Vaccine Institute, University of Cape Town, South Africa
| | - Roland Lanzersdorfer
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Marlene Wimleitner
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Katharina Tischlinger
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
| | - Wolfgang Högler
- Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Austria
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12
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Bernardor J, Flammier S, Cabet S, Lemoine S, Chapurlat R, Molin A, Bertholet-Thomas A, Bacchetta J. Intermittent Bi-Daily Sub-cutaneous Teriparatide Administration in Children With Hypoparathyroidism: A Single-Center Experience. Front Pediatr 2021; 9:764040. [PMID: 34820344 PMCID: PMC8606674 DOI: 10.3389/fped.2021.764040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The use of teriparatide has been reported in children with hypoparathyroidism as an investigational physiologic replacement therapy. Methods: We aimed to retrospectively report our pediatric experience of bi-daily sub-cutaneous teriparatide. Results are presented as median (25th-75th quartile). As part of the routine follow-up of these patients with hypoparathyroidism, total calcium at H0 (i.e., just before injection) and H4 (i.e., 4 h after teriparatide injection) and other biomarker parameters were regularly assessed. Results: At a median age of 10.7 (8.1-12.6) years, an estimated glomerular filtration rate (eGFR) of 110 (95-118) mL/min/1.73 m2, calcium levels of 1.87 (1.81-1.96) mmol/L and an age-standardized phosphate of 3.8 (2.5-4.9) SDS, teriparatide therapy was introduced in 10 patients at the dose of 1.1 (0.7-1.5) μg/kg/day (20 μg twice daily), with further adjustment depending on calcium levels. Six patients already displayed nephrocalcinosis. Severe side effects were reported in one child: two episodes of symptomatic hypocalcemia and one of iatrogenic hypercalcemia; one teenager displayed dysgueusia. Calcium levels at H0 did not significantly increase whilst calcium at H4 and phosphate levels significantly increased and decreased, respectively. After 12 months, eGFR, calcium and age-standardized phosphate levels were 108 (90-122) mL/min/1.73 m2, 2.36 (2.23-2.48) mmol/L, 0.5 (-0.1 to 1.5), and 68 (63-74) nmol/L, respectively, with a significant decrease in phosphate levels (p = 0.01). Urinary calcium and calcium/creatinine ratio remained stable; no nephrolithiasis was observed but two moderate nephrocalcinosis appeared. Conclusion: Intermittent teriparatide therapy significantly improves calcium and phosphate control, without increasing calciuria. It appears to be safe and well-tolerated in children.
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Affiliation(s)
- Julie Bernardor
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Service de Néphrologie Pédiatrique, CHU de Nice, Hôpital Archet, Nice, France.,Faculté de Médecine, Université Côte d'Azur, Nice, France
| | - Sacha Flammier
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France
| | - Sara Cabet
- Département de Radiologie Pédiatrique et Fœtale, Hôpital Femme Mère Enfant, Lyon, France
| | - Sandrine Lemoine
- Service d'Exploration Fonctionnelle Rénale, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR et ORKID, Département de Néphrologie, Hôpital Edouard Herriot, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
| | - Roland Chapurlat
- INSERM UMR S1033 Research Unit, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.,Service de Rhumatologie, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Molin
- Université de Normandie, UNICAEN, Unité de génétique, EA7450 BioTARGen, CHU de Caen Normandie, Caen, France
| | - Aurélia Bertholet-Thomas
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rares du Calcium et du Phosphore, Centre de Référence des Maladies Rénales Rares, Filières de Santé Maladies Rares OSCAR, ORKID et ERKNet, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Bron, France.,INSERM UMR S1033 Research Unit, Lyon, France.,Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
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13
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Hawkes CP, Shulman DI, Levine MA. Recombinant human parathyroid hormone (1-84) is effective in CASR-associated hypoparathyroidism. Eur J Endocrinol 2020; 183:K13-K21. [PMID: 33112267 PMCID: PMC7853300 DOI: 10.1530/eje-20-0710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/29/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Gain-of-function mutations in the CASR gene cause Autosomal Dominant Hypocalcemia Type 1 (ADH1), the most common genetic cause of isolated hypoparathyroidism. Subjects have increased calcium sensitivity in the renal tubule, leading to increased urinary calcium excretion, nephrocalcinosis and nephrolithiasis when compared with other causes of hypoparathyroidism. The traditional approach to treatment includes activated vitamin D but this further increases urinary calcium excretion. METHODS In this case series, we describe the use of recombinant human parathyroid hormone (rhPTH)1-84 to treat subjects with ADH1, with improved control of serum and urinary calcium levels. RESULTS We describe two children and one adult with ADH1 due to heterozygous CASR mutations who were treated with rhPTH(1-84). Case 1 was a 9.4-year-old female whose 24-h urinary calcium decreased from 7.5 to 3.9 mg/kg at 1 year. Calcitriol and calcium supplementation were discontinued after titration of rhPTH(1-84). Case 2 was a 9.5-year-old male whose 24-h urinary calcium decreased from 11.7 to 1.7 mg/kg at 1 year, and calcitriol was also discontinued. Case 3 was a 24-year-old female whose treatment was switched from multi-dose teriparatide to daily rhPTH(1-84). All three subjects achieved or maintained target serum levels of calcium and normal or improved urinary calcium levels with daily rhPTH(1-84) monotherapy. CONCLUSIONS We have described three subjects with ADH1 who were treated effectively with rhPTH(1-84). In all cases, hypercalciuria improved by comparison to treatment with conventional therapy consisting of calcium supplementation and calcitriol.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dorothy I Shulman
- University of South Florida Diabetes Center, USF Morsani College of Medicine, Tampa, FL, USA
| | - Michael A Levine
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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14
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Zavatta G, Clarke BL. Challenges in the management of chronic hypoparathyroidism. Endocr Connect 2020; 9:EC-20-0366.R2. [PMID: 33486471 PMCID: PMC7707836 DOI: 10.1530/ec-20-0366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 01/12/2023]
Abstract
The first adjunctive hormone therapy for chronic hypoparathyroidism, recombinant human parathyroid hormone (1-84) [rhPTH(1-84)] was approved by the FDA in January 2015. Since the approval of rhPTH(1-84), growing interest has developed in other agents to treat this disorder in both the scientific community and among pharmaceutical companies. For several reasons, conventional therapy with calcium and activated vitamin D supplementation, magnesium supplementation as needed, and occasionally thiazide-type diuretic therapy remains the mainstay of treatment, while endocrinologists and patients are constantly challenged by limitations of conventional treatment. Serum calcium fluctuations, increased urinary calcium, hyperphosphatemia, and a constellation of symptoms that limit mental and physical functioning are frequently associated with conventional therapy. Understanding how conventional treatment and hormone therapy work in terms of pharmacokinetics and pharmacodynamics is key to effectively managing chronic hypoparathyroidism. Multiple questions remain regarding the effectiveness of PTH adjunctive therapy in preventing or slowing the onset and progression of the classical complications of hypoparathyroidism, such as chronic kidney disease, calcium-containing kidney stones, cataracts, or basal ganglia calcification. Several studies point toward an improvement in quality of life during replacement therapy. This review will discuss current clinical and research challenges posed by treatment of chronic hypoparathyroidism.
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Affiliation(s)
- Guido Zavatta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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15
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Abstract
Parathyroid hormone is an essential regulator of extracellular calcium and phosphate. PTH enhances calcium reabsorption while inhibiting phosphate reabsorption in the kidneys, increases the synthesis of 1,25-dihydroxyvitamin D, which then increases gastrointestinal absorption of calcium, and increases bone resorption to increase calcium and phosphate. Parathyroid disease can be an isolated endocrine disorder or part of a complex syndrome. Genetic mutations can account for diseases of parathyroid gland formulation, dysregulation of parathyroid hormone synthesis or secretion, and destruction of the parathyroid glands. Over the years, a number of different options are available for the treatment of different types of parathyroid disease. Therapeutic options include surgical removal of hypersecreting parathyroid tissue, administration of parathyroid hormone, vitamin D, activated vitamin D, calcium, phosphate binders, calcium-sensing receptor, and vitamin D receptor activators to name a few. The accurate assessment of parathyroid hormone also provides essential biochemical information to properly diagnose parathyroid disease. Currently available immunoassays may overestimate or underestimate bioactive parathyroid hormone because of interferences from truncated parathyroid hormone fragments, phosphorylation of parathyroid hormone, and oxidation of amino acids of parathyroid hormone.
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Affiliation(s)
- Edward Ki Yun Leung
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Pathology, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States.
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16
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Cusano NE, Rubin MR, Williams JM, Agarwal S, Tabacco G, Tay D, Majeed R, Omeragic B, Bilezikian JP. Changes in Skeletal Microstructure Through Four Continuous Years of rhPTH(1-84) Therapy in Hypoparathyroidism. J Bone Miner Res 2020; 35:1274-1281. [PMID: 32155287 PMCID: PMC7363559 DOI: 10.1002/jbmr.4005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 11/12/2022]
Abstract
Bone remodeling is reduced in hypoparathyroidism, resulting in increased areal bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) and abnormal skeletal indices by transiliac bone biopsy. We have now studied skeletal microstructure by high-resolution peripheral quantitative computed tomography (HR-pQCT) through 4 years of treatment with recombinant human PTH(1-84) (rhPTH[1-84]) in 33 patients with hypoparathyroidism (19 with postsurgical disease, 14 idiopathic). We calculated Z-scores for our cohort compared with previously published normative values. We report results at baseline and 1, 2, and 4 years of continuous therapy with rhPTH(1-84). The majority of patients (62%) took rhPTH(1-84) 100 μg every other day for the majority of the 4 years. At 48 months, areal bone density increased at the lumbar spine (+4.9% ± 0.9%) and femoral neck (+2.4% ± 0.9%), with declines at the total hip (-2.3% ± 0.8%) and ultradistal radius (-2.1% ± 0.7%) (p < .05 for all). By HR-pQCT, at the radius site, very similar to the ultradistal DXA site, total volumetric BMD declined from baseline but remained above normative values at 48 months (Z-score + 0.56). Cortical volumetric BMD was lower than normative controls at baseline at the radius and tibia (Z-scores -1.28 and - 1.69, respectively) and further declined at 48 months (-2.13 and - 2.56, respectively). Cortical porosity was higher than normative controls at baseline at the tibia (Z-score + 0.72) and increased through 48 months of therapy at both sites (Z-scores +1.80 and + 1.40, respectively). Failure load declined from baseline at both the radius and tibia, although remained higher than normative controls at 48 months (Z-scores +1.71 and + 1.17, respectively). This is the first report of noninvasive high-resolution imaging in a cohort of hypoparathyroid patients treated with any PTH therapy for this length of time. The results give insights into the effects of long-term rhPTH(1-84) in hypoparathyroidism. © 2020 American Society for Bone and Mineral Research.
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Affiliation(s)
- Natalie E Cusano
- Department of Medicine, Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - Mishaela R Rubin
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - John M Williams
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Sanchita Agarwal
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Gaia Tabacco
- Unit of Endocrinology and Diabetes, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Donovan Tay
- Department of Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Rukshana Majeed
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Beatriz Omeragic
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
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17
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Abstract
BACKGROUND Hypoparathyroidism is a rare endocrine disorder characterized by hypocalcemia and low or undetectable levels of parathyroid hormone. METHODS This review is an evidence-based summary of hypoparathyroidism in terms of relevant pathophysiological, clinical, and therapeutic concepts. RESULTS Many clinical manifestations of hypoparathyroidism are due to the lack of the physiological actions of parathyroid hormone on its 2 major target organs: the skeleton and the kidney. The skeleton is inactive, accruing bone without remodeling it. The kidneys lose the calcium-conserving actions of parathyroid hormone and, thus, excrete a greater fraction of calcium. Biochemical manifestations, besides hypocalcemia and low or undetectable levels of parathyroid hormone, include hyperphosphatemia and low levels of 1,25-dihydroxyvitamin D. Calcifications in the kidney, brain, and other soft tissues are common. Removal of, or damage to, the parathyroid glands at the time of anterior neck surgery is, by far, the most likely etiology. Autoimmune destruction of the parathyroid glands and other genetic causes represent most of the other etiologies. Conventional treatment with calcium and active vitamin D can maintain the serum calcium level but high doses may be required, adding to the risk of long-term soft tissue calcifications. The advent of replacement therapy with recombinant human PTH(1-84) represents a major step in the therapeutics of this disease. CONCLUSIONS Advances in our knowledge of hypoparathyroidism have led to greater understanding of the disease itself and our approach to it.
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Affiliation(s)
- John P Bilezikian
- Department of Medicine, Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Correspondence and Reprint Requests: John P. Bilezikian, Vice-Chair, International Research and Education, Department of Medicine, Vagelos College of Physicians and Surgeons, 630 W. 168th Street, New York, NY 10032. E-mail:
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18
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Abstract
The 11 existing FDA-approved osteoporosis drug treatments include hormone replacement therapy, 2 SERMs (raloxifene and bazedoxifene), 5 inhibitors of bone-resorbing osteoclasts (4 bisphosphonates and anti-RANKL denosumab), 2 parathyroid hormone analogues (teriparatide and abaloparatide), and 1 WNT signaling enhancer (romosozumab). These therapies are effective and provide multiple options for patients and physicians. As the genomic revolution continues, potential novel targets for future drug development are identified. This review takes a wide perspective to describe potentially rewarding topics to explore, including knowledge of genes and pathways involved in bone cell metabolism, the utility of animal models, targeting drugs to bone, and ongoing advances in drug design and delivery.
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19
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Zhou YY, Yang Y, Qiu HM. Hypoparathyroidism with Fahr’s syndrome: A case report and review of the literature. World J Clin Cases 2019; 7:3662-3670. [PMID: 31750351 PMCID: PMC6854411 DOI: 10.12998/wjcc.v7.i21.3662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/24/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hypoparathyroidism with basal ganglia calcification is clinically rare. Here, we report a case of Fahr’s syndrome due to hypoparathyroidism and review the literature in terms of etiology, clinical manifestation, diagnosis, and treatment.
CASE SUMMARY A 62-year-old man experienced repeated twitching of both hands in recent 10 years. On July 28, 2017, the patient was admitted to our hospital due to slow response and speech difficulties. On medical examinations, he had a positive Chvostek sign, while no Albright’s hereditary osteodystrophy signs or history of neck surgery or radiation, and his family members had no similar medical history. Laboratory examinations revealed hypocalcemia, hyperphosphatemia, and low parathyroid hormone (PTH) levels. Computed tomography revealed basal ganglia calcification. Based on these investigations, a diagnosis of Fahr’s syndrome due to hypoparathyroidism was suggested. After receiving intravenous calcium gluconate to relieve symptoms, the patient continued to take oral calcium carbonate and calcitriol for treatment.
CONCLUSION The possibility of hypoparathyroidism should be considered in patients with chronic hypocalcemia, recurrent tetany, and even neuropsychiatric symptoms. Hypoparathyroidism is a common cause of basal ganglia calcification. Therefore, it is recommended that blood calcium, phosphorus, and PTH levels should be measured in all individuals with basal ganglia calcification to exclude hypoparathyroidism.
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Affiliation(s)
- Yuan-Yuan Zhou
- Department of Endocrinology and Metabolism, Fourth Affiliated Hospital of Kunming Medical University and The Second People’s Hospital of Yunnan Province, Kunming 650021, Yunnan Province, China
- Department of Endocrinology and Metabolism, Sixth Affiliated Hospital of Kunming Medical University and The People’s Hospital of Yuxi City, Yuxi 653100, Yunnan Province, China
| | - Ying Yang
- Department of Endocrinology and Metabolism, Fourth Affiliated Hospital of Kunming Medical University and The Second People’s Hospital of Yunnan Province, Kunming 650021, Yunnan Province, China
| | - Hong-Mei Qiu
- Department of Endocrinology and Metabolism, Sixth Affiliated Hospital of Kunming Medical University and The People’s Hospital of Yuxi City, Yuxi 653100, Yunnan Province, China
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20
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Abstract
Parathyroid hormone (PTH) exerts both anabolic and catabolic actions on bone,depending on the duration and periodicity of exposure. Hypoparathyroidism is defined by inadequate production of PTH in the presence oflow serum calcium. In hypoparathyroidism it has been reported an increase in corticaland trabecular bone mass, but it is still unknown if these quantitative variations maybe accompanied by qualitative ones and increased bone strength. Despite the extensive data available on the effects of hypoparathyroidism on bone, itseffect on the hard end point in this area which is the risk of fractures still remainsunresolved and highly debated. As a matter of fact no previous review has focused onthis relevant clinical topic. This review will deal with the various aspects of bone metabolism (turn-over,density, quality) in hypoparathyroidism, focusing on the few data available on therisk of fracture and in particular of morphometric vertebral fractures, the emerging way to assess actual skeletal fragility particularly in secondary forms of osteoporosis.
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Affiliation(s)
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University Via Olgettina, Milano, Italy.
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21
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Affiliation(s)
- Rachel I Gafni
- From the Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Michael T Collins
- From the Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
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Yoon SH, Grynpas M, Mitchell J. Intermittent PTH treatment improves bone and muscle in glucocorticoid treated Mdx mice: A model of Duchenne Muscular Dystrophy. Bone 2019; 121:232-242. [PMID: 30716510 DOI: 10.1016/j.bone.2019.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 01/07/2023]
Abstract
Duchenne Muscular Dystrophy (DMD) is a progressive muscle disorder caused by genetic mutations of the dystrophin encoding gene. In the absence of functional dystrophin, DMD patients suffer from muscle inflammation and wasting, as well as compromised bone health with increased risk of fracture. The use of high dose glucocorticoids (GC) as the standard therapy also contributes to bone fragility. This study examined the effects of intermittent, daily administered parathyroid hormone (iPTH), an approved bone anabolic therapy, on growing bone and dystrophic muscle in the presence and absence of prednisone treatment using the Mdx mouse model of DMD. Five-weeks of prednisone treatment in Mdx mice decreased cortical bone thickness and area (p < 0.001), with a large increase in endocortical osteoclasts that were significantly improved by PTH treatment (p < 0.001). GC-induced decreases in cortical bone toughness and modulus were improved with iPTH therapy (p < 0.05). Mdx mice showed significantly less bone mass in trabecular compartments of lumbar vertebrae and iPTH treatment, with or without glucocorticoids, significantly improved structural and material properties of this bone. Prednisone improved grip strength and endurance of treadmill running, which were maintained and further improved, respectively, in co-treated Mdx mice. Altogether, our study demonstrates that iPTH therapy significantly ameliorated GC-induced bone loss and maintained or further enhanced the positive effects of GCs on dystrophic muscle function. These findings give insight into the potential for use of teriparatide to treat growing bone in children with DMD.
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Affiliation(s)
- Sung-Hee Yoon
- Department of Pharmacology and Toxicology, University of Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Health System, Toronto, ON, Canada
| | - Marc Grynpas
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Health System, Toronto, ON, Canada
| | - Jane Mitchell
- Department of Pharmacology and Toxicology, University of Toronto, ON, Canada.
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Ovejero D, Misof BM, Gafni RI, Dempster D, Zhou H, Klaushofer K, Collins MT, Roschger P. Bone Matrix Mineralization in Patients With Gain-of-Function Calcium-Sensing Receptor Mutations Is Distinctly Different From that in Postsurgical Hypoparathyroidism. J Bone Miner Res 2019; 34:661-668. [PMID: 30496603 DOI: 10.1002/jbmr.3638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/10/2018] [Accepted: 11/12/2018] [Indexed: 12/19/2022]
Abstract
The role of the calcium-sensing receptor (CaSR) as a regulator of parathyroid hormone secretion is well established, but its function in bone is less well defined. In an effort to elucidate the CaSR's skeletal role, bone tissue and material characteristics from patients with autosomal dominant hypocalcemia (ADH), a genetic form of primary hypoparathyroidism caused by CASR gain-of-function mutations, were compared to patients with postsurgical hypoparathyroidism (PSH). Bone structure and formation/resorption indices and mineralization density distribution (BMDD), were examined in transiliac biopsy samples from PSH (n = 13) and ADH (n = 6) patients by histomorphometry and quantitative backscatter electron imaging, respectively. Bone mineral density (BMD by DXA) and biochemical characteristics were measured at the time of the biopsy. Because both study groups comprised children and adults, all measured biopsy parameters and BMD outcomes were converted to Z-scores for comparison. Histomorphometric indices were normal and not different between ADH and PSH, with the exception of mineral apposition rate Z-score, which was higher in the ADH group. Similarly, average BMD Z-scores were normal and not different between ADH and PSH. Significant differences were observed for the BMDD: average Z-scores of mean and typical degree of mineralization (CaMean, CaPeak, respectively) were lower (p = 0.02 and p = 0.03, respectively), whereas the heterogeneity of mineralization (CaWidth) and percentage of lower mineralized areas (CaLow) were increased in ADH versus PSH (p = 0.01 and p = 0.002, respectively). The BMDD outcomes point toward a direct, PTH-independent role of the CaSR in the regulation of bone mineralization. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Diana Ovejero
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Musculoskeletal Research group, Hospital del Mar Research Institute, Barcelona, Barcelona (Spain).,National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - Barbara M Misof
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - David Dempster
- Columbia University College of Physicians & Surgeons, New York, NY, USA.,Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Paul Roschger
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
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24
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Pediatric bone evaluation with HR-pQCT: A comparison between standard and height-adjusted positioning protocols in a cohort of teenagers with chronic kidney disease. Arch Pediatr 2019; 26:151-157. [PMID: 30827777 DOI: 10.1016/j.arcped.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 12/07/2018] [Accepted: 02/03/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND High-resolution peripheral quantitative computed tomography (HR-pQCT) evaluates different components of bone fragility. The positioning and length of the region of interest (ROI) in growing populations remain to be defined. METHODS Using HR-pQCT at the ultradistal tibia, we compared a single-center cohort of 28 teenagers with chronic kidney disease (CKD) at a median age of 13.6 (range, 10.2-19.9) years to local age-, gender-, and puberty-matched healthy peers. Because of the potential impact of short stature, bone parameters were assessed on two different leg-length-adjusted ROIs in comparison to the standard analysis, namely the one applied in adults. The results are presented as median (range). RESULTS After matching, SDS height was -0.9 (-3.3;1.6) and 0.3 (-1.4;2.0) in patients and controls, respectively (P<0.001). In younger children (e.g., prepubertal, n=11), bone texture parameters and bone strength were not different using standard analysis. However, using a height-adjusted ROI enabled better characterization of cortical bone structure. In older patients (e.g., pubertal, n=17), there were no differences for height between patients and controls: with the standard evaluation, cortical bone area and cortical thickness were significantly lower in CKD patients: 85 (50-124) vs. 108 (67-154) mm2 and 0.89 (0.46-1.31) vs 1.09 (0.60-1.62) mm, respectively (both P<0.05). CONCLUSIONS Adapting the ROI to leg length enables better assessment of bone structure, especially when height discrepancies exist between controls and patients. Larger cohorts are required to prospectively validate this analytic HR-pQCT technique.
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Abstract
Chronic PTH deficiency has a marked effect on the skeleton, leading to characteristic decreases in bone remodeling and increases in bone mass. An effect on fracture risk has not been demonstrated, although biochemical, imaging, and histomorphometric data indicate abnormalities in skeletal properties1,21,21,21,2. Replacement with PTH leads to a new skeletal state that is maintained with long-term treatment.
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Affiliation(s)
- Mishaela R Rubin
- Metabolic Bone Disease Unit, Columbia University College of P&S, PH8W-864, 630 W. 168th St, New York, NY 10032, United States of America.
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26
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Abstract
Chronic parathyroid hormone (PTH) deficiency has a marked effect on the skeleton, leading to characteristic decreases in bone remodeling and increases in bone mass. Numerous lines of evidence using biochemical, imaging, and histomorphometric methodologies have demonstrated that the skeleton is altered when PTH is absent and that these abnormalities might be reversed with PTH treatment. More evidence is needed to determine whether fracture risk is altered in hypoparathyroidism.
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Affiliation(s)
- Mishaela R Rubin
- Metabolic Bone Disease Unit, Columbia University College of P&S, PH8W-864, 630 West 168th Street, New York, NY 10032, USA.
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27
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Abstract
The history of parathyroid hormone (PTH) replacement therapy for hypoparathyroidism begins in 1929. In 2015, the Food and Drug Administration approved recombinant human PTH(1-84) [rhPTH(1-84)] as a treatment for hypoparathyroidism. Long-term studies of rhPTH(1-84), up to 6 years, have demonstrated continued efficacy of this replacement agent. Approaches to optimize PTH treatment in hypoparathyroidism include subcutaneous pump delivery systems, long-lived carrier molecules, and long-acting PTH analogues that show promise to prolong efficacy. Calcilytic compounds have been explored as a treatment for autosomal dominant hypocalcemia. Calcilytics are negative modulators of the calcium-sensing receptor and may present a therapeutic opportunity to increase endogenous PTH synthesis and secretion.
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Affiliation(s)
- Gaia Tabacco
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA; Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, Rome 00128, Italy
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
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28
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Recurrent kidney stones in a family with a mitochondrial disorder due to the m.3243A>G mutation. Urolithiasis 2018; 47:489-492. [PMID: 30406307 DOI: 10.1007/s00240-018-1087-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/30/2018] [Indexed: 01/13/2023]
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29
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Rubin MR, Zhou H, Cusano NE, Majeed R, Omeragic B, Gomez M, Nickolas TL, Dempster DW, Bilezikian JP. The Effects of Long-term Administration of rhPTH(1-84) in Hypoparathyroidism by Bone Histomorphometry. J Bone Miner Res 2018; 33:1931-1939. [PMID: 29972871 PMCID: PMC6546298 DOI: 10.1002/jbmr.3543] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/04/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022]
Abstract
Hypoparathyroidism is a rare disorder that is associated with abnormal bone properties. Recombinant human parathyroid hormone (1-84) [rhPTH(1-84)] in short-term studies has beneficial skeletal effects. Although rhPTH(1-84) will likely be used indefinitely, long-term effects on skeletal microstructure are unknown. We therefore studied histomorphometric changes with transiliac crest bone biopsies before and after 8.3 ± 1 years of rhPTH(1-84) in 13 hypoparathyroid subjects compared with 45 controls. Before institution of rhPTH(1-84), skeletal remodeling indices were markedly suppressed. With long-term treatment, indices of bone remodeling increased. Mineralizing surface increased by 26-fold (0.3 ± 1 to 7.9 ± 7%, p = 0.003), bone formation rate increased by 15-fold (0.003 ± 0.01 to 0.047 ± 0.05 μm2 /μm/day, p = 0.007), osteoid width doubled (1.9 ± 1 to 4.3 ± 1 lamellae, p = 0.017), and osteoid surface tripled (3.3 ± 3 to 10.8 ± 6%, p = 0.011). Bone resorption as measured by eroded surface increased (4.6 ± 2 to 7.5 ± 3%, p = 0.021). Structural changes demonstrated intratrabecular tunneling, with increases in cancellous bone volume (19.6 ± 5 to 29.1 ± 11%, p = 0.017) and trabecular number (1.8 ± 1 to 2.5 ± 1 #/mm, p = 0.025). Cortical porosity tended to increase (6.3 ± 5 to 9.5 ± 3%, p = 0.07). Mineralizing surface, osteoid surface, and eroded surface surpassed control levels, as did cancellous bone volume, trabecular number, and cortical porosity. These data, the first to reflect such long exposure of any PTH for any disease, illustrate that PTH establishes and maintains a new skeletal state for at least 8 years in hypoparathyroidism. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Mishaela R Rubin
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, USA
| | - Natalie E Cusano
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Rukshana Majeed
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Beatriz Omeragic
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Maximo Gomez
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Thomas L Nickolas
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - David W Dempster
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, USA.,Department of Pathology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - John P Bilezikian
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
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30
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Gafni RI, Langman CB, Guthrie LC, Brillante BA, James R, Yovetich NA, Boyce AM, Collins MT. Hypocitraturia Is an Untoward Side Effect of Synthetic Human Parathyroid Hormone (hPTH) 1-34 Therapy in Hypoparathyroidism That May Increase Renal Morbidity. J Bone Miner Res 2018; 33:1741-1747. [PMID: 29878514 DOI: 10.1002/jbmr.3480] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 11/06/2022]
Abstract
Subcutaneous human parathyroid hormone (hPTH) therapy can effectively manage hypocalcemia in hypoparathyroidism, with varying effects on hypercalciuria. However, little is known about its ability to decrease the renal comorbidities of hypoparathyroidism: nephrocalcinosis (NC), nephrolithiasis (NL), and renal insufficiency. Urinary citrate (Ucit) promotes the solubility of urinary calcium (UCa); hypocitraturia is a risk factor for NC/NL. Twenty-four-hour UCa, Ucit, and UCa/Ucit were determined in 31 hypoparathyroid subjects receiving hPTH 1-34 therapy for up to 5 years. Before hPTH 1-34, the geometric least squares mean UCa was 346 mg/day (normal <250) and Ucit was 500 mg/day (normal 250-1190); UCa/Ucit was 0.67 mg/mg. After 6 months of hPTH 1-34, UCa decreased (238, p < 0.001), but with a greater decrease in Ucit (268, p < 0.001), increasing UCa/Ucit, which became significant over time (p < 0.001). After stopping hPTH 1-34 and resuming conventional therapy (follow-up; FU), compared to the last measures on hPTH 1-34, Ucit rose to 626 (p < 0.001), reducing UCa/Ucit to 0.44, (p < 0.05); UCa also rose (273), but was still lower than baseline (p < 0.05). Daily hPTH 1-34 dose did not correlate with UCa, but was inversely related to Ucit, and directly related to UCa/Ucit (p < 0.01). Mean blood bicarbonate decreased significantly on hPTH 1-34 and remained lower than baseline at FU (p < 0.01). Mean eGFR increased on hPTH 1-34 (86 to 96 mL/min/1.73 m2 , p < 0.001) and returned to baseline at FU. On renal imaging, 6 subjects did not have NC/NL, 8 had NC/NL prior to hPTH 1-34 that remained unchanged, and 16 developed new-onset (n = 10) or progressive (n = 6) NC/NL while on hPTH 1-34. Our data demonstrate that treatment with subcutaneous hPTH 1-34 may have an untoward effect of hypocitraturia and high UCa/Ucit ratio that may increase renal morbidity. With increasing use of PTH therapy in hypoparathyroidism, close monitoring and exploration for treatment of hypocitraturia seem warranted. Published 2018. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Rachel I Gafni
- Skeletal Distorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Craig B Langman
- Feinberg School of Medicine, Northwestern University and the Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Lori C Guthrie
- Skeletal Distorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Beth A Brillante
- Skeletal Distorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Alison M Boyce
- Skeletal Distorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Collins
- Skeletal Distorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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31
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Di Maio S, Soliman AT, De Sanctis V, Kattamis CC. Current treatment of hypoparathyroidism: Theory versus reality waiting guidelines for children and adolescents. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:122-131. [PMID: 29633734 PMCID: PMC6357623 DOI: 10.23750/abm.v89i1.7118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 12/22/2022]
Abstract
The diagnosis of hypoparathyroidism(HPT)is readily made in the presence of hypocalcemia with markedly reduced or absent parathormone (PTH) levels. Currently available treatments for HPT include high dose vitamin D (ergocalciferol, D2 and cholecalciferol, D3) or, the active metabolite dihydroxy vitamin D (calcitriol), in addition to calcium supplements.This regimen, if not well monitored, can lead to hypercalciuria, as PTH deficiency impairs renal calcium reabsorption. Thus the goal of treatment, is to maintain serum calcium at the low end of the normal range. Undertreatment can cause symptomatic hypocalcemia, while overtreatment hypercalciuria, which may lead to nephrolithiasis, nephrocalcinosis, and renal insufficiency. At present, there is no consensus on the management of HPT in children and adolescents and only few studies are available on the long term outcome of patients with recombinant HPT treatment. The purpose of this article is to review, in a comprehensive manner, the major aspects of HPT management in children and adolescents waiting for authoritative guidelines for the treatment of HPT in this group of patients. Further research, addressing specific questions for this population are urgently needed to improve long-term safety of patients. Educational interventions are also needed for professionals, parents and patients to enable them to improve knowledge, quality of life and effective management care at home. (www.actabiomedica.it)
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Affiliation(s)
- Salvatore Di Maio
- Emeritus Director in Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy.
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32
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Underbjerg L, Malmstroem S, Sikjaer T, Rejnmark L. Bone Status Among Patients With Nonsurgical Hypoparathyroidism, Autosomal Dominant Hypocalcaemia, and Pseudohypoparathyroidism: A Cohort Study. J Bone Miner Res 2018; 33:467-477. [PMID: 29087612 DOI: 10.1002/jbmr.3328] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 11/09/2022]
Abstract
Nonsurgical hypoparathyroidism (Ns-HypoPT) and pseudohypoparathyroidism (PHP) are both rare diseases, characterized by hypocalcemia. In Ns-HypoPT, PTH levels are low, whereas patients with PHP often have very high levels due to receptor-insensitivity to PTH (PTH-resistance). Accordingly, we hypothesized that indices of bone turnover and bone mineralization/architecture are similar in Ns-HypoPT and PHP despite marked differences in PTH levels. We studied 62 patients with Ns-HypoPT and 31 with PHP as well as a group of age- and sex-matched healthy controls. We found a significantly higher areal BMD (aBMD) by DXA among patients with Ns-HypoPT, both compared with PHP and the background population. Compared with Ns-HypoPT, PHP patients had significantly lower total and trabecular volumetric BMD (vBMD) assessed by quantitative computed tomography (QCT) scans at the spine and hip. High-resolution peripheral quantitative computed tomography (HRpQCT) scans showed a lower trabecular area and vBMD as well as a lower trabecular number at the tibia in PHP compared to Ns-HypoPT and matched controls. In PHP, PTH levels correlated with levels of markers of bone formation (osteocalcin, bone-specific alkaline phosphatase, P1NP), and bone resorption (CTx). In adult males, levels of bone markers were significantly higher in PHP compared with Ns-HypoPT. Levels of procalcitonin and calcitonin were significantly higher in PHP compared with Ns-HypoPT. In conclusion, indices of bone turnover, density, and microarchitecture differ between patients with Ns-HypoPT and PHP. Our data suggest that patients with PHP do not have a complete skeletal resistance to PTH and that the effects of chronically high PTH levels in PHP are mostly confined to the trabecular tissue. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Line Underbjerg
- Department of Endocrinology and Internal Medicine, Tage-Hansens Gade (THG), Aarhus University Hospital, Aarhus, Denmark
| | - Sofie Malmstroem
- Department of Endocrinology and Internal Medicine, Tage-Hansens Gade (THG), Aarhus University Hospital, Aarhus, Denmark
| | - Tanja Sikjaer
- Department of Endocrinology and Internal Medicine, Tage-Hansens Gade (THG), Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Tage-Hansens Gade (THG), Aarhus University Hospital, Aarhus, Denmark
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33
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Tay D, Cremers S, Bilezikian JP. Optimal dosing and delivery of parathyroid hormone and its analogues for osteoporosis and hypoparathyroidism - translating the pharmacology. Br J Clin Pharmacol 2018; 84:252-267. [PMID: 29049872 PMCID: PMC5777439 DOI: 10.1111/bcp.13455] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/30/2017] [Accepted: 10/08/2017] [Indexed: 12/14/2022] Open
Abstract
In primary hyperparathyroidism (PHPT), bone loss results from the resorptive effects of excess parathyroid hormone (PTH). Under physiological conditions, PTH has actions that are more targeted to homeostasis and to bone accrual. The predominant action of PTH, either catabolic, anabolic or homeostatic, can be understood in molecular and pharmacokinetic terms. When administered intermittently, PTH increases bone mass, but when present continuously and in excess (e.g. PHPT), bone loss ensues. This dual effect of PTH depends not only on the dosing regimen, continuous or intermittent, but also on how the PTH molecule interacts with various states of its receptor (PTH/PTHrP receptor) influencing downstream signalling pathways differentially. Altering the amino-terminal end of PTH or PTHrP could emphasize the state of the receptor that is linked to an osteoanabolic outcome. This concept led to the development of a PTHrP analogue that interacts preferentially with the transiently linked state of the receptor, emphasizing an osteoanabolic effect. However, designing PTH or PTHrP analogues with prolonged state of binding to the receptor would be expected to be linked to a homeostatic action associated with the tonic secretory state of the parathyroid glands that is advantageous in treating hypoparathyroidism. Ideally, further development of a drug delivery system that mimics the physiological tonic, circadian, and pulsatile profile of PTH would be optimal. This review discusses basic, translational and clinical studies that may well lead to newer approaches to the treatment of osteoporosis as well as to different PTH molecules that could become more advantageous in treating hypoparathyroidism.
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Affiliation(s)
- Donovan Tay
- Department of Medicine, College of Physicians and SurgeonsColumbia UniversityNew YorkNY10032USA
- Department of MedicineSengkang HealthSingapore
- Osteoporosis and Bone Metabolism Unit, Department of EndocrinologySingapore General HospitalSingapore
| | - Serge Cremers
- Department of Medicine, College of Physicians and SurgeonsColumbia UniversityNew YorkNY10032USA
- Department of Pathology and Cell BiologyColumbia University Medical CenterNew YorkNY10032USA
- Irving Institute for Clinical and Translational ResearchColumbia University Medical CenterNew YorkNY10032USA
| | - John P. Bilezikian
- Department of Medicine, College of Physicians and SurgeonsColumbia UniversityNew YorkNY10032USA
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34
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Krishnan V, Ma YL, Chen CZ, Thorne N, Bullock H, Tawa G, Javella-Cauley C, Chu S, Li W, Kohn W, Adrian MD, Benson C, Liu L, Sato M, Zheng W, Pilon AM, Yang NN, Bryant HU. Repurposing a novel parathyroid hormone analogue to treat hypoparathyroidism. Br J Pharmacol 2017; 175:262-271. [PMID: 28898923 DOI: 10.1111/bph.14028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 08/31/2017] [Accepted: 09/03/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Human parathyroid hormone (PTH) is critical for maintaining physiological calcium homeostasis and plays an important role in the formation and maintenance of the bone. Full-length PTH and a truncated peptide form are approved for treatment of hypoparathyroidism and osteoporosis respectively. Our initial goal was to develop an improved PTH therapy for osteoporosis, but clinical development was halted. The novel compound was then repurposed as an improved therapy for hypoparathyroidism. EXPERIMENTAL APPROACH A longer-acting form of PTH was synthesised by altering the peptide to increase cell surface residence time of the bound ligand to its receptor. In vitro screening identified a compound, which was tested in an animal model of osteoporosis before entering human trials. This compound was subsequently tested in two independent animal models of hypoparathyroidism. KEY RESULTS The peptide identified, LY627-2K, exhibited delayed internalization kinetics. In an ovariectomy-induced bone loss rat model, LY627-2K demonstrated improved vertebral bone mineral density and biomechanical properties at skeletal sites and a modest increase in serum calcium. In a Phase I clinical study, dose-dependent increases in serum calcium were reproduced. These observations prompted us to explore a second indication, hypoparathyroidism. In animal models of this disease, LY627-2K restored serum calcium, comparing favourably to treatment with wild-type PTH. CONCLUSIONS AND IMPLICATIONS We summarize the repositioning of a therapeutic candidate with substantial preclinical and clinical data. Our results support its repurposing and continued development, from a common indication (osteoporosis) to a rare disease (hypoparathyroidism) by exploiting a shared molecular target. LINKED ARTICLES This article is part of a themed section on Inventing New Therapies Without Reinventing the Wheel: The Power of Drug Repurposing. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.2/issuetoc.
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Affiliation(s)
- Venkatesh Krishnan
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Yanfei L Ma
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Catherine Z Chen
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - Natasha Thorne
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - Heather Bullock
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Gregory Tawa
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - Christy Javella-Cauley
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Shaoyou Chu
- Lead Optimization Biology, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Weiming Li
- Lead Optimization Biology, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Wayne Kohn
- Biotechnology Discovery Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Mary D Adrian
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Charles Benson
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Lifei Liu
- Lead Optimization Biology, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Masahiko Sato
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Wei Zheng
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - Andre M Pilon
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - N Nora Yang
- Therapeutics for Rare and Neglected Diseases (TRND), National Center for Advancing Translational Sciences (NCATS), NIH, Bethesda, MD, USA
| | - Henry U Bryant
- Musculoskeletal Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
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Marcucci G, Della Pepa G, Brandi ML. Hypoparathyroidism and treatment with recombinant human PTH. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1328307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Gemma Marcucci
- Bone Metabolic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Giuseppe Della Pepa
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Maria Luisa Brandi
- Bone Metabolic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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Upreti V, Somani S, Kotwal N. Efficacy of Teriparatide in Patients with Hypoparathyroidism: A Prospective, Open-label Study. Indian J Endocrinol Metab 2017; 21:415-418. [PMID: 28553597 PMCID: PMC5434725 DOI: 10.4103/ijem.ijem_340_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Conventional treatment of hypoparathyroidism with calcium, Vitamin D analogs, and thiazide diuretics is often suboptimal, and these patients have poor quality of life. Teriparatide (parathyroid hormone 1-34 [PTH (1-34)]), an amide of PTH, is widely available for the use in osteoporosis; however, its use in hypoparathyroidism is limited. AIMS The aim of this study is to evaluate the efficacy of PTH (1-34) in the treatment of patients with hypoparathyroidism. SETTINGS AND DESIGN This was a prospective, open-label interventional study in a tertiary care hospital of Indian Armed Forces. SUBJECTS AND METHODS All patients with hypoparathyroidism presented to the endocrinology outpatient department were included and were exhibited injection PTH (1-34) 20 μg twice daily that was gradually reduced to 10 μg twice daily along with calcium, active Vitamin D (alfacalcidol), and hydrochlorothiazide. Oral calcium and alfacalcidol doses were also reduced to maintain serum calcium within normal range. The quality of life (QOL) score was calculated using RAND 36 QOL questionnaire at baseline and termination of the study. STATISTICAL ANALYSIS USED Paired t-test was used to calculate pre- and post-treatment variables. RESULTS Eight patients (two males) were included in this study having mean age of 35.8 years. PTH (1-34) treatment led to the improvement in serum calcium (6.81-8.84 mg/dl), phosphorous (5.8-4.2 mg/dl), and 24 h urinary calcium excretion (416-203.6 mg). Parameters of QOL showed the improvement in overall QOL, physical performance, energy, and fatigue scores. No major adverse events were noted. CONCLUSIONS Treatment of hypoparathyroidism with PTH (1-34) leads to improvement in calcium profile, reduction in hypercalciuria, and improvement in QOL, whereas it is safe and well tolerated.
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Affiliation(s)
- Vimal Upreti
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Shrikant Somani
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Narendra Kotwal
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
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Silva BC, Rubin MR, Cusano NE, Bilezikian JP. Bone imaging in hypoparathyroidism. Osteoporos Int 2017; 28:463-471. [PMID: 27577725 DOI: 10.1007/s00198-016-3750-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 08/19/2016] [Indexed: 10/21/2022]
Abstract
Hypoparathyroidism (HypoPT) is an uncommon endocrine disorder characterized by chronic deficiency or absence of parathyroid hormone (PTH), which leads to a profound reduction in bone remodeling. Subjects with HypoPT typically have bone mineral densities (BMDs) by dual-energy X-ray absorptiometry (DXA) above average at all skeletal sites, with greatest scores observed at the lumbar spine. Trabecular bone score (TBS), an indirect measure of bone microarchitecture, also appears to be normal in HypoPT. By peripheral quantitative computed tomography (pQCT) of the radius, volumetric BMD at cancellous and cortical compartments, as well as cortical area and thickness, are greater in hypoparathyroid subjects than in controls. The use of high-resolution pQCT (HRpQCT) confirmed the increase in cortical volumetric BMD but demonstrated reduced cortical thickness, associated with lower cortical porosity in HypoPT. Trabeculae tend to be more numerous but thinner in hypoparathyroid subjects. It is not clear whether these structural and the dynamic skeletal abnormalities in HypoPT affect bone strength or fracture risk. Treatment of HypoPT with PTH leads to improvement in bone remodeling rate, variable changes in bone density, and a transient increase in estimated bone strength. The effect of PTH therapy on fracture risk remains unknown. This article reviews skeletal involvement and the effect of PTH treatment in patients with HypoPT, as assessed by DXA, TBS, QCT, and HRpQCT. Data on bone strength and fracture risk in HypoPT are also reviewed here.
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Affiliation(s)
- B C Silva
- Department of Medicine, UNI BH, Felicio Rocho Hospital and Santa Casa de Belo Horizonte, Belo Horizonte, Brazil.
- , R. Uberaba, 370/705, Belo Horizonte, MG, 30180-080, Brazil.
| | - M R Rubin
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - N E Cusano
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - J P Bilezikian
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Short-Term PTH(1-34) Therapy in Children to Correct Severe Hypocalcemia and Hyperphosphatemia due to Hypoparathyroidism: Two Case Studies. Case Rep Endocrinol 2016; 2016:6838626. [PMID: 27957353 PMCID: PMC5124465 DOI: 10.1155/2016/6838626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022] Open
Abstract
The standard treatment of hypoparathyroidism is to control hypocalcemia using calcitriol and calcium supplementation. However, in severe cases this approach is insufficient, and the risks of intravenous (i.v.) calcium administration and prolonged hospitalization must be considered. While the use of recombinant human parathyroid hormone 1-34 [rhPTH(1-34)] for long-term control of hypocalcemia has been established, the benefits of short-term rhPTH(1-34) treatment in children have not been explored. We report two patients with hypoparathyroidism treated with rhPTH(1-34). Patient 1 is a 10-year-old female with polyglandular autoimmune syndrome type 1. Patient 2 is a 12-year-old female with hypoparathyroidism after total thyroidectomy. Both patients showed poor response to i.v. and oral calcium and calcitriol, and patient 1 did not respond to phosphate binders. Patient 1 had rapid increase in serum calcium with a decrease in serum phosphate after a 3-day course of subcutaneous rhPTH(1-34). Patient 2 had normalization of calcium and phosphate levels after a 7-day course of rhPTH(1-34). These cases support a role for rhPTH(1-34) in the acute management of hypoparathyroidism in hospitalized patients to more rapidly correct hypocalcemia and hyperphosphatemia, shorten hospitalization, and reduce the need for frequent i.v. calcium boluses.
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39
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Cusano NE, Nishiyama KK, Zhang C, Rubin MR, Boutroy S, McMahon DJ, Guo XE, Bilezikian JP. Noninvasive Assessment of Skeletal Microstructure and Estimated Bone Strength in Hypoparathyroidism. J Bone Miner Res 2016; 31:308-16. [PMID: 26234545 PMCID: PMC4832602 DOI: 10.1002/jbmr.2609] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 07/21/2015] [Accepted: 07/29/2015] [Indexed: 01/09/2023]
Abstract
In hypoparathyroidism, areal bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) is above average, and skeletal indices by bone biopsy are abnormal. We used high-resolution peripheral quantitative computed tomography (HRpQCT) and finite element analyses (FEA) to further investigate skeletal microstructure and estimated bone strength. We studied 60 hypoparathyroid subjects on conventional therapy using DXA, HRpQCT, and FEA of the distal radius and tibia compared with normative controls from the Canadian Multicentre Osteoporosis Study. In hypoparathyroid women and men, areal BMD was above average at the lumbar spine and hip sites by DXA; radial BMD was also above average in hypoparathyroid women. Using HRpQCT, cortical volumetric BMD was increased in the hypoparathyroid cohort compared with controls at both the radius and tibia. Cortical porosity was reduced at both sites in pre- and postmenopausal women and at the tibia in young men with a downward trend at the radius in men. At the tibia, trabecular number was increased in premenopausal women and men and trabecular thickness was lower in women. Ultimate stress and failure load at both sites for the hypoparathyroid subjects were similar to controls. Using a linear regression model, at both radius and tibia, each increment in age decreased ultimate stress and failure load, whereas each increment in duration of hypoparathyroidism increased these same indices. These results provide additional evidence for the critical role of parathyroid hormone in regulating skeletal microstructure. Longer disease duration may mitigate the adverse effects of age on estimated bone strength in hypoparathyroidism.
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Affiliation(s)
- Natalie E Cusano
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Kyle K Nishiyama
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Chengchen Zhang
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mishaela R Rubin
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Stephanie Boutroy
- INSERM UMR 1033, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Donald J McMahon
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - X Edward Guo
- Bone Bioengineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Misof BM, Roschger P, Dempster DW, Zhou H, Bilezikian JP, Klaushofer K, Rubin MR. PTH(1-84) Administration in Hypoparathyroidism Transiently Reduces Bone Matrix Mineralization. J Bone Miner Res 2016; 31:180-9. [PMID: 26111772 PMCID: PMC4830900 DOI: 10.1002/jbmr.2588] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 06/20/2015] [Accepted: 06/23/2015] [Indexed: 11/07/2022]
Abstract
Patients with hypoparathyroidism have low circulating parathyroid (PTH) levels and higher cancellous bone volume and trabecular thickness. Treatment with PTH(1-84) was shown to increase abnormally low bone remodeling dynamics. In this work, we studied the effect of 1-year or 2-year PTH(1-84) treatment on cancellous and cortical bone mineralization density distribution (Cn.BMDD and Ct.BMDD) based on quantitative backscattered electron imaging (qBEI) in paired transiliac bone biopsy samples. The study cohort comprised 30 adult hypoparathyroid patients (14 treated for 1 year; 16 treated for 2 years). At baseline, Cn.BMDD was shifted to higher mineralization densities in both treatment groups (average degree of mineralization Cn.CaMean +3.9% and +2.7%, p < 0.001) compared to reference BMDD. After 1-year PTH(1-84), Cn.CaMean was significantly lower than that at baseline (-6.3%, p < 0.001), whereas in the 2-year PTH(1-84) group Cn.CaMean did not differ from baseline. Significant changes of Ct.BMDD were observed in the 1-year treatment group only. The change in histomorphometric bone formation (mineralizing surface) was predictive for Cn.BMDD outcomes in the 1-year PTH(1-84) group, but not in the 2-year PTH(1-84) group. Our findings suggest higher baseline bone matrix mineralization consistent with the decreased bone turnover in hypoparathyroidism. PTH(1-84) treatment caused differential effects dependent on treatment duration that were consistent with the histomorphometric bone formation outcomes. The greater increase in bone formation during the first year of treatment was associated with a decrease in bone matrix mineralization, suggesting that PTH(1-84) exposure to the hypoparathyroid skeleton has the greatest effects on BMDD early in treatment.
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Affiliation(s)
- Barbara M Misof
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Paul Roschger
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - David W Dempster
- Regional Bone Center Helen Hayes Hospital, West Haverstraw, New York, NY, USA.,Metabolic Bone Diseases Unit, College of Physicians and Surgeons, Columbia University New York, NY, USA
| | - Hua Zhou
- Regional Bone Center Helen Hayes Hospital, West Haverstraw, New York, NY, USA
| | - John P Bilezikian
- Metabolic Bone Diseases Unit, College of Physicians and Surgeons, Columbia University New York, NY, USA
| | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of Social Health Insurance Vienna (WGKK) and Austrian Social Insurance for Occupational Risk (AUVA) Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Mishaela R Rubin
- Metabolic Bone Diseases Unit, College of Physicians and Surgeons, Columbia University New York, NY, USA
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Dong B, Endo I, Ohnishi Y, Kondo T, Hasegawa T, Amizuka N, Kiyonari H, Shioi G, Abe M, Fukumoto S, Matsumoto T. Calcilytic Ameliorates Abnormalities of Mutant Calcium-Sensing Receptor (CaSR) Knock-In Mice Mimicking Autosomal Dominant Hypocalcemia (ADH). J Bone Miner Res 2015; 30:1980-93. [PMID: 25967373 DOI: 10.1002/jbmr.2551] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/16/2015] [Accepted: 05/07/2015] [Indexed: 02/01/2023]
Abstract
Activating mutations of calcium-sensing receptor (CaSR) cause autosomal dominant hypocalcemia (ADH). ADH patients develop hypocalcemia, hyperphosphatemia, and hypercalciuria, similar to the clinical features of hypoparathyroidism. The current treatment of ADH is similar to the other forms of hypoparathyroidism, using active vitamin D3 or parathyroid hormone (PTH). However, these treatments aggravate hypercalciuria and renal calcification. Thus, new therapeutic strategies for ADH are needed. Calcilytics are allosteric antagonists of CaSR, and may be effective for the treatment of ADH caused by activating mutations of CaSR. In order to examine the effect of calcilytic JTT-305/MK-5442 on CaSR harboring activating mutations in the extracellular and transmembrane domains in vitro, we first transfected a mutated CaSR gene into HEK cells. JTT-305/MK-5442 suppressed the hypersensitivity to extracellular Ca(2+) of HEK cells transfected with the CaSR gene with activating mutations in the extracellular and transmembrane domains. We then selected two activating mutations locating in the extracellular (C129S) and transmembrane (A843E) domains, and generated two strains of CaSR knock-in mice to build an ADH mouse model. Both mutant mice mimicked almost all the clinical features of human ADH. JTT-305/MK-5442 treatment in vivo increased urinary cAMP excretion, improved serum and urinary calcium and phosphate levels by stimulating endogenous PTH secretion, and prevented renal calcification. In contrast, PTH(1-34) treatment normalized serum calcium and phosphate but could not reduce hypercalciuria or renal calcification. CaSR knock-in mice exhibited low bone turnover due to the deficiency of PTH, and JTT-305/MK-5442 as well as PTH(1-34) increased bone turnover and bone mineral density (BMD) in these mice. These results demonstrate that calcilytics can reverse almost all the phenotypes of ADH including hypercalciuria and renal calcification, and suggest that calcilytics can become a novel therapeutic agent for ADH.
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Affiliation(s)
- Bingzi Dong
- Department of Medicine and Bioregulatory Sciences, University of Tokushima Graduate School of Medical Sciences, Tokushima, Japan
| | - Itsuro Endo
- Department of Medicine and Bioregulatory Sciences, University of Tokushima Graduate School of Medical Sciences, Tokushima, Japan
| | - Yukiyo Ohnishi
- Department of Medicine and Bioregulatory Sciences, University of Tokushima Graduate School of Medical Sciences, Tokushima, Japan
| | - Takeshi Kondo
- Department of Medicine and Bioregulatory Sciences, University of Tokushima Graduate School of Medical Sciences, Tokushima, Japan
| | - Tomoka Hasegawa
- Department of Developmental Biology of Hard Tissue, Hokkaido University Graduate School of Dental Medicine, Sapporo, Japan
| | - Norio Amizuka
- Department of Developmental Biology of Hard Tissue, Hokkaido University Graduate School of Dental Medicine, Sapporo, Japan
| | - Hiroshi Kiyonari
- Animal Resource Development Unit, RIKEN Center for Life Science Technologies, Kobe, Japan
| | - Go Shioi
- Genetic Engineering Team, RIKEN Center for Life Science Technologies, Kobe, Japan
| | - Masahiro Abe
- Department of Medicine and Bioregulatory Sciences, University of Tokushima Graduate School of Medical Sciences, Tokushima, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, Tokushima, Japan
| | - Toshio Matsumoto
- Fujii Memorial Institute of Medical Sciences, Tokushima University, Tokushima, Japan
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Gafni RI, Guthrie LC, Kelly MH, Brillante BA, Christie CM, Reynolds JC, Yovetich NA, James R, Collins MT. Transient Increased Calcium and Calcitriol Requirements After Discontinuation of Human Synthetic Parathyroid Hormone 1-34 (hPTH 1-34) Replacement Therapy in Hypoparathyroidism. J Bone Miner Res 2015; 30:2112-8. [PMID: 25990370 DOI: 10.1002/jbmr.2555] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/05/2015] [Accepted: 05/11/2015] [Indexed: 11/06/2022]
Abstract
Synthetic human PTH 1-34 (hPTH 1-34) replacement therapy in hypoparathyroidism maintains eucalcemia and converts quiescent bone to high-turnover bone. However, the skeletal and metabolic effects of drug discontinuation have not been reported. Nine subjects with hypoparathyroidism received subcutaneous injections of hPTH 1-34 two to three times daily for 19.8 to 61.3 months and then transitioned back to calcium and calcitriol. Biochemistries and bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) were assessed at baseline, while on treatment, and at follow-up 3 to 12 months after drug discontinuation. Two subjects developed hypocalcemia when hPTH 1-34 was abruptly discontinued. Thus, to avoid hypocalcemia, subjects were slowly weaned from hPTH 1-34 over several weeks. When hPTH 1-34 was stopped, subjects were requiring two to three times pretreatment doses of calcitriol and calcium to maintain blood calcium levels. Doses were gradually reduced over many weeks until calcium levels were stable on doses similar to baseline. Bone-specific alkaline phosphatase (BSAP), N-telopeptide (NTX), and osteocalcin (OC) increased significantly with hPTH 1-34; at follow-up, BSAP and NTX had returned to baseline while OC was still slightly elevated. During treatment, BMD was unchanged at the hip and lateral spine but declined at the anterior-posterior (AP) spine, radius, and total body. During weaning, BMD increased, with the hip and lateral spine exceeding pre-hPTH 1-34 values and the whole body returning to baseline. AP spine was increased non-significantly compared to baseline at follow-up. hPTH 1-34 must be gradually weaned in hypoparathyroid patients with high doses of oral medications given to avoid hypocalcemia. The transient increased requirements accompanied by increased BMD after long-term hPTH 1-34 therapy suggest a reversal of the expanded remodeling space favoring bone formation as the skeleton returns to a low-turnover state, reminiscent of the hungry bone syndrome. Further study and close monitoring is required to ensure safe transition to conventional therapy and to elucidate the physiological mechanism of this phenomenon.
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Affiliation(s)
- Rachel I Gafni
- Skeletal Clinical Studies Unit (SCSU), Craniofacial and Skeletal Diseases Branch (CSDB), National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lori C Guthrie
- Skeletal Clinical Studies Unit (SCSU), Craniofacial and Skeletal Diseases Branch (CSDB), National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Marilyn H Kelly
- Skeletal Clinical Studies Unit (SCSU), Craniofacial and Skeletal Diseases Branch (CSDB), National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Beth A Brillante
- Skeletal Clinical Studies Unit (SCSU), Craniofacial and Skeletal Diseases Branch (CSDB), National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | | | - James C Reynolds
- Clinical Center (CC)/Nuclear Medicine Department (NMD), National Institutes of Health (NIH), Bethesda, MD, USA
| | | | | | - Michael T Collins
- Skeletal Clinical Studies Unit (SCSU), Craniofacial and Skeletal Diseases Branch (CSDB), National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
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Abstract
Age-related fragility fractures are an enormous public health problem. Both acquisition of bone mass during growth and bone loss associated with ageing affect fracture risk late in life. The development of high-resolution peripheral quantitative CT (HRpQCT) has enabled in vivo assessment of changes in the microarchitecture of trabecular and cortical bone throughout life. Studies using HRpQCT have demonstrated that the transient increase in distal forearm fractures during adolescent growth is associated with alterations in cortical bone, which include cortical thinning and increased porosity. Children with distal forearm fractures in the setting of mild, but not moderate, trauma also have increased deficits in cortical bone at the distal radius and in bone mass systemically. Moreover, these children transition into young adulthood with reduced peak bone mass. Elderly men, but not elderly women, with a history of childhood forearm fractures have an increased risk of osteoporotic fractures. With ageing, men lose trabecular bone primarily by thinning of trabeculae, whereas the number of trabeculae is reduced in women, which is much more destabilizing from a biomechanical perspective. However, age-related losses of cortical bone and increases in cortical porosity seem to have a much larger role than previously recognized, and increased cortical porosity might characterize patients at increased risk of fragility fractures.
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Affiliation(s)
- Joshua N Farr
- Endocrine Research Unit and Kogod Center on Aging, Mayo Clinic, Guggenheim 7-11, 200 First Street SW, Rochester, MN 55905, USA
| | - Sundeep Khosla
- Endocrine Research Unit and Kogod Center on Aging, Mayo Clinic, Guggenheim 7-11, 200 First Street SW, Rochester, MN 55905, USA
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44
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Clarke BL. Bone disease in hypoparathyroidism. ACTA ACUST UNITED AC 2015; 58:545-52. [PMID: 25166046 DOI: 10.1590/0004-2730000003399] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 05/14/2014] [Indexed: 01/09/2023]
Abstract
Hypoparathyroidism is a rare disorder that may be acquired or inherited. Postsurgical hypoparathyroidism is responsible for the majority of acquired hypoparathyroidism. Bone disease occurs in hypoparathyroidism due to markedly reduced bone remodeling due to the absence or low levels of parathyroid hormone. Chronically reduced bone turnover in patients with hypoparathyroidism typically leads to higher bone mass than in age- and sex-matched controls. Whether this increased bone density reduces fracture risk is less certain, because while increased bone mineralization may be associated with increased brittleness of bone, this does not appear to be the case in hypoparathyroidism. Treatment of hypoparathyroidism with recombinant parathyroid hormone may reduce bone mineral density but simultaneously strengthen the mechanical properties of bone.
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Affiliation(s)
- Bart L Clarke
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, Minnesota, United States
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Cusano NE, Rubin MR, Bilezikian JP. PTH(1-84) replacement therapy for the treatment of hypoparathyroidism. Expert Rev Endocrinol Metab 2015; 10:5-13. [PMID: 25705243 PMCID: PMC4334142 DOI: 10.1586/17446651.2015.971755] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hypoparathyroidism is a rare disease characterized by hypocalcemia and insufficient circulating levels of parathyroid hormone (PTH). Conventional therapy includes calcium and active vitamin D supplementation, often in large doses. Therapy with calcium and vitamin D, however, does not address certain problematic aspects of the disease, including abnormal bone metabolism and reduced quality of life. Hypoparathyroidism is the only classic endocrine deficiency disease for which the missing hormone, PTH, is not yet an approved treatment. PTH(1-84) may soon become a therapeutic option for patients with hypoparathyroidism. PTH (1-84) has been demonstrated to maintain serum calcium while reducing or eliminating requirements for calcium and active vitamin D supplementation. Data from bone densitometry, bone turnover markers and histomorphometry of bone biopsy specimens show positive structural and dynamic effects on the skeleton. PTH replacement therapy may also be associated with improved quality of life. PTH(1-84) replacement therapy for hypoparathyroidism is promising, although further acquisition of long-term data is needed.
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Affiliation(s)
- Natalie E Cusano
- Author for correspondence: Tel.: +1 212 305 6486, Fax: +1 212 305 2801,
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Abstract
Hypoparathyroidism is a disease characterized by hypocalcemia and insufficient parathyroid hormone (PTH). It is a rare disorder that has been given an orphan disease designation in the United States and European Union. Hypoparathyroidism is the only endocrine deficiency disease for which the missing hormone, PTH, is not yet an approved therapy. Conventional therapy includes calcium and active vitamin D supplementation, often in large doses. Although serum calcium can be controlled with conventional therapy, it can be a challenge and, moreover, does not address other aspects of the disease, such as abnormal skeletal features and reduced quality of life. This review focuses on PTH replacement therapy in hypoparathyroidism, utilizing the full-length molecule PTH(1-84) as well as the fully active but truncated form PTH(1-34). PTH therapy addresses some aspects of the disease not ameliorated with conventional therapy.
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Affiliation(s)
- Natalie E Cusano
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH 8W-864, New York, NY 10032, USA.
| | - Mishaela R Rubin
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH 8W-864, New York, NY 10032, USA.
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH 8W-864, New York, NY 10032, USA.
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Amugongo SK, Yao W, Jia J, Dai W, Lay YAE, Jiang L, Harvey D, Zimmermann EA, Schaible E, Dave N, Ritchie RO, Kimmel DB, Lane NE. Effect of sequential treatments with alendronate, parathyroid hormone (1-34) and raloxifene on cortical bone mass and strength in ovariectomized rats. Bone 2014; 67:257-68. [PMID: 25016965 PMCID: PMC4157684 DOI: 10.1016/j.bone.2014.04.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 04/03/2014] [Accepted: 04/16/2014] [Indexed: 01/10/2023]
Abstract
UNLABELLED Anti-resorptive and anabolic agents are often prescribed for the treatment of osteoporosis continuously or sequentially for many years. However their impact on cortical bone quality and bone strength is not clear. METHODS Six-month old female rats were either sham operated or ovariectomized (OVX). OVX rats were left untreated for two months and then were treated with vehicle (Veh), hPTH (1-34) (PTH), alendronate (Aln), or raloxifene (Ral) sequentially for three month intervals, for a total of three periods. Mid-tibial cortical bone architecture, mass, mineralization, and strength were measured on necropsy samples obtained after each period. Bone indentation properties were measured on proximal femur necropsy samples. RESULTS Eight or more months of estrogen deficiency in rats resulted in decreased cortical bone area and thickness. Treatment with PTH for 3months caused the deposition of endocortical lamellar bone that increased cortical bone area, thickness, and strength. These improvements were lost when PTH was withdrawn without followup treatment, but were maintained for the maximum times tested, six months with Ral and three months with Aln. Pre-treatment with anti-resorptives was also somewhat successful in ultimately preserving the additional endocortical lamellar bone formed under PTH treatment. These treatments did not affect bone indentation properties. SUMMARY Sequential therapy that involved both PTH and anti-resorptive agents was required to achieve lasting improvements in cortical area, thickness, and strength in OVX rats. Anti-resorptive therapy, either prior to or following PTH, was required to preserve gains attributable to an anabolic agent.
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Affiliation(s)
- Sarah K Amugongo
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Wei Yao
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Junjing Jia
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Weiwei Dai
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Yu-An E Lay
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Li Jiang
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA
| | - Danielle Harvey
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA 95616, USA
| | - Elizabeth A Zimmermann
- Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA
| | - Eric Schaible
- Experimental Systems Group, Advanced Light Source, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA
| | - Neil Dave
- Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA
| | - Robert O Ritchie
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA; Department of Materials Science and Engineering, University of California, Berkeley, CA 94720, USA
| | - Donald B Kimmel
- Osteoporosis Research Center, School of Medicine, Creighton University, Omaha, NE 68131, USA
| | - Nancy E Lane
- Musculoskeletal Research Unit, Department of Medicine, University of California Davis Medical Center, Sacramento, CA 95817, USA.
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Xiaodan L, Chi N, Zhen Z, Guanxi W, Guangwen Y, Yunliang G. ZJXG Decoctions Enhance the Fracture Healing by Keeping the Serum Levels of GH,CT and PTH in Rats with Femur Fracture. INT J PHARMACOL 2014. [DOI: 10.3923/ijp.2014.175.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Hypoparathyroidism is a disorder characterized by hypocalcemia, deficient PTH, and abnormal bone remodeling. Standard treatment of hypoparathyroidism consists of oral calcium and vitamin D supplementation. However, maintaining serum calcium levels can be a challenge. In addition, concerns exist regarding hypercalciuria and ectopic calcifications that can be associated with such treatment. Hypoparathyroidism is the only classic endocrine deficiency disease for which the missing hormone, PTH, is not yet an approved treatment. This review focuses on the use of PTH in the treatment of hypoparathyroidism, in the form of teriparatide [PTH(1-34)] and the full-length molecule, PTH(1-84). Studies in hypoparathyroid subjects demonstrate that PTH(1-34) and PTH(1-84) lower or abolish supplemental calcium and vitamin D requirements as well as increase markers of bone turnover. Densitometric and histomorphometric studies in some subjects treated with PTH(1- 34) and PTH(1-84) show an improvement in bone-remodeling dynamics and return of bone metabolism toward normal levels. Given the chronic nature of hypoparathyroidism, and the expectation that PTH will be used for extended periods of time in hypoparathyroidism, further studies are needed to determine the long-term safety of PTH therapy in this population.
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Affiliation(s)
- N E Cusano
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Mannstadt M, Clarke BL, Vokes T, Brandi ML, Ranganath L, Fraser WD, Lakatos P, Bajnok L, Garceau R, Mosekilde L, Lagast H, Shoback D, Bilezikian JP. Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (REPLACE): a double-blind, placebo-controlled, randomised, phase 3 study. Lancet Diabetes Endocrinol 2013; 1:275-83. [PMID: 24622413 DOI: 10.1016/s2213-8587(13)70106-2] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypoparathyroidism results in impaired mineral homoeostasis, including hypocalcaemia and hyperphosphataemia. Treatment with high-dose oral calcium and active vitamin D does not provide adequate or consistent control of biochemical indices and can lead to serious long-term complications. We aimed to test the efficacy, safety, and tolerability of once-daily recombinant human parathyroid hormone 1-84 (rhPTH[1-84]) in adults with hypoparathyroidism. METHODS In this double-blind, placebo-controlled, randomised phase 3 study (REPLACE), we recruited patients with hypoparathyroidism (≥ 18 months duration) aged 18-85 years from 33 sites in eight countries. After an optimisation period, during which calcium and active vitamin D doses were adjusted to achieve consistent albumin-corrected serum calcium, patients were randomly assigned (2:1) via an interactive voice response system to 50 μg per day of rhPTH(1-84) or placebo for 24 weeks. Active vitamin D and calcium were progressively reduced, while rhPTH(1-84) could be titrated up from 50 μg to 75 μg and then 100 μg (weeks 0-5). The primary endpoint was the proportion of patients at week 24 who achieved a 50% or greater reduction from baseline in their daily dose of oral calcium and active vitamin D while maintaining a serum calcium concentration greater than or the same as baseline concentrations and less than or equal to the upper limit of normal, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00732615. FINDINGS Between June 23, 2009, and Feb 28, 2011, 134 eligible patients were recruited and randomly assigned to rhPTH(1-84) (n=90) or placebo (n=44). Six patients in the rhPTH(1-84) group and seven in the placebo group discontinued before study end. 48 (53%) patients in the rhPTH(1-84) group achieved the primary endpoint compared with one (2%) patient in the placebo group (percentage difference 51.1%, 95% CI 39.9-62.3; p<0.0001). The proportions of patients who had at least one adverse event were similar between groups (84 [93%] patients in the rhPTH[1-84] group vs 44 [100%] patients in the placebo group), with hypocalcaemia, muscle spasm, paraesthesias, headache, and nausea being the most common adverse events. The proportions of patients with serious adverse events were also similar between the rhPTH(1-84) group (ten [11%] patients) and the placebo group (four [9%] patients). INTERPRETATION 50 μg, 75 μg, or 100 μg per day of rhPTH(1-84), administered subcutaneously in the outpatient setting, is efficacious and well tolerated as a PTH replacement therapy for patients with hypoparathyroidism.
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Affiliation(s)
- Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Tamara Vokes
- Section of Endocrinology, University of Chicago Medicine, Chicago, IL, USA
| | - Maria Luisa Brandi
- Department of Internal Medicine, University of Florence, Florence, Italy
| | - Lakshminarayan Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
| | - William D Fraser
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Peter Lakatos
- 1st Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Laszlo Bajnok
- 1st Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | | | - Leif Mosekilde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Dolores Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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