Growth hormone (GH) replacement in GH-deficient adults: a crossover trial comparing the effect on metabolic control, well-being and compliance of three injections per week versus daily injections

Investigating the Bioavailability and Insulin-like Growth Factor-I Release of Two Different Strengths of Somapacitan: A Randomised, Double-Blind Crossover Trial

STUDY DESIGN AND OBJECTIVE

Randomised, double-blind, crossover trial to confirm bioequivalence of somapacitan, a long-acting growth hormone (GH), in 5 mg/1.5 mL and 10 mg/1.5 mL strengths in equimolar doses.

METHODS

Healthy participants were randomised (1:1:1) to subcutaneous somapacitan treatment in one dosing period with 5 mg/1.5 mL and two periods with 10 mg/1.5 mL. Eligibility criteria included age 18-45 years and body mass index 18.5-24.9 kg/m2. Exclusion criteria included history of GH deficiency, previous GH treatment, weight > 100.0 kg and participation in any clinical trial of an investigational medicinal product within 45 days or five times the half-life of the previous investigational product before screening. Area under the curve from time 0 until last quantifiable observation (AUC0-t), maximum serum concentration (Cmax), time to Cmax and terminal half-life of somapacitan and safety were assessed.

RESULTS

In total, 33 participants were randomised. For AUC0-t, estimated treatment ratio (ETR) (5 mg/1.5 mL versus 10 mg/1.5 mL) was 0.95 (90% confidence interval [CI] 0.89-1.01). Point estimate and 90% CIs were within the acceptance range (0.80-1.25). For Cmax, ETR was 0.77 (90% CI 0.68-0.89). Point estimate and 90% CIs were outside the acceptance range (0.80-1.25). Mean insulin-like growth factor-I (IGF-I) and IGF-I standard deviation score concentration-time curves for each strength were almost identical. No new safety issues were identified.

CONCLUSIONS

Bioequivalence criterion for somapacitan 5 mg/1.5 mL and 10 mg/1.5 mL was met for AUC0-t but not for Cmax. The two strengths had equivalent IGF-I responses.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03905850 (3 April 2019).

Guidance for the treatment of adult growth hormone deficiency with somapacitan, a long-acting growth hormone preparation

Adult growth hormone deficiency (AGHD) is a rare endocrine disorder characterized by an abnormal body composition, metabolic abnormalities associated with increased cardiovascular diseases, bone loss, and impaired quality of life. Daily subcutaneous injections with recombinant growth hormone (GH) can alleviate the abnormalities associated with AGHD. Several long-acting GH (LAGH) preparations are currently in development that aim to reduce treatment burden for patients receiving daily GH injections. Somapacitan (Sogroya^®; Novo Nordisk, Denmark) is the first LAGH preparation that has been approved for treatment of AGHD in the United States, Europe, and Japan. The recent approval of somapacitan and anticipated approval of other LAGH molecules presents new questions for physicians planning to treat AGHD with LAGH in the future. Differences in the technologies used to prolong the half-life of recombinant GH are expected to result in variations in pharmacokinetic and pharmacodynamic profiles between preparations. Therefore, it is essential that physicians understand and consider such variations when treating patients with these novel GH replacement therapies. Here, we present a set of treatment recommendations that have been created to guide physicians initiating therapy with somapacitan in patients with AGHD who are eligible for GH replacement. Furthermore, we will review the published data that underlie these recommendations to explain the rationale for the treatment and monitoring advice provided.

Patient preferences for growth hormone treatment in Japanese children

BACKGROUND

There are not clear evidence to date evaluating patients' and caregivers' preferences for the recombinant-human growth hormone (r-hGH) injection in children in Japan. This study aimed to quantitatively evaluated the factors driving preferences for daily r-hGH injections among Japanese children with growth hormone deficiency (GHD) or their caregivers and to determine the relative importance of treatment delivery factors.

METHODS

This study was performed among Japanese children with GHD or their caregivers who visited a specialized clinic in Japan as part of their routine care. The participants were asked to complete a web-based discrete choice experiment (DCE) questionnaire.

RESULTS

Choice-based conjoint analysis was used to evaluate the relative importance of the attributes of the choice predictors and determine utility scores for each attribute. Of the 47 respondents who participated in this study, 41 were caregivers who responded on behalf of the patients, the remaining six were patients who completed the DCE themselves. The injection schedule was found to be the most important factor for both patients and caregivers; a once-weekly injection schedule was preferred over a daily injection schedule. Storage and preparation was deemed more important to patients than it was to caregivers, with patients preferring storage at room temperature even if it required additional mixing (reconstitution). Both patients and caregivers showed a clear preference for devices that offered a dose-setting memory.

CONCLUSIONS

A less frequent injection schedule may enhance adherence to r-hGH treatment and expected improve quality of life for GHD patients over the long term.

Adherence, Attitudes and Beliefs of Growth Hormone Deficient Patients - A Questionnaire-based Cohort Study

INTRODUCTION

GHD is a chronic and systemic disease requiring daily replacement of growth hormone (GHRT). Adherence and attitudes of adult GHD patients are not well known. We sought to assess patients' knowledge of growth hormone deficiency (GHD) in association with treatment adherence and attitudes regarding available and upcoming treatment options.

METHODS

We performed a cross-sectional survey with a custom-made questionnaire at a single centre assessing data on demographics, knowledge of GHD, adherence and attitudes towards GHRT.

RESULTS

Of 106 eligible patients actively followed for GHD 70 returned the completed survey (return-rate 66%, 34 m/36 f; age 56±14 years). 46 patients were actively treated, but almost one third (n=24) refused GHRT. 12 patients had participated in clinical trials with LAGH (long-acting growth hormone). Overall, patients with GHRT showed good adherence. Patients refusing GHRT mostly feared side effects and/or had a lack of information/perceived effect. Disease knowledge and level of education were higher in treated than untreated patients (p=0.023/0.017). Only 36% of respondents would initiate treatment with LAGH. Patients with prior LAGH experience and patients with childhood-onset GHD were more likely to adopt LAGH (p=0.048/0.031).

DISCUSSION

Most often, misinformation causes patients to refuse GHRT. Possibly the understanding of their condition and consequences of non-treatment is limited. To improve adherence more focused educational and behavioural strategies may be needed. Willingness to begin a therapy with LAGH was lower than expected (36%). The reasons for reluctance against LAGH need to be elucidated.

More Favorable Metabolic Impact of Three-Times-Weekly versus Daily Growth Hormone Treatment in Naïve GH-Deficient Children

OBJECTIVE

To evaluate whether two different regimens of weekly injections could lead to similar auxological and metabolic effects in children with growth hormone deficiency (GHD).

DESIGN

32 GHD children (25 males, mean age 10.5 ± 2.2 yr) were randomly assigned to receive daily (group A, 16 patients) or TIW (group B, 16 patients) GHT for 12 months.

METHODS

Auxological parameters, insulin-like growth factor-I (IGF-I), glucose and insulin during OGTT, glycosylated hemoglobin (HbA1c), lipid profile, the oral disposition index (DIo), the homeostasis model assessment estimate of insulin resistance (Homa-IR), and the insulin sensitivity index (ISI).

RESULTS

After 12 months, both groups showed a significant and comparable improvement in height (p < 0.001) and IGF-I (p < 0.001). As regards the metabolic parameters, in both groups, we found a significant increase in fasting insulin (p < 0.001 and p = 0.026) and Homa-IR (p < 0.001 and p = 0.019). A significant increase in fasting glucose (p = 0.001) and a decrease in ISI (p < 0.001) and DIo (p = 0.002) were only found in group A.

CONCLUSIONS

The TIW regimen is effective and comparable with the daily regimen in improving auxological parameters and has a more favorable metabolic impact in GHD children. This trial is registered with ClinicalTrials.gov NCT03033121.

Is insulin-like growth factor-I a good marker for treatment adherence in growth hormone deficiency in adulthood?

OBJECTIVE

There is a paucity of studies on adherence to growth hormone treatment in growth hormone deficient (GHD) adults. Therefore, this study reports on adherence to GH-replacement therapy in adults with GHD, with a special focus on the course and potential predictors of nonadherence.

DESIGN

Retrospective single-centre cohort study.

PATIENTS

From the local patient database, 179 suitable patients with GHD were identified.

MEASUREMENTS

The primary outcome was adherence assessed by calculating the percentage of available prescription data in comparison with recommended GH dosages over a mean follow-up period of 92·4 months. Patients were categorized into five adherence categories ranging from <20% to >80%.

RESULTS

Mean overall adherence was 74·0%, with 52·9% of patients falling into the adherence group of >80% and 8·8% of <20%. There was a significant drop in adherence (9·8%) between the first and second years of treatment (P < 0·001). Patients with childhood-onset GHD were significantly less adherent to GH treatment than patients with adult-onset GHD (62·0% vs 77·0%, P = 0·012); however, this finding was no longer significant after including age as a covariate. Frequency of IGF-1 levels lying outside the age- and sex-specific reference range was not a good indicator for adherence.

CONCLUSION

Although overall adherence was relatively high in our study sample, there is a significant amount of patients who should be regarded as nonadherent. This applies in particular to younger patients. Treating physicians should be aware of the fact that IGF-1 levels do not seem to be a good indicator for adherence.

Understanding the growth hormone therapy adherence paradigm: a systematic review

INTRODUCTION

Growth hormone (GH) therapy is used to treat a variety of growth disorders in childhood/adolescence. Its efficacy is thought to be dependent on patients' adherence to their treatment regimen.

METHODS

PubMed was searched using the keywords 'growth hormone', 'child'[Mesh], 'adolescent'[Mesh], and 'patient compliance'[Mesh].

RESULTS

Most studies of adherence to paediatric GH therapy have used either issued/encashed GH prescriptions or questionnaires. Estimates of prevalence of non-adherence vary from 5-82%, depending on the methods and definitions used. Different studies have variously demonstrated an association (or lack thereof) between adherence and age, socioeconomic status, treatment duration, injection device used and injection-giver. A number of interventions have been proposed to improve adherence, including offering a choice of injection device, but none are supported by trials. Poor adherence is associated with reduced height velocity and likely increased economic costs; evidence for other effects is circumstantial.

CONCLUSION

Adherence to paediatric GH therapy is suboptimal, which may partially explain why the mean final height attained is below that of the general population. Analysis of the causes of non-adherence is complicated by conflicting evidence from different studies. Multifactorial interventions are most likely to be successful in improving adherence. We make recommendations for further research.

Developments in administration of growth hormone treatment: focus on Norditropin® Flexpro®

Recombinant human growth hormone is used for the treatment of growth failure in children and metabolic dysfunction in adults with growth hormone deficiency. However, conventional growth hormone therapy requires daily subcutaneous injections that may affect treatment adherence, and subsequently efficacy outcomes. To enhance potential treatment adherence, improved ease of use of growth hormone delivery devices and long-acting growth hormone formulations are now being developed. Flexpro(®), approved by the US Food and Drug Administration in March 2010, is the most recent pen device developed by Novo Nordisk A/S to deliver Norditropin(®). It is a multidose, premixed, preloaded, disposable pen device that requires relatively less force to inject and does not require refrigeration after initial use. Dose adjustments can be optimized by small dose increments of the pen delivery device at 0.025 mg, 0.05 mg and 0.1 mg. In addition, for patients with needle anxiety, NovoFine(®) needles, some of the shortest and thinnest available, and Autocover(®), which hides the needle during injections, can be used with the Flexpro pen device. This article reviews the Norditropin Flexpro pen device in the context of other growth hormone delivery devices, sustained-release growth hormone formulations in development, and future prospects.

Human growth hormone treatment: synthesis of literature on product delivery systems and administration practices

PURPOSE

To synthesize current literature on recombinant human growth hormone (rhGH) use and to identify areas of research that have received little to no attention in light of administration practice and patient perception/behavior.

DESIGN AND METHODS

Relevant articles for a systematic review were identified through PubMed.

RESULTS

A total of 43 articles were identified: 9 (15.9%) studies on product administration practices and 34 (84.1%) on patient behavior patterns. Patients primarily preferred simple, convenient, and easy-to-use delivery devices. However, literature addressing the effect of convenient product administration practices on treatment outcomes using real-world patient/caregiver data is lacking.

PRACTICE IMPLICATIONS

Better understanding of real-world product administration practices will help nurses identify areas of improvement in patient education and training.

Observations of nonadherence to recombinant human growth hormone therapy in clinical practice

BACKGROUND

The effectiveness of all prescribed treatments is contingent on patient adherence. The reported levels of adherence to recombinant human growth hormone (r-hGH) therapy are highly variable, but it has been suggested that nonadherence might be as high as 36% to 49%.

OBJECTIVES

This commentary discusses the factors that affect long-term adherence to injection treatment, of which r-hGH therapy is a particular challenge. It also explores potential strategies to improve adherence to injection treatments in clinical practice.

METHODS

The opinion of the authors was validated and supported by published literature. A PubMed literature search was conducted in November 2006, identifying English-language articles containing key terms growth hormone, adherence, and compliance.

RESULTS

This study found that factors associated with poor adherence to injection treatments include patients' lack of understanding of their disease, patient age, chronicity of the disease, complex treatment regimens, and insufficient information on the implications of nonadherence. Strengthening the patient-physician relationship by providing the patient with a clear understanding of his/her disease and the benefits of adherence, making improvements in injection devices, and eliminating subjective illness concepts, might increase adherence to SC injection treatments, thereby reducing increasing health care costs associated with nonadherence.

CONCLUSIONS

Poor adherence to r-hGH therapy has a dual effect, in that it leads to reduced efficacy out-comes and increased health care costs. Implementing strategies to improve adherence with injection treatment might be of particular clinical benefit to patients undergoing r-hGH therapy.

Malnutrition during lactation changes growth hormone mRNA expression in offspring at weaning and in adulthood

Mothers' nutrition during lactation programs growth in their offspring. We studied the contribution of the growth hormone (GH) for this programming, evaluating GH mRNA expression. Lactating dams were grouped as follows: C, control diet with 23% protein; PR, 8% protein-restricted diet; and ER, energy-restricted diet, receiving the control diet in restricted quantities of the PR group's ingestion. Some pups were killed at weaning; the others received the control diet until they were sacrificed as adults. Pituitary GH mRNA was analyzed by Northern blot analysis. At weaning, the ER and PR animals had lower GH mRNA levels (-29% and -18%, respectively) and lower length as well as body weight. Ninety-day-old PR offspring showed a lower body length (-5%), whereas ER offspring showed a higher one (+5%); however, at 180 days, the lengths were not different. Both 90- and 180-day-old animals showed body weight differences against control animals, with PR offspring showing a lower (-10%) and ER offspring showing a higher (+12%) body weight. GH mRNA was higher in ER offspring at 90 and 180 days (+19% and +22%, respectively); it was lower in PR offspring at 90 and 180 days (-19% and -17%, respectively). Thus, we showed a direct relation between GH mRNA expression and length as well as body weight. We suggest that malnutrition during lactation may program GH mRNA expression patterns in adulthood and that these changes could be responsible for differences in growth patterns.

Long-term GH treatment of GH-deficient adults: comparison between one and two daily injections

The physiological pulsatile secretion of GH in humans might be important for the metabolic effects of GH. In the treatment of GH-deficient (GHD) patients, the most common regimen is a single sc injection at bedtime. It has not been completely established if this is the optimal mode of GH administration during long-term GH treatment. The aim of the present study was to evaluate the metabolic effects of two different GH replacement regimens comparing one to two daily injections. Eight men and six women, 42-78 yr old, with verified severe GHD, participated. Patients were matched for gender, age and body mass index (BMI) and were randomized to GH therapy (one or two injections daily) for 12 months. GH doses were individually titrated to IGF-I levels of age-matched controls. IGF-I, glucose, insulin, oral glucose tolerance test (OGTT), cholesterol, triglycerides, lipoproteins, including size fractionation with fast performance liquid chromatography, BMI and body composition were analyzed. After 12 months the median GH dose was 0.45 mg (range 0.25-0.50 mg) in both groups. Body fat had decreased by 20% (p<0.05) in the group receiving one daily GH injection. There were no differences between the two treatment groups in indices of carbohydrate or lipid metabolism. The administration of GH divided into two daily doses offered no major advantage as compared to the more convenient single injection in the evening. The GH-induced reduction in body fat occurred independently from changes in serum lipids.

Effects of resistance exercise and growth hormone administration at low doses on lipid metabolism in middle-aged female rats

hGH (human growth hormone) is a key factor for metabolism as well as for growth. Lack of hGH usually increases LDL (low-density lipoprotein) while impairing exercise capacity and cardiac function [Amato G., Carella C., Fazio S., La Montagna G., Cittadini A., Sabatini D., Marciano-Mone C., Sacca L., and Bellastella A., 1993. Body composition, bone metabolism, and heart structure and function in growth hormone (GH)-deficient adults before and after GH replacement therapy at low doses. J. Clin. Endocrinol. Metab. 77, 1671-1676.]. It is still unclear, however, whether the administration of hGH to humans or animals has a synergic effects on body composition and the desired metabolic parameters with endurance resistance exercise. Therefore, the present study seeks to establish whether or not lipid metabolism is altered by both recombinant GH (growth hormone) and X (resistance exercise) in middle-aged female rats. GH administration resulted in greater weight gain compared with control and exercised animals, but the effect was reduced when combined with exercise. The increased body weight was largely due to increased muscle mass. Exercise did not result in any additional effect of GH on muscle mass. In the exercise group, hepatic HDL (high density lipoprotein) increased compared to the C (control group). The GX (growth hormone+exercise) group's serum and X group's kidney IGF-I (Insulin-like growth factor-I) concentration increased compared to the C group. In G and GX groups, serum insulin and leptin concentrations were higher than in the control, suggesting that GH may induce an insulin resistant state. Any gains in muscle mass were minimal and were not synergistic with exercise. These results suggest that hGH may not be useful for increasing performance in athletes and may induce and acquired insulin resistance.