Idiopathic short stature

Effect of long-acting PEGylated growth hormone for catch-up growth in children with idiopathic short stature: a 2-year real-world retrospective cohort study

Several evidence gaps exist regarding the use of long-acting polyethylene glycol recombinant human growth hormone (PEG-rhGH) in children with idiopathic short stature (ISS), particularly studies conducted in real-world settings, with long-term follow-up, involving varied dosing regimens, and in comparison with daily rhGH. The study aimed to evaluate the effectiveness, safety, and adherence of once-weekly PEG-rhGH for catch-up growth in children with prepubertal ISS compared to daily rhGH. A real-world retrospective cohort study was conducted in prepubertal children with ISS in China. Children who voluntarily received once-weekly PEG-rhGH or daily rhGH were included and were followed up for 2 years. Ninety-five children were included, 47 received PEG-rhGH 0.2-0.3 mg/kg weekly and 48 received daily rhGH. Outcome measures included effectiveness in catch-up growth, adverse events, and treatment adherence. Height velocity increased significantly in both groups during rhGH therapy. In children who received PEG-rhGH treatment, height velocity was 10.59 ± 1.37 cm/year and 8.75 ± 0.86 cm/year in the first and second year, respectively, which were significantly more than those who received daily rhGH (9.80 ± 1.05 cm/year, P = 0.002, and 8.03 ± 0.89 cm/year, P < 0.001). The height standard deviation score improved at the end of the second year for all children (P < 0.001). However, children who received PEG-rhGH showed more excellent improvement than those with daily rhGH (1.65 ± 0.38 vs. 1.50 ± 0.36, P = 0.001). In children who received PEG-rhGH, lower missed doses were observed than those with daily rhGH (0.75 ± 1.06 vs. 4.4 ± 2.0, P < 0.001). No serious adverse events were observed.

CONCLUSION

PEG-rhGH demonstrated superior effectiveness and adherence compared to daily rhGH in the treatment of children with ISS. The safety profiles were similar between the two treatments.

WHAT IS KNOWN

• Recombinant human growth hormone (rhGH) has been used to increase adult height in children with idiopathic short stature (ISS), and its safety profile is comparable to other indications for growth hormone treatment. • The use of long-acting rhGH in children with ISS is still an area of uncertainty.

WHAT IS NEW

• This 2-year real-world study provides new evidence that PEGylated rhGH (PEG-rhGH) is more effective than daily rhGH in promoting catch-up growth in children with ISS. • PEG-rhGH also demonstrated superior treatment adherence compared to daily rhGH in children with ISS. • The safety profiles of PEG-rhGH and daily rhGH were found to be similar.

Long-acting PEGylated growth hormone in children with idiopathic short stature

OBJECTIVE

To evaluate the safety and efficacy of weekly PEGylated-recombinant human growth hormone (PEG-rhGH) in children with idiopathic short stature (ISS) in China.

DESIGN AND METHODS

This was a multicenter, phase II study in which all subjects were randomized 1:1:1 to weekly s.c. injections of PEG-rhGH 0.1 (low-dose (LD) group) or 0.2 mg/kg/week (high-dose (HD) group) or control for 52 weeks. The primary end point was change (Δ) in height s.d. score (HT-SDS) from baseline to week 52. Secondary end points were height velocity (HV), bone maturity, insulin-like growth factor-1 (IGF-1) SDS, and IGF-1/insulin-like growth factor-binding protein-3 (IGFBP-3) molar ratio.

RESULTS

A total of 360 children with ISS were recruited in the study (n = 120 in each group). At week 52, ΔHT-SDS was 0.56 ± 0.26, 0.98 ± 0.35, and 0.20 ± 0.26 in the LD, HD, and control groups, respectively (within-group P < 0.0001; intergroup P < 0.0001). Statistically significant values of ΔHV, IGF-1, IGF-1/IGFBP-3 ratio, and IGF-1 SDS at week 52 from baseline were observed in both treatment groups (P < 0.0001). There were clear dose-dependent responses for all auxological variables. PEG-rhGH was well tolerated throughout the treatment period with treatment-emergent adverse events (TEAEs) reported in 86.5%, 84.6%, and 91.3% of children in the HD, LD, and control groups, respectively. The incidence of TEAEs was similar in all treatment groups despite the difference in doses. A total of 27 (8.7%) children experienced drug-related TEAEs.

CONCLUSION

Fifty-two-week treatment with PEG-rhGH 0.1 or 0.2 mg/kg/week achieved significant improvement in HT-SDS and other growth-related variables, including HV, IGF-1 SDS, and IGF-1/IGFBP-3 ratio, in a dose-dependent manner. Both doses were well tolerated with similar safety profiles.

A Randomized Controlled Phase 3 Study on the Efficacy and Safety of Recombinant Human Growth Hormone in Children With Idiopathic Short Stature

BACKGROUND

To evaluate the safety and efficacy of daily somatropin (Jintropin^®), a recombinant human growth hormone, in prepubertal children with ISS in China.

METHODS

This study was a multicenter, randomized, controlled, open-label, phase 3 study. All subjects were randomized 3:1 to daily somatropin 0.05 mg/kg/day or no treatment for 52 weeks. A total of 481 subjects with a mean baseline age of 5.8 years were enrolled in the study. The primary endpoint was change in (△) height standard deviation score (HT-SDS) for chronological age (CA). Secondary endpoints included △height from baseline; △bone age (BA)/CA; △height velocity (HV) and △insulin-like growth factor 1 (IGF-1 SDS).

RESULTS

△HT-SDS at week 52 was 1.04 ± 0.31 in the treatment group and 0.20 ± 0.33 in the control group (P < 0.001). At week 52, statistical significance was observed in the treatment group compared with control for △height (10.19 ± 1.47 cm vs. 5.85 ± 1.80 cm; P < 0.001), △BA/CA (0.04 ± 0.09 vs. 0.004 ± 0.01; P < 0.001), △HV (5.17 ± 3.70 cm/year vs. 0.75 ± 4.34 cm/year; P < 0.001), and △IGF-1 SDS (2.31 ± 1.20 vs. 0.22 ± 0.98; P < 0.001). The frequencies of treatment-emergent adverse events (TEAEs) were similar for the treatment and the control groups (89.8% vs. 82.4%); most TEAEs were mild to moderate in severity and 23 AEs were considered study-drug related.

CONCLUSIONS

Daily subcutaneous administration of somatropin at 0.05 mg/kg/day for 52 weeks demonstrated improvement in growth outcomes and was well tolerated with a favorable safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT03635580). URL: https://clinicaltrials.gov/ct2/show/NCT03635580.

Effect of growth hormone treatment on children with idiopathic short stature (ISS), idiopathic growth hormone deficiency (IGHD), small for gestational age (SGA) and Turner syndrome (TS) in a tertiary care center

OBJECTIVES

To assess the long-term effect of growth hormone (GH) therapy in a large cohort of short children with different etiologies.

PATIENTS AND METHODS

We evaluated retrospectively the anthropometric data of 252 short children [height SDS <-2: 154 children with growth hormone deficiency (GHD), 63 with idiopathic short stature (ISS), 26 with SGA, and 9 with Turner syndrome (TS)] who were treated, in our center, with GH between 1-2007 and 1-2018. Before and during recombinamt growth-hormone (recGH) treatment, auxological parameters including height (Ht), weight (Wt), Ht - Z score (HtSDS), body mass index (BMI) and BMISDS were recorded every 6 months; bone age (BA) was assessed every 12 months.

RESULTS

At the end of first year of rhGH therapy and after an average of 3 years treatment all groups of short children had significant increase in HtSDS, which was higher in GHD compared to other groups. Children with GHD, SGA, ISS and TS increased their HtSDS by an average of 2.2, 1.46, 0.6 and 0.99 SD, respectively at the end of follow up period (for all groups, p: <0.001). The bone age/chronological age (BA/CA) ratio did not differ significantly among ISS, GHD and SGA groups after GH therapy. The HtSDS gain was higher in children with GHD compared to other ISS, SGA and TS groups (p:< 0.01; p: 0.015 and p: 0.029, respectively).  HtSDS improvement occurred during the first 3 years of rhGH therapy. The BMISDS increased significantly in children with GHD, after 3 years of rhGH therapy (p: < 0.001). After rhGH treatment, the BMISDS decreased significantly in children with ISS and SGA (p: < 0.01 and < 0.001, respectively) but did not change in children with TS (p: 0.199).

CONCLUSIONS

Children with GHD, SGA, ISS and TS exhibited significant increases in HtSDS when treated with rhGH for 3 years. The HtSDS gain was higher in children with GHD compared to other groups.

Effect of growth hormone treatment on children with idiopathic short stature and idiopathic growth hormone deficiency

PURPOSE

There are inconsistencies in the results reported in a small number of previous studies into growth hormone (GH) treatment in Korean children with idiopathic short stature (ISS) and idiopathic growth hormone deficiency (IGHD). Thus, the authors retrospectively compared the effects of GH in ISS and IGHD.

METHODS

From the medical records of 26 ISS and 30 IGHD children, auxological and biochemical changes including chronologic age (CA), bone age (BA), height standard deviation score (HT-SDS), predicted adult height (PAH), midparental height (MPH), insulin-like growth factor-1 (IGF-1), and insulin-like growth factor binding protein-3 (IGFBP-3) were compared.

RESULTS

Before treatment, IGHD group had younger BA, lower BA/CA ratio, and lower IGF-1 level than those in the ISS group. During GH treatment, the levels of IGF-1 and IGFBP-3 were not different. Although annual BA increment was higher in IGHD group, and annual PAH-SDS increment was higher in ISS group, annual HT-SDS increments were not different. Both HT-SDS and PAH-SDS in the ISS group increased significantly until the end of the second year, and then those were not significantly different from MPH-SDS. In the IGHD group, the HT-SDS showed a significant increase till the end of the second year, and the PAH-SDS was not significantly changed at each year, but both HT-SDS and PAH-SDS were not significantly different from MPH-SDS at the end of the third year.

CONCLUSION

During GH treatment, both HT-SDS and PAH-SDS approached the genetic target range of MPH-SDS after 2 years in ISS children and 3 years in IGHD children.

The Korean herbal formulation Yukmijihwangtang stimulates longitudinal bone growth in animal models

Background

Yukmijihwangtang (YJT) is a traditional Korean medicine that has been used to treat kidney-yin deficiency symptoms such as dizziness and tinnitus. In addition, because it is also thought to nourish kidney-yin, it has been used to treat short stature from congenital deficiency. This study evaluated the effects of YJT on longitudinal bone growth in rats.

Methods

Female adolescent rats were randomly assigned to groups that received distilled water (per os [p.o.] twice a day; control), recombinant human growth hormone (rhGH; 20 μg/kg, subcutaneous [s.c.] once a day), or two different doses of YJT (100 or 300 mg/kg, p.o. twice a day). In each group, treatment was maintained for 4 days. Rats were injected intraperitoneally with 5-bromo-2’-deoxyuridine (BrdU; 50 mg/kg) to label proliferating chondrocytes on days 2 – 4. Tetracycline hydrochloride (20 mg/kg) was injected intraperitoneally to form fluorescent bands on the growth plates on day 3 for measuring the longitudinal bone growth rate. Expression of insulin-like growth factor-1 (IGF-1) and bone morphogenetic protein-2 (BMP-2) in the growth plate was identified using immunohistochemistry.

Results

There was a significant increase in the rate of bone growth in the 300 mg/kg YJT group (523.8 ± 23.7 μm/day; P < 0.05) compared to the control group (498.0 ± 23.8 μm/day), while the 100 mg/kg YJT group exhibited a non-significant increase. The number of BrdU-positive cells in the chondrocytes of the rhGH-treated group exhibited a significant increase (103.8 ± 34.2 cells/mm²) compared to that of the control group (70.3 ± 19.7 cells/mm²), while the 300 mg/kg YJT group had a non-significant increase. Additionally, IGF-1 and BMP-2 were highly expressed in the growth plate in the 300 mg/kg YJT and rhGH groups.

Conclusions

YJT increased the longitudinal bone growth rate by stimulating chondrocyte proliferation with increasing increments of local IGF-1 and BMP-2 expression. Based on these findings, YJT may be a therapeutic candidate for the treatment of growth retardation during adolescence.

An SNP of the ZBTB38 gene is associated with idiopathic short stature in the Chinese Han population

OBJECTIVE

Idiopathic short stature (ISS) refers to extreme short stature without any diagnostic explanation. Recently, three genome-wide association studies discovered associations between the ZBTB38 and adult height in different populations. Therefore, variations in the ZBTB38 might contribute to ISS. Furthermore, one study in Korean population showed that ZBTB38 gene was significantly associated with adult height, but not with ISS. We want to examine whether the variants in ZBTB38 are associated with ISS in Chinese Han.

METHODS

A case-control association study was performed in 268 ISS patients and 513 healthy controls from Chinese Han population. Fourteen tag SNPs were selected and genotyped using SNaPshot method. Furthermore, expression of mRNA was quantified by RT-qPCR, and assessment of allelic expression imbalance was conducted with SNaPshot method.

RESULTS

Seven ZBTB38 SNPs were significantly associated with ISS by allele tests (rs724016, rs1582874, rs11919556, rs6440006, rs7612543, rs62282002, rs18651435). And five loci were associated with ISS according to genotype (rs11919556, rs16851419, rs6440006, rs62282002, rs18651435). Notably, after applying the stringent Bonferroni correction for multiple testing, one SNP, rs16851435, remained significantly associated by allele and genotype (P = 5·30 × 10⁻⁴ for allele and P = 0·002 for genotype). Furthermore, the rs16851435 alleles were investigated association with ZTBT38 mRNA expression levels. The G allele showed a higher transcriptional activity than the T allele (P = 0·002).

CONCLUSIONS

Our study indicated that the nonsynonymous SNP (rs16851435:T > G,p.Ser319Ala) of ZBTB38 was contributed to susceptibility of ISS in the Chinese Han population.

Amomum villosum induces longitudinal bone growth in adolescent female rats

OBJECTIVE

This study was conducted to evaluate the effect of Amomum villosum on longitudinal bone growth.

METHODS

Adolescent female Sprague-Dawley rats were divided into 3 groups and treated for 4 days: control (distilled water, p.o.), recombinant human growth hormone (rhGH; 100 microg/kg, s.c.), and A. villosum (500 mg/kg, p.o.) groups. On day 3, tetracycline (20 g/kg, i.p.) was injected for growth plate identification. On days 2, and 4, 5-bromo-2'-deoxyuridine (BrdU) (50 mg/kg, i.p.) was injected to label proliferating cells. On day 5, tibias were dissected and fixed in 4% paraformaldehyde, dehydrated, and sectionedfor immunohistochemistry and histomorphometry.

RESULTS

The rate of bone growth in the A. villosum and rhGH groups increased to (410 +/- 44) and (389 +/- 46) microm/day (P<0.01), respectively, as compared with the control (330.7 +/- 34.7) microm/day. The thickness of the growth plates also increased to (591 +/- 37) and (598 +/- 32) microm, respectively, as compared with the control (524 +/- 89) microm (P<0.001). The number of BrdU-positive cells in the chondrocytes of the A. villosum and rhGH groups was also significantly higher (126 +/- 24) and (143 +/- 18) cells/mm2, respectively) than in the control (109 +/- 25) mm2 (P<0.05). Insulin-like growth factor-1 and bone morphogenetic protein-2 in the A. villosum and rhGH groups were highly expressed in the growth plate as compared with the control samples, indicating increased bone formation.

CONCLUSIONS

A. villosum could be used to treat growth retardation during adolescence.

Analysis of short stature cases referred for genetic evaluation

OBJECTIVE

To retrospectively analyze the profile of patients who presented with chief complaint of short stature to Medical Genetics OPD of SGPGIMS, Lucknow, India.

METHODS

Medical Genetics OPD records were searched for cases presenting with short stature, from January 2008 through December 2010. Short stature was defined as height less than -2 SD from mean for the corresponding age and sex for the Indian population. The workup done for the cases was analyzed, following which they were placed in one of the etiological categories of short stature.

RESULTS

A total of 137 cases were analyzed. The number of female and male patients was 92 and 45 respectively. The evaluation done in majority of cases included anthropometry, calculation of mid-parental height, medical history, routine biochemistry and hematology, bone age assessment, thyroid function tests, antiendomysial antibody testing, karyotyping and other appropriate investigations as required. The percentages of cases in the various diagnostic categories were- skeletal dysplasia (32.1 %), turner syndrome (16.7 %), endocrine deficiencies (8 %), genetic syndromes (7.3 %), chronic diseases (5.8 %). Twenty one (15.3 %) cases grouped as idiopathic short stature consisted of 9 familial and 12 non-familial cases. Twenty (14.6 %) cases were found to be incompletely evaluated.

CONCLUSIONS

Skeletal dysplasias and turner syndrome accounted for majority of cases of short stature. Cause remains unidentified in 15.3 % cases and these idiopathic cases need further workup especially for the molecular defects in the pituitary GH-IGF1 axis. A detailed evaluation and good follow up of cases of short stature is required.

Puberty and pubertal growth dynamics in children with idiopathic short stature

OBJECTIVE

As the prognosis for final height is unfavorable for children with idiopathic short stature (ISS), we studied the pubertal growth dynamics in these children, which is a determinant factor in final height.

SUBJECTS/METHODS

In a retrospective cohort study, we analyzed the pubertal period, age of puberty and peripubertal growth in 50 children with ISS.

RESULTS

The onset of puberty occurred later. Growth rate tended to become increasingly subnormal in the prepubertal period and height was -2.45 SD at puberty onset. Growth reaccelerated at this point, which tended to correct the deviation from the mean height, but it was insufficient to obtain a normal final height.

CONCLUSIONS

The dynamics of growth in children with ISS showed a distinct pattern in the prepubertal and pubertal periods and puberty is significantly delayed in this population. These patterns could explain the unfavorable prognosis for children with ISS.

Skeletal age in idiopathic short stature: An analytical study by the TW3 method, Greulich and Pyle method

BACKGROUND

The skeletal age in short stature and in various other growth abnormalities is well documented. We lack the study pertaining to the analysis of the skeletal age in idiopathic short stature or analyzing the difference in skeletal age delay or advancement between the familial short stature (FSS) and non-familial short stature (non-FSS) groups, hence this study. Present retrospective study is designed to study the variation in patterns of skeletal age in ISS.

MATERIALS AND METHODS

One hundred and eighty six patients, 95 males and 91 females of idiopathic short stature were examined to assess the skeletal age deviation in relation to chronological age. The radiographs of the left hand and wrist were done. The skeletal age was assessed using Tanner and Whitehouse (TW3) method and Greulich and Pyle (GP) atlas. The patients were divided into two groups based on the parental heights. Group A (Familial Short Stature; FSS) with 100 patients (55 males, 45 females) included patients whose at least one parent was short and Group B (non-Familial Short Stature; non-FSS) with 86 patients (40 males, 46 females), included patients whose parental height was normal. The carpal scores, RUS (Radius, Ulna and Short bone) scores and GP age were determined and the respective delay or advances were calculated.

RESULTS

The skeletal age in Group A was delayed relative to chronological age by a mean of 1.9 years in males and 2.3 years in females (P<0.05) by RUS method, mean of 2.7 years in males and 2.6 years in females by Carpal score (P<0.05), 2.2 years in males and 2.7 years in females by GP atlas age (P<0.05). The skeletal age in Group B was advanced by a mean of 0.9 years in males and 1.4 years in females (P<0.05) by RUS method, mean of 0.4 years in males and 0.35 years in females by Carpal score (P<0.05), mean of 1.1 years in males and 0.2 years in females by GP atlas method (P<0.05). The Pearson's coefficient of correlation (P<.001) demonstrated good agreement association between all three scores.

CONCLUSIONS

There is definite age delay in both males and females in the FSS group while the bone maturation is accelerated in the non-FSS group. Both RUS and GP show good correlation amongst both the genders in both the groups and there is good inter observer correlation for both the methods. We can hypothesize that while treatment protocols to accelerate bone age will be beneficial in the FSS group, these should be avoided in the non-FSS group. Our study also indicates that there definitely exists a difference in normal growth curves in both these groups and a detailed study is required to plot their respective normal growth lines so as to make proper adjustments in the assessment of the remaining growth and limb lengthening protocols.

Comparison of the prevalence of shortness, underweight, and overweight among US children aged 0 to 59 months by using the CDC 2000 and the WHO 2006 growth charts

OBJECTIVE

To compare the prevalence of shortness, underweight, and overweight by using the Centers for Disease Control and Prevention (CDC) 2000 and the World Health Organization (WHO) 2006 growth charts. These comparisons are undertaken with 2 sets of cutoff values.

STUDY DESIGN

Data from the National Health and Nutrition Examination Survey 1999-2004 were used to calculate the prevalence estimates in US children aged 0 to 59 months (n = 3920). Cutoff values commonly used in the United States, on the basis of the 5th percentile of height-for-age to define shortness, the 5th percentile of weight-for-height or weight-for-age to define underweight, and the 95th percentile of weight-for-height or body mass index-for-age to define overweight were compared with the cutoff values recommended by WHO, which use <-2 z-score (equivalent to 2.3rd percentile) to define shortness and underweight and >or=2 z-score (equivalent to 97.7th percentile) to define overweight. A comparison with the same cutoff values (5th and 95th) in the 2 charts was also performed.

RESULTS

Applying the 5th or 95th percentile, we observed a higher prevalence of shortness and overweight for all the age groups when the WHO 2006 growth charts were used than when the CDC 2000 growth charts were used. Applying the 5th percentile to the WHO 2006 charts produced lower rates of underweight than did the CDC 2000 charts. However, applying the 5th or 95th percentiles to the CDC 2000 charts and the WHO-recommended cutoff values of -2 or +2 z-score to the WHO charts produced smaller differences in the prevalence of shortness and overweight than were seen when the 5th and 95th percentiles were applied to both the CDC and WHO charts.

CONCLUSIONS

Estimates of the prevalence of key descriptors of growth in children aged 0 to 59 months vary by the chart used and the cutoff values applied. The use of the 5th and 95th percentiles for the CDC growth charts and the 2.3rd and 97.7th percentiles for the WHO growth charts appear comparable in the prevalence of shortness and overweight, but not underweight. If practitioners were to use the WHO growth charts, it might be more appropriate to adopt the WHO recommended cutoff values as well, but this would be a change for office practice.

[Growth hormone and idiopathic short stature]

Idiopathic short stature is defined by height below 3rd percentile, in a child with normal birth height and weight, lack of dysmorphy, endocrine deficiency or systemic disease. Food and Drugs administration approved GH treatment in this indication in the United States, because it induces height gain, and sometimes may increase quality of life. There is no consensus in terms of duration, monitoring parameters, benefits and risks of long term GH treatment in these patients. Cost effectiveness of such a treatment is under debate, and ethical considerations also have to be taken into account. Recombinant IGF1 should not be proposed in this indication at the moment, due to the lack of sufficient data on potential GH insensitivity in a subgroup of these patients.

Individualized therapy for growth hormone deficiency

The use of human growth hormone to treat children with short stature resulting from growth hormone deficiency or insufficiency has now accrued over 40 years of clinical experience with a satisfactory safety and efficacy record. Growth hormone deficiency is the primary indication for growth hormone treatment in childhood. It is basically a clinical diagnosis, based upon auxologic features, and confirmed by biochemical testing. For assurance of compliance, dosing and, perhaps, safety considerations, a dosing algorithm based upon insulin-like growth factor-I response seems to be appropriate. Current data suggest that such algorithms reflect the true growth hormone needs of a patient, and allow optimization of growth hormone treatment. For patients who display a suboptimal growth response or in whom the insulin growth factor levels remain low with assurance of adherence to the injection schedule, it is reasonable to increase the growth hormone dose. The availability of recombinant human insulin-like growth factor-I treatment may provide an alternative for massively increasing the dose of growth hormone. Dose reductions should be considered for patients with serum insulin-like growth factor-I levels substantially above the normal range.