Growth hormone, insulin-like growth factor I, and benign intracranial hypertension

Utilizing Somapacitan, a Long-acting Growth Hormone Formulation, for the Treatment of Adult Growth Hormone Deficiency: A Guide for Clinicians

OBJECTIVE

Somapacitan is the first approved and currently the only long-acting growth hormone (GH) formulation in the United States for treatment of adults with growth hormone deficiency (GHD). The aim of this review was to provide a practical approach for clinicians on how to utilize somapacitan in the treatment of adults with GHD.

METHODS

Literature search was performed on PubMed using key words, including adult GHD, long-acting growth hormone, somapacitan, treatment, and management. The discussion of treatment aspects utilizing somapacitan was based on evidence from previous clinical studies and personal experience.

RESULTS

Clinical trial data demonstrated that somapacitan, a once-weekly reversible albumin-binding GH derivative, decreased truncal fat, improved visceral fat and lean body mass, increased insulin-like growth factor-I standard deviation score and exerted neutral effects on glucose metabolism. Overall, somapacitan was well-tolerated, adverse event rates were comparable with daily GH, antisomapacitan or anti-GH antibodies were not detected, and treatment satisfaction was in favor of somapacitan vs daily GH.

CONCLUSION

Somapacitan is an efficacious, safe, convenient and well-tolerated once-weekly long-acting GH formulation that reduces the treatment burden of once-daily GH injections for adults with GHD. This article provides a review of the pharmacology of somapacitan and offers practical recommendations based on previous clinical trial data on how to initiate, dose titration, monitoring and dose adjustments whilst on therapy in adults with GHD. Timing of measurement of serum insulin-like growth factor-I levels, information on administration, recommendations on missed doses, and clinical recommendations on dosing in certain sub-population of patients are also discussed.

Management of a Growth Hormone-Secreting Pituitary Macroadenoma Associated With Idiopathic Intracranial Hypertension and an Empty Sella

Idiopathic intracranial hypertension (IIH) is a -condition associated with elevated intracranial pressure (ICP) and frequently presents with headaches, papilledema, and visual loss. Rarely, IIH has been reported in association with acromegaly. Although removal of the tumor may reverse this process, elevated ICP, especially in the setting of an otherwise empty sella, may result in a cerebrospinal fluid (CSF) leak that is exceedingly difficult to manage. We present the first case of a patient with a functional pituitary adenoma causing acromegaly associated with IIH and an otherwise empty sella and discuss our management paradigm for this rare condition.

Growth Hormone Treatment and Papilledema: A Prospective Pilot Study

Objective

To investigate the incidence of pseudotumor cerebri syndrome (PTCS) in children treated with growth hormone (GH) in a paediatric hospital and to identify risk factors for this complication.

Methods

Prospective pilot study of paediatric patients treated with recombinant human GH, prescribed by the Paediatric Endocrinology Department, between February 2013 and September 2017. In all these patients, a fundus examination was performed before starting treatment and 3-4 months later.

Results

Two hundred and eighty-nine patients were included, of whom 244 (84.4%) had GH deficiency, 36 (12.5%) had short stature associated with small for gestational age, six (2.1%) had a mutation in the SHOX gene and three (1.0%) had Prader-Willi syndrome. Five (1.7%) developed papilledema, all were asymptomatic and had GH deficiency due to craniopharyngioma (n=1), polymalformative syndrome associated with hypothalamic-pituitary axis anomalies (n=2), a non-specified genetic disease with hippocampal inversion (n=1) and one with normal magnetic resonance imaging who had developed a primary PTCS years before.

Conclusion

GH treatment is a cause of PTCS. In our series, at risk patients had GH deficiency and hypothalamic-pituitary anatomic anomalies or genetic or chromosomal diseases. Fundus examination should be systematically screened in all patients in this at-risk group, irrespective of the presence or not of symptoms.

Pediatric Pseudotumor Cerebri: Epidemiological Features

Objective:

The purpose was to study the epidemiological and clinical features of Pediatric Pseudotumor Cerebri; we especially evaluated age, sex, sexual maturity, weight, symptoms, duration of the episode, visual acuity, correlation with systemic diseases or drugs.

Methods:

We investigated a population of 40 children (80 eyes), aged between 2 and 18 years, that referred to our Centre (Città della Salute e della Scienza di Torino - presidio Ospedale Regina Margherita) from 2000 to 2018.

All the patients were monitored with visual field exam, fundus exam and Frisen classification, pupillary reflexes, best corrected visual acuity, orthoptic exam.

Then, the demographic characteristics, BMI (body max index) and weight changes, the correlation with systemic diseases or drugs, the Relative Afferent Pupillary Defect (RAPD), the VI cranial nerve deficit, the time required for the diagnosis, the modality of onset, the correlation between diagnosis delay and best corrected visual acuity, the resolution time and the probability of recurrence were studied.

Results:

We observed 2 age peaks in our population, one consisting of adolescents (aged between 11 and 14 years) and one consisting of younger children aged between 4 and 7 years, with a statistically significant correlation between age and BMI.

The deficit of the VI cranial nerve and the diplopia were resolved within the first month, despite the longer time of resolution of the papilledema.

Headache was the main onset symptom, but after reclassifying onset symptoms per weight classes, in overweight children, we found an increased variability of symptoms (dizziness, postural instability, photophobia, nausea, vomit, strabism and diplopia, visual fogging, drowsiness, irritability). Moreover, we found only one totally asymptomatic case, during a routine visit, in a 6 years old overweight child with Down syndrome.

Conclusion:

The Pediatric Pseudotumor Cerebri is, even nowadays, a little known pathology.

To provide a correct diagnostic assessment, it will be imperative to recollect the epidemiological features of this disease.

[Current aspects of diagnosis and treatment of adult GH-deficiency]

Adult growth hormone (GH) deficiency (AGHD) is a condition characterized by alterations in body composition, lipid and carbohydrate metabolism, bone mineral density and poor quality of life; however, clinical presentations of AGHD are mostly non-specific. Untreated AGHD is associated with increased cardiovascular morbidity and mortality. Stimulation tests are used for the diagnosis: insulin tolerance test, glucagon stimulation test, growth-hormone releasing hormone and arginine stimulation test. Moreover, in 2017 FDA approved the use of macimorelin (oral GH secretagogue) for the diagnosis of AGHD. In childhood GH-deficiency, apolipoprotein A-IV, CFHR4 (complement factor H-related protein 4) and PBP (platelet basic protein) were identified as potential biomarkers of the disease, however, this was not investigated in AGHD. GH treatment starts from the minimal dose, which allows minimizing the adverse effects. According to published meta-analyses, AGHD treatment generally does not lead to increased risk of malignancy and recurrence of sellar neoplasms in adult patients. Published data on GH receptor polymorphism associations with treatment efficacy remains controversial. Development of long-acting GH formulations is a currect perspective for the increase of treatment compliance.

Delayed Onset of Pseudotumor Cerebri Syndrome 7 Years after Starting Human Recombinant Growth Hormone Treatment

Purpose

To report a case of pseudotumor cerebri (PTC) following treatment with human recombinant growth hormone (GH).

Methods

A 42-year-old man who developed pseudotumor cerebri 7 years after starting human recombinant GH treatment is presented.

Results

The patient's medical history was significant for hypophyseal dwarfism with a serious deficit of GH, hypogonadotropic hypogonadism, and hypothyroidism. In 1996 he started taking GH, testosterone, and l-thyroxine. Fundus examination showed disc edema in the left eye. GH was discontinued, and acetazolamide therapy was initiated. At the 3-month follow-up the acuity without correction was patch and the unilateral papilledema had resolved.

Conclusions

Pseudotumor cerebri or idiopathic intracranial hypertension is an uncommon and complex disorder. The diagnosis is possible when important criteria symptoms and signs are met. Several conditions and risk factors are associated with PTC. The most recently recognized risk factor is GH therapy.

Pediatric Pseudotumor Cerebri Syndrome: Diagnosis, Classification, and Underlying Pathophysiology

Pseudotumor cerebri syndrome (PTCS) is defined by the presence of elevated intracranial pressure in the setting of normal brain parenchyma and cerebrospinal fluid. PTCS can occur in the pediatric and adult populations and, if untreated, may lead to permanent visual loss. In this review, discussion will focus on PTCS in the pediatric population and will outline its distinct epidemiology and key elements of diagnosis, evaluation and management. Finally, although the precise mechanisms are unclear, the underlying pathophysiology will be considered.

Management of GH treatment in adult GH deficiency

Growth hormone (GH) replacement therapy in adults with GH deficiency is still a challenge for the clinical endocrinologist and its implementation has still numerous difficulties and uncertainties. The decision to treat GH deficient adults requires a thoughtful and individualized evaluation of risks and benefits. Benefits have been found in body composition, bone health, cardiovascular risk factors, and quality of life. However, evidences for a reduction in cardiovascular events and mortality are still lacking, and treatment costs remain high. It is advisable to start treatment with low doses of GH, the goals being an appropriate clinical response, an avoidance of side effects, and IGF-I levels in the age-adjusted reference range. Although treatment appears to be overall safe, certain areas continue to require long-term surveillance, such as risks of glucose intolerance, pituitary/hypothalamic tumor recurrence, and cancer.

Pediatric Intracranial Hypertension

Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache.

Octreotide: The IIH therapy beyond weight loss, carbonic anhydrase inhibitors, lumbar punctures and surgical/interventional treatments

OBJECTIVE

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without a space-occupying cerebral lesion, venous sinus thrombosis or hydrocephalus and with normally composited cerebrospinal fluid (CSF). Main symptoms are headache, sight disturbances and potential visual impairment. Weight loss, carbonic anhydrase inhibitors, lumbar punctures with CSF drain, CSF shunting, optic nerve sheath fenestration, and venous sinus stenting are common IIH therapies. Octreotide, a synthetic somatostatin analogue, also effectively suspends IIH symptoms. Here, treatment with octreotide on five so far inefficiently treated IIH patients is presented and discussed.

METHODS

Five female patients with IIH and a history of failed therapy regimes were treated with octreotide, to be administered everyday subcutaneously for six months with identified doses high enough to suspend all clinical IIH symptoms. After tapering for two months, the further clinical course was to be monitored.

RESULTS

All patients were IIH symptom-free under octreotide. After tapering, one patient remained IIH symptom-free; one patient became IIH symptom-free under intramuscular octreotide after failure of former therapy regimes; one patient became IIH symptom-free on low-dose carbonic anhydrase inhibitors; one patient had an allergic reaction and paused octreotide, after successful desensitization, tooth ache developed, forcing octreotide tapering; one patient had another shunt revision alleviating IIH symptoms.

CONCLUSION

We confirmed that a) clinical IIH symptoms are suspended during octreotide exposure; b) 6-month administration can sustainably abolish IIH symptoms; c) desensitization is possible for octreotide allergy. When IIH symptoms reoccur after limited-time octreotide administration, re-application of formerly ineffective carbonic anhydrase inhibitors can suspend IIH symptoms. Intramuscular octreotide is a promising long-term therapy option.

Pediatric Idiopathic Intracranial Hypertension: Age, Gender, and Anthropometric Features at Diagnosis in a Large, Retrospective, Multisite Cohort

PURPOSE

To examine anthropometric and maturational characteristics at diagnosis in pediatric idiopathic intracranial hypertension (IIH).

DESIGN

Retrospective, international, multisite study.

PARTICIPANTS

Pediatric patients (2-18 years of age at diagnosis) with IIH.

MAIN OUTCOME MEASURES

Body mass index (BMI), height, and weight Z-scores; sexual maturation.

METHODS

Cases of IIH were identified retrospectively based on diagnostic code, pediatric neuro-ophthalmologist databases, or both and updated diagnostic criteria (2013) were applied to confirm definite IIH. Anthropometric measurements were converted into age- and gender-specific height, weight, and BMI Z-scores CDC 2000 growth charts. When available, sexual maturation was noted.

RESULTS

Two hundred thirty-three cases of definite IIH were identified across 8 sites. In boys, a moderate association between age and BMI Z-scores was noted (Pearson's correlation coefficient, 0.50; 95% confidence interval [CI], 0.30-0.66; P < 0.001; n = 72), and in girls, a weak association was noted (Pearson's correlation coefficient, 0.34; 95% CI, 0.20-0.47; P < 0.001; n = 161). The average patient was more likely to be overweight at diagnosis at age 6.7 years in girls and 8.7 years in boys, and obese at diagnosis at age 12.5 years in girls and 12.4 years in boys. Compared with age- and gender-matched reference values, early adolescent patients were taller for age (P = 0.002 in girls and P = 0.02 in boys). Data on Tanner staging, menarchal status, or both were available in 25% of cases (n = 57/233). Prepubertal participants (n = 12) had lower average BMI Z-scores (0.95±1.98) compared with pubertal participants (n = 45; 1.92±0.60), but this result did not reach statistical significance (P = 0.09).

CONCLUSIONS

With updated diagnostic criteria and pediatric-specific assessments, the present study identifies 3 subgroups of pediatric IIH: a young group that is not overweight, an early adolescent group that is either overweight or obese, and a late adolescent group that is mostly obese. Data also suggest that the early adolescent group with IIH may be taller than age- and gender-matched reference values. Understanding these features of pediatric IIH may help to illuminate the complex pathogenesis of this condition.

A synopsis on aging-Theories, mechanisms and future prospects

Answering the question as to why we age is tantamount to answering the question of what is life itself. There are countless theories as to why and how we age, but, until recently, the very definition of aging - senescence - was still uncertain. Here, we summarize the main views of the different models of senescence, with a special emphasis on the biochemical processes that accompany aging. Though inherently complex, aging is characterized by numerous changes that take place at different levels of the biological hierarchy. We therefore explore some of the most relevant changes that take place during aging and, finally, we overview the current status of emergent aging therapies and what the future holds for this field of research. From this multi-dimensional approach, it becomes clear that an integrative approach that couples aging research with systems biology, capable of providing novel insights into how and why we age, is necessary.

Pseudotumor Cerebri in a Child with Idiopathic Growth Hormone Insufficiency Two Months after Initiation of Recombinant Human Growth Hormone Treatment

Purpose. To report a rare case of pseudotumor cerebri (PTC) in a child two months after receiving treatment with recombinant human growth hormone (rhGH) and to emphasize the need of close collaboration between ophthalmologists and pediatric endocrinologists in monitoring children receiving rhGH. Methods. A 12-year-old boy with congenital hypothyroidism started treatment with rhGH on a dose of 1,5 mg/daily IM (4.5 IU daily). Eight weeks later, he was complaining of severe headache without any other accompanying symptoms. The child was further investigated with computed tomography scan and lumbar puncture. Results. Computed tomography scan showed normal ventricular size and lumbar puncture revealed an elevated opening pressure of 360 mm H₂O. RhGH was discontinued and acetazolamide 250 mg per os twice daily was initiated. Eight weeks later, the papilledema was resolved. Conclusions. There appears to be a causal relationship between the initiation of treatment with rhGH and the development of PTC. All children receiving rhGH should have a complete ophthalmological examination if they report headache or visual disturbances shortly after the treatment. Discontinuation of rhGH and initiation of treatment with acetazolamide may be needed and regular follow-up examinations by an ophthalmologist should be recommended.

Overweight and obesity in pediatric secondary pseudotumor cerebri syndrome

PURPOSE

To examine the clinical, demographic, and anthropometric patient characteristics of secondary pseudotumor cerebri syndrome in children and adolescents based on the recently revised diagnostic criteria.

DESIGN

Retrospective observational case series.

METHODS

Patients seen at a tertiary children's hospital for pseudotumor cerebri syndrome were classified as having either primary idiopathic (n = 59) or secondary pseudotumor cerebri syndrome (n = 16), as rigorously defined by recently revised diagnostic criteria. Outcomes included body mass index Z-scores (BMI-Z), height and weight Z-scores, demographics, and clinical features at presentation, such as headache, sixth nerve palsy, and cerebrospinal fluid (CSF) opening pressure.

RESULTS

In this cohort, the associated conditions and exposures seen in definite secondary pseudotumor cerebri syndrome included tetracycline-class antibiotics (n = 11), chronic kidney disease (n = 3), withdrawal from chronic glucocorticoids (n = 1), and lithium (n = 1). Other associations observed in the possible secondary pseudotumor cerebri syndrome group included Down syndrome, vitamin A derivatives, and growth hormone. In comparison with primary pseudotumor cerebri syndrome, definite secondary pseudotumor cerebri syndrome patients were on average older (15.0 vs 11.6 years; P = .003, Mann-Whitney test). According to US Centers for Disease Control (CDC) classifications, 79% of children with secondary pseudotumor cerebri syndrome were either overweight or obese (36% overweight [n = 5] and 43% obese [n = 6]), as compared to 32% nationally.

CONCLUSIONS

Even when a potential inciting exposure is identified for pediatric pseudotumor cerebri syndrome, the possible contribution of overweight and obesity should be considered.

An integrated mechanism of pediatric pseudotumor cerebri syndrome: evidence of bioenergetic and hormonal regulation of cerebrospinal fluid dynamics

Pseudotumor cerebri syndrome (PTCS) is defined by the presence of elevated intracranial pressure (ICP) in the setting of normal brain parenchyma and cerebrospinal fluid (CSF). Headache, vision changes, and papilledema are common presenting features. Up to 10% of appropriately treated patients may experience permanent visual loss. The mechanism(s) underlying PTCS is unknown. PTCS occurs in association with a variety of conditions, including kidney disease, obesity, and adrenal insufficiency, suggesting endocrine and/or metabolic derangements may occur. Recent studies suggest that fluid and electrolyte balance in renal epithelia is regulated by a complex interaction of metabolic and hormonal factors; these cells share many of the same features as the choroid plexus cells in the central nervous system (CNS) responsible for regulation of CSF dynamics. Thus, we posit that similar factors may influence CSF dynamics in both types of fluid-sensitive tissues. Specifically, we hypothesize that, in patients with PTCS, mitochondrial metabolites (glutamate, succinate) and steroid hormones (cortisol, aldosterone) regulate CSF production and/or absorption. In this integrated mechanism review, we consider the clinical and molecular evidence for each metabolite and hormone in turn. We illustrate how related intracellular signaling cascades may converge in the choroid plexus, drawing on evidence from functionally similar tissues.

Further observations on the effects of long-term treatment with recombinant human insulin-like growth factor 1 in growth hormone insensitivity syndrome

BACKGROUND/AIM

Growth hormone insensitivity syndrome (GHIS) is a spectrum of disorders. Laron syndrome was the earliest discovered. Insulin-like growth factor 1 (IGF-1) therapy is used to improve growth. IGF-1 has diverse effects on the growth of body organs. We aim to assess the long-term effects of IGF-1 therapy in patients with GHIS particularly on adiposity and acral growth.

METHODS

Six patients (5 with Laron syndrome and 1 with type 1A growth hormone deficiency) were followed for a mean (±SD) of 8.2 ± 1.8 years. Mean age at start of therapy was 7.6 ± 4.1 years. Anthropometric evaluation including growth of hand, foot, ear, and skin folds, and assessment of internal organ growth were done.

RESULTS

Hand and foot sizes improved significantly, especially when treatment was initiated early. Prominent effects on adiposity were observed, reflected by increment in body mass index standard deviation score (SDS) and skin fold SDS. Mean height, height velocity, sitting height, and head circumference SDS improved with therapy. A significant increase in spleen and right kidney was appreciated.

CONCLUSION

IGF-1 therapy improves growth in GHIS. The hand and foot sizes increase significantly with therapy, and can even normalize with early initiation of treatment. Ear length further improves with therapy. Other effects include increase in adiposity and internal organ growth.

Idiopathic intracranial hypertension and obesity

Idiopathic intracranial hypertension (IIH), also known as primary pseudotumor cerebri syndrome (PTCS), is a condition of unknown etiology which affects primarily overweight, reproductive-aged women and causes increased intracranial pressure (ICP). This review discusses the recently revised diagnostic criteria for PTCS for adults and children. Additionally, the role of obesity in the epidemiology, etiology, and management of IIH as well as the current knowledge of obesity profiles and markers in IIH are reviewed. We also highlight the emerging, unifying theory of the neuroendocrine effects on the mineralocorticoid receptor to explain a possible mechanism for the increased cerebrospinal fluid production and ICP in secondary PTCS.

Growth hormone, insulin-like growth factor-1, and the kidney: pathophysiological and clinical implications

Besides their growth-promoting properties, GH and IGF-1 regulate a broad spectrum of biological functions in several organs, including the kidney. This review focuses on the renal actions of GH and IGF-1, taking into account major advances in renal physiology and hormone biology made over the last 20 years, allowing us to move our understanding of GH/IGF-1 regulation of renal functions from a cellular to a molecular level. The main purpose of this review was to analyze how GH and IGF-1 regulate renal development, glomerular functions, and tubular handling of sodium, calcium, phosphate, and glucose. Whenever possible, the relative contributions, the nephronic topology, and the underlying molecular mechanisms of GH and IGF-1 actions were addressed. Beyond the physiological aspects of GH/IGF-1 action on the kidney, the review describes the impact of GH excess and deficiency on renal architecture and functions. It reports in particular new insights into the pathophysiological mechanism of body fluid retention and of changes in phospho-calcium metabolism in acromegaly as well as of the reciprocal changes in sodium, calcium, and phosphate homeostasis observed in GH deficiency. The second aim of this review was to analyze how the GH/IGF-1 axis contributes to major renal diseases such as diabetic nephropathy, renal failure, renal carcinoma, and polycystic renal disease. It summarizes the consequences of chronic renal failure and glucocorticoid therapy after renal transplantation on GH secretion and action and questions the interest of GH therapy in these conditions.

Adult growth hormone deficiency - benefits, side effects, and risks of growth hormone replacement

Deficiency of growth hormone (GH) in adults results in a syndrome characterized by decreased muscle mass and exercise capacity, increased visceral fat, impaired quality of life, unfavorable alterations in lipid profile and markers of cardiovascular risk, decrease in bone mass and integrity, and increased mortality. When dosed appropriately, GH replacement therapy (GHRT) is well tolerated, with a low incidence of side effects, and improves most of the alterations observed in GH deficiency (GHD); beneficial effects on mortality, cardiovascular events, and fracture rates, however, remain to be conclusively demonstrated. The potential of GH to act as a mitogen has resulted in concern over the possibility of increased de novo tumors or recurrence of pre-existing malignancies in individuals treated with GH. Though studies of adults who received GHRT in childhood have produced conflicting reports in this regard, long-term surveillance of adult GHRT has not demonstrated increased cancer risk or mortality.

Adult growth hormone deficiency

Adult growth hormone deficiency (AGHD) is being recognized increasingly and has been thought to be associated with premature mortality. Pituitary tumors are the commonest cause for AGHD. Growth hormone deficiency (GHD) has been associated with neuropsychiatric-cognitive, cardiovascular, neuromuscular, metabolic, and skeletal abnormalities. Most of these can be reversed with growth hormone therapy. The insulin tolerance test still remains the gold standard dynamic test to diagnose AGHD. Growth hormone is administered subcutaneously once a day, titrated to clinical symptoms, signs and IGF-1 (insulin like growth factor-1). It is generally well tolerated at the low-doses used in adults. Pegylated human growth hormone therapy is on the horizon, with a convenient once a week dosing.

Pseudotumor cerebri

INTRODUCTION

Pseudotumor cerebri is a condition characterized by raised intracranial pressure, normal CSF contents, and normal brain with normal or small ventricles on imaging studies. It affects predominantly obese women of childbearing age; however, its incidence seems to be increasing among adolescent and children. While among older children the clinical picture is similar to that of adults, younger children present demographic and clinical peculiarities. Different diagnostic criteria for adults and pre-pubertal children have been proposed. Etiology and pathogenesis are still unclear, particular concerning the role of obstruction to venous outflow.

METHODS

An extensive literature review concerning all the aspects of pseudotumor cerebri has been performed, both among adults and pre-pubertal children.

CONCLUSION

Pseudotumor cerebri is an avoidable cause of visual loss, both in adults and children. Few diagnostic measures are usually sufficient to determine the correct diagnosis. Since pseudotumor cerebri is a diagnosis of exclusion, the differential diagnosis work out is of special importance. Modern neuroimaging techniques, especially magnetic resonance imaging and magnetic resonance venography may clarify the role of obstruction to venous outflow in each case. Various therapeutic options are available: medical, surgical, and endovascular procedures may be used to prevent irreversible visual loss. Treatment is usually effective, and most patients will experience complete resolution of symptoms without persistent deficits.

Intracranial hypertension in pediatric patients treated with recombinant human growth hormone: data from 25 years of the Genentech National Cooperative Growth Study

Intracranial hypertension (IH) is a rare condition in children. However, a relationship between recombinant human growth hormone (rhGH) therapy and IH has been well documented. Risk factors were assessed for 70 rhGH-naive patients enrolled in the National Cooperative Growth Study with reports of IH after treatment initiation. Patients with severe growth hormone deficiency, Turner syndrome, chronic renal insufficiency (CRI), and obesity (particularly in the CRI group) were at highest risk of developing IH during the first year of therapy, suggesting initiation of careful early monitoring. In some patients, factors such as corticosteroid use or other chromosomal abnormalities appear to confer a delayed risk of IH, and these patients should be monitored long-term for signs and symptoms of IH.

[Recombinant human growth hormone treatment in short children with renal disease--our first experience]

INTRODUCTION

Growth retardation is a hallmark of chronic illnesses such as chronic kidney disease in children, and it is associated with increased morbidity and mortality. The growth hormone (GH) resistance observed in uraemia can be overcome by supraphysiological doses of exogenous GH.

OBJECTIVE

We would like to present our first results of recombinant human growth hormone (rhGH) treatment, mainly in children on haemodialysis.

METHODS

Sixteen children, aged 4.5-17.1 years (mean age 11.25 +/- 3.57) with height below -2.0 standard deviation score (SDS) for age or height velocity below -2.0 SDS for age, were selected to receive rhGH therapy at our Nephrology and Haemodialysis Department. Most of them were on haemodialysis (14 children) with mean spent time 2.88 +/- 2.68 years (0-9 years) before the initiation of rhGH therapy. One half of patients were prepubertal (8 children) and the second half were in early puberty (testicular volume between 4 and 8 ml for boys and breast development B2 or B3 in girls). All patients received 28-30 IU/m2 rhGH per week by daily subcutaneous injection. The year before rhGH therapy served as a control period.

RESULTS

During the first year of treatment, mean height velocity in haemodialysis patients increased from 2.25 cm/year to 6.59 cm/year (p < 0.0001) and in the second year it was 5.25 cm/ year (p = 0.004). The mean height SDS in haemodialysis children did not improve significantly during the first year of rhGH treatment (from -3.01 SDS to -2.77 SDS, p = 0.063). Neither weight nor the body mass index varied compared with the pretreatment period. Two patients developed worsened secondary hyperparathyroidism and were excluded from the study, but the relationship with rhGH remains uncertain.

CONCLUSION

Mean height velocity significantly improved during rhGH therapy in haemodialysis patients. No significant side-effects were observed in children during three-year treatment with GH.

Double adverse drug reaction: Recombinant human growth hormone and idiopathic intracranial hypertension - acetazolamide and metabolic acidosis: a case report

A 9-year-old girl, treated for growth hormone deficiency, developed bitemporal progressive headache, diplopia, acute comitant esotropia and visual loss 3 months after starting recombinant growth hormone. An increased intracranial pressure was revealed by examination of ocular fundus and lumbar puncture, and the absence of other causes, ruled out through a brain scan, led to the diagnosis of idiopathic intracranial hypertension.

Recombinant growth hormone was discontinued and acetazolamide started up to 30 mg/kg/die without any clinical improvement but developing metabolic acidosis. The switch to intravenous dexamethasone (0.4 mg/kg/die) led to a dramatic clinical improvement after only 1 day, then confirmed by examination of ocular fundus and visual evoked potentials. Currently, there are no evidence-based guidelines for the management of intracranial hypertension, and even though acetazolamide is recognized as the first-line drug, its efficacy and safety have not been proven: some patients might not respond and others will present unacceptable side-effects. Therefore we suggest the use of corticosteroids in intracranial hypertension when acetazolamide is inefficient or intolerable.

Arterial pulse wave velocity, inflammatory markers, pathological GH and IGF states, cardiovascular and cerebrovascular disease

Blood pressure (BP) measurements provide information regarding risk factors associated with cardiovascular disease, but only in a specific artery. Arterial stiffness (AS) can be determined by measurement of arterial pulse wave velocity (APWV). Separate from any role as a surrogate marker, AS is an important determinant of pulse pressure, left ventricular function and coronary artery perfusion pressure. Proximal elastic arteries and peripheral muscular arteries respond differently to aging and to medication. Endogenous human growth hormone (hGH), secreted by the anterior pituitary, peaks during early adulthood, declining at 14% per decade. Levels of insulin-like growth factor-I (IGF-I) are at their peak during late adolescence and decline throughout adulthood, mirror imaging GH. Arterial endothelial dysfunction, an accepted cause of increased APWV in GH deficiency (GHD) is reversed by recombinant human (rh) GH therapy, favorably influencing the risk for atherogenesis. APWV is a noninvasive method for measuring atherosclerotic and hypertensive vascular changes increases with age and atherosclerosis leading to increased systolic blood pressure and increased left ventricular hypertrophy. Aerobic exercise training increases arterial compliance and reduces systolic blood pressure. Whole body arterial compliance is lowered in strength-trained individuals. Homocysteine and C-reactive protein are two inflammatory markers directly linked with arterial endothelial dysfunction. Reviews of GH in the somatopause have not been favorable and side effects of treatment have marred its use except in classical GHD. Is it possible that we should be assessing the combined effects of therapy with rhGH and rhIGF-I? Only multiple intervention studies will provide the answer.

Insulin-like growth factor I: a potential neuroprotective compound for the treatment of acute ischemic stroke?

BACKGROUND AND PURPOSE

Insulin-like growth factor I (IGF-I) exerts neuroprotective effects in both white and gray matter under different detrimental conditions. The purpose of this review is to collect the evidence whether IGF-I is a candidate neuroprotective drug in patients with acute ischemic stroke.

RESULTS

IGF-I was found to be neuroprotective in animal models of focal brain ischemia when given >or=2 hours after the insult. Different routes of administration (eg, cerebroventricular, intravenous, and intranasal) were found to be effective. In addition to inhibition of apoptosis and reduction of the infarct volume, IGF-I also improved neurological outcome. Furthermore, there are strong indications that IGF-I can also stimulate the regeneration of neural tissue.

CONCLUSIONS

Additional studies are required to reveal the neuroprotective mechanisms of IGF-I in detail and to elucidate the role of IGF-binding proteins. Preclinical studies in relevant animal models for studying stroke (ie, hypertensive, diabetic, or aged animals) should be done testing different doses and routes of IGF-I administration and different combinations of IGF-I and IGF-binding proteins.

[Safety aspects of treatments with hrGH]

Recombinant human growth hormone (hrGH) has been used for treatment of growth hormone deficient children over 20 years and it can be considered to have an excellent safety profile. The main international surveys show few adverse drug reactions reported, specially in idiopathic growth hormone deficiency and in idiopathic short stature. With regard to cancer risk or tumor recurrence, it seems that there is no greater risk with hrGH treatment in comparison to general population. The idiopathic intracranial hypertension is a rare condition, but its incidence is higher in patients with chronic renal failure. The adverse events are rare in patients treated with hrGH, but these patients should be carefully monitored, specially those with pharmacologycal doses or with another clinical condition of greater risk.

Pediatric idiopathic intracranial hypertension

Our understanding of pediatric idiopathic intracranial hypertension has been refined since Dr. Simmons Lessell's review in 1992. The use of rigorous methodologies and standard definitions in recent studies has demonstrated distinct demographic trends. Specifically, the incidence of idiopathic intracranial hypertension seems to be increasing among adolescent children, and among older children its clinical picture is similar to that of adult idiopathic intracranial hypertension (female and obese). Within younger age groups there are more boys and nonobese children who may develop idiopathic intracranial hypertension. The pathogenesis of the disease has yet to be elucidated. Idiopathic intracranial hypertension among young children has been associated with several new etiologies, including recombinant growth hormone and all-trans-retinoic acid. More modern neuroimaging techniques such as MRI and MRI-venograms are being used to exclude intracranial processes. Although most cases of pediatric idiopathic intracranial hypertension improve with medical treatment, those who have had visual progression despite medical treatment have undergone optic nerve sheath fenestration and lumboperitoneal shunting. Because idiopathic intracranial hypertension in young children appears to be a different disorder than in adolescents and adults, separate diagnostic criteria for younger children are warranted. We propose new criteria for pediatric idiopathic intracranial hypertension in which children should have signs or symptoms consistent with elevated intracranial pressure, be prepubertal, have normal sensorium, can have reversible cranial nerve palsies, and have an opening cerebrospinal fluid pressure greater than 180 mm H(2)O if less than age 8 and papilledema is present, but greater than 250 mm H(2)0 if age 8 or above or less than 8 without papilledema.

Headache, idiopathic intracranial hypertension and slipped capital femoral epiphysis during growth hormone treatment: a safety update from the KIGS database

BACKGROUND

Several uncommon adverse effects may be related to growth hormone (GH) treatment. Three potential side effects, headache, idiopathic intracranial hypertension (IIH) and slipped capital femoral epiphysis (SCFE), will be discussed. Data from 57,968 children in the KIGS (Pfizer International Growth Study database) were analyzed to determine the effects of recombinant human GH (Genotropin) on these side effects. The diagnostic groups were idiopathic GH deficiency (IGHD) (n = 27,690), congenital GHD (CGHD) (n = 2,547), craniopharyngioma (n = 1,155), cranial tumours (n = 2,203), Turner syndrome (TS) (n = 6,092), idiopathic short stature (ISS) (n = 5,286), small for gestational age (SGA) (n = 2,973), chronic renal insufficiency (CRI) (n = 1,753) and Prader-Willi syndrome (PWS) (n = 1,368).

RESULTS

Total incidence (per 100,000 treatment years) of headache was 793.5 (n = 569). The incidence was significantly higher in the groups of patients with craniopharyngiomas, CGHD and cranial tumours than in the other diagnostic groups (p < 0.05 for all). IIH occurred in 41 children resulting in a total incidence (per 100,000 treatment years) of 27.7. The incidence (per 100,000 treatment years) was significantly lower in patients with IGHD (12.2) than in those with TS (56.4) (p = 0.0004), CGHD (54.5) (p = 0.0064), PWS (68.3) (p = 0.0263) and CRI (147.8) (p < 0.001). No cases of IIH were reported in the ISS group of patients. The median duration from onset of GH therapy to IIH ranged from 0.01 to 1.3 years in various diagnostic groups. SCFE was observed in a total of 52 children resulting in a total incidence (per 100,000 treatment years) of 73.4. The incidence (per 100,000 treatment years) was significantly lower in patients with IGHD (18.3) and in those children with ISS (14.5) than in the TS (84.5), cranial tumours (86.1) and craniopharyngioma groups (120.5) (p < 0.05 for all). No cases of SCFE were reported in the SGA and PWS groups. The median duration from onset of GH therapy to SCFE ranged from 0.4 to 2.5 years.

CONCLUSIONS

The incidences of IIH and SCFE in this analysis are lower than the values reported in previous KIGS analyses and comparable to other databases. Patients with TS, organic GHD, PWS and CRI seem to be more prone to these side effects.

Long-term treatment with recombinant insulin-like growth factor (IGF)-I in children with severe IGF-I deficiency due to growth hormone insensitivity

CONTEXT

Children with severe IGF-I deficiency due to congenital or acquired defects in GH action have short stature that cannot be remedied by GH treatment.

OBJECTIVES

The objective of the study was to examine the long-term efficacy and safety of recombinant human IGF-I (rhIGF-I) therapy for short children with severe IGF-I deficiency.

DESIGN

Seventy-six children with IGF-I deficiency due to GH insensitivity were treated with rhIGF-I for up to 12 yr under a predominantly open-label design.

SETTING

The study was conducted at general clinical research centers and with collaborating endocrinologists.

SUBJECTS

Entry criteria included: age older than 2 yr, sd scores for height and circulating IGF-I concentration less than -2 for age and sex, and evidence of resistance to GH.

INTERVENTION

rhIGF-I was administered sc in doses between 60 and 120 microg/kg twice daily.

MAIN OUTCOME MEASURES

Height velocity, skeletal maturation, and adverse events were measured.

RESULTS

Height velocity increased from 2.8 cm/yr on average at baseline to 8.0 cm/yr during the first year of treatment (P < 0.0001) and was dependent on the dose administered. Height velocities were lower during subsequent years but remained above baseline for up to 8 yr. The most common adverse event was hypoglycemia, which was observed both before and during therapy. It was reported by 49% of treated subjects. The next most common adverse events were injection site lipohypertrophy (32%) and tonsillar/adenoidal hypertrophy (22%).

CONCLUSIONS

Treatment with rhIGF-I stimulates linear growth in children with severe IGF-I deficiency due to GH insensitivity. Adverse events are common but are rarely of sufficient severity to interrupt or modify treatment.

Evaluation and treatment of adult growth hormone deficiency: an Endocrine Society Clinical Practice Guideline

OBJECTIVE

The objective is to provide guidelines for the evaluation and treatment of adults with GH deficiency (GHD).

PARTICIPANTS

The chair of the Task Force was selected by the Clinical Guidelines Subcommittee of The Endocrine Society (TES). The chair selected five other endocrinologists and a medical writer, who were approved by the Council. One closed meeting of the group was held. There was no corporate funding, and members of the group received no remuneration.

EVIDENCE

Only fully published, peer-reviewed literature was reviewed. The Grades of Evidence used are outlined in the Appendix.

CONSENSUS PROCESS

Consensus was achieved through one group meeting and e-mailing of drafts that were written by the group with grammatical/style help from the medical writer. Drafts were reviewed successively by the Clinical Guidelines Subcommittee, the Clinical Affairs Committee, and TES Council, and a version was placed on the TES web site for comments. At each level, the writing group incorporated needed changes.

CONCLUSIONS

GHD can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. GH therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.

Insulin-like growth factor-I treatment of growth disorders, diabetes mellitus and insulin resistance

Insulin-like growth factor I (IGF-I) has many potential therapeutic uses because of its varied effects--growth promotion, insulin-like influence on glucose metabolism, and neuroprotection resulting from cell-proliferative and antiapoptotic properties--but they have not been investigated systematically in clinical situations. The growth-promoting effect of recombinant human IGF-I (rhIGF-I) in the extensively studied growth hormone insensitivity syndrome (GHIS; Laron syndrome) signifies an endocrine role for the GH-IGF system. The metabolism of (adult) patients with severe insulin resistance is improved by rhIGF-I, which--together with insulin therapy--also improves metabolic control in type 1 and 2 diabetes. Further studies on IGF-I metabolic effects and growing understanding of the IGF-I-IGF-binding protein system could open new therapeutic avenues.

Idiopathic intracranial hypertension immediately after kidney transplantation in a pediatric recipient

Idiopathic intracranial hypertension, characterized by headache, visual disturbance, papilledema, and increased intracranial pressure in the absence of space-occupying lesions, has been reported in pediatric recipients several months to years following kidney transplantation (KTx). We describe the development of idiopathic intracranial hypertension in a 10-year-old girl in the first few hours after KTx. We hypothesize that this event was associated with thymoglobulin administration, perhaps on the background of growth hormone therapy. Awareness of this possibility could lead to earlier diagnosis and treatment of children with similar risk factors.

Hormones and Supplements: Do They Work?: Use of Growth Hormone for Prevention or Treatment of Effects of Aging

Decreases in growth hormone (GH) and insulin-like growth factor-I, estrogen deficiency in women, diminished testosterone in men, and loss of lean body mass, increased fat, and other changes consistent with hormone deficiencies occur during aging. Treatment of nonelderly GH-deficient adults with recombinant human GH (rhGH) improves body composition, muscle strength, physical function, and bone density, and reduces blood cholesterol and cardiovascular disease risk, but is often accompanied by carpal tunnel syndrome, peripheral edema, joint pain and swelling, gynecomastia, glucose intolerance, and possibly increased cancer risk. Reports that rhGH augments lean body mass and reduces body fat in aged individuals increased use of rhGH to delay aging effects. However, clinically significant functional benefits, prolongation of youth, and life extension have not been demonstrated. Moreover, marketing of rhGH and other hormone supplements largely ignores adverse effects. Until more research has better defined the risk/benefit relationships, treatment of elderly individuals with rhGH should be confined to controlled research studies.

Managing growth hormone treatment in pediatric patients

In general, GH is a safe medication. Patients overwhelmingly enjoy its benefits. Infrequently, its side effects produce worrisome problems. Knowledge of these effects may allow families to choose treatment more judiciously and may allow physicians to detect adverse effects at an early stage.

Adverse events with rhGH treatment of patients with chronic renal insufficiency and end-stage renal disease

OBJECTIVE

Recombinant human growth hormone (rhGH) has been used to improve the growth retardation associated with chronic renal insufficiency (CRI) and end-stage renal disease. We determined the incidence of one of four targeted adverse events (AEs): malignancy, slipped capital femoral epiphysis (SCFE), avascular necrosis (AN), and intracranial hypertension (ICH).

STUDY DESIGN

During a 6.5-year period, we prospectively assessed patients enrolled in the CRI, dialysis, and transplant registries of the North American Renal Transplant Cooperative Study. The availability of an untreated control population facilitated determining whether or not there was the association between the AE and rhGH treatment.

RESULTS

Of the targeted AE, the only significant relation with rhGH treatment was the presence of ICH in patients with CRI; however, in all 3 instances, ICH occurred 2, 50, and 1131 days after discontinuation of rhGH. Considering that the mechanism of ICH in rhGH-treated patients is thought to be increased CSF production, rhGH probably had no role in the development of ICH in at least 2 of the 3 patients with CRI. A number of nontargeted AE were identified that have been associated with rhGH treatment in patients without renal disease. The incidence of glucose intolerance, pancreatitis, progressive deterioration of renal function, acute allograft rejection, and fluid retention were not more frequent in those receiving rhGH treatment compared with the control population.

CONCLUSIONS

This report validates the importance of a control population in ascribing AE to any therapeutic intervention. Previously identified AE associated with rhGH treatment are infrequent in patients with CRI and end-stage renal disease.

Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, can be a serious vision-threatening disease. Visual acuity, visual fields, and ocular fundus appearance should be followed closely in all patients with IIH. Obese patients with IIH should be encouraged to lose weight. Medications that might cause or exacerbate IIH should be identified and discontinued if possible. Mild headaches can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or migraine prophylactic agents. Some patients may not require additional treatment if they are otherwise asymptomatic and have no evidence of vision loss. Symptomatic patients (significant headache, visual complaints, tinnitus) or patients with visual field or acuity loss should be treated initially with acetazolamide. Furosemide may be a useful second-line agent. If vision loss is progressive despite maximal medical therapy or severe at the time of diagnosis, surgical intervention may be required. Optic nerve sheath fenestration is effective and safe, and may be repeated if initially unsuccessful. Lumboperitoneal shunting is also an option, especially if symptoms of headache are prominent and refractory to medical therapy, but it has significant complication and failure rates. Bariatric surgery can be an effective treatment for IIH in severely obese patients, but is not a useful acute intervention. Special issues must be considered when treating IIH in children or pregnant women.

Musculoskeletal effects of the recombinant human IGF-I/IGF binding protein-3 complex in osteoporotic patients with proximal femoral fracture: a double-blind, placebo-controlled pilot study

The administration of recombinant human IGF-I complexed with its predominant binding protein IGF binding protein-3 (rhIGF-I/IGFBP-3) may allow the safe administration of higher doses of IGF-I than can be accomplished with rhIGF-I alone. The aim of this randomized, double-blind, placebo- controlled pilot study was to evaluate the short-term safety and musculoskeletal effects of rhIGF-I/IGFBP-3 in older women (aged 65-90 yr) with recent hip fracture. Within 72 h after the event, 30 patients received continuous administration of either placebo (n = 10), 0.5 mg/kg.d rhIGF-I/IGFBP-3 (n = 9), or 1 mg/kg.d rhIGF-I/IGFBP-3 (n = 11). Treatment was administered by sc infusion through a portable mini-pump for a total of 8 wk after hip fracture surgery, with patient follow-up to 6 months after surgery. Efficacy evaluations included a contralateral hip bone density determination, markers of bone turnover (including serum osteocalcin and urinary excretion of N-telopeptide), grip strength, and tests of functional ability. During the administration of rhIGF-I/IGFBP-3, mean serum levels of IGF-I significantly (P < 0.001) increased from 83 ng/ml to 289 ng/ml (0.5 mg/kg.d) and 393 ng/ml (1 mg/kg.d), respectively. Both doses were well tolerated, and no hypoglycemia or other therapy-induced side effects were observed. After an initial loss of hip bone density after hip fracture surgery, patients treated with 1 mg/kg.d rhIGF-I/IGFBP-3 regained a substantial portion of their femoral bone mass. At 6 months postfracture (4 months after the 2-month infusion), they showed a statistically not significant decrease from baseline in hip bone density (-2.6%, P = 0.53). Placebo-treated patients, on the other hand, failed to regain lost bone: at 6 months postfracture, bone density in the placebo group had declined by 6.1% (P = 0.04). Additionally, in patients treated with 1.0 mg/kg.d rhIGF-I/IGFBP-3, grip strength had increased from baseline by 11.4% by the end of the study (P = 0.04) whereas patients on placebo lost 11.6% from baseline (P = 0.16). This increase in muscle strength in the high-dose group was associated with a positive effect on functional recovery. We conclude that a 2-month infusion of rhIGF-I/IGFBP-3 in patients with recent hip fracture is feasible, safe, and well tolerated. Analyzing the effects on bone mass, muscle strength, and functional ability, we observed beneficial trends. In the context of a small exploratory study, these findings should be interpreted with caution, but they support the need for future trials to further assess the therapeutic potential of rhIGF-I/IGFBP-3 in elderly subjects with osteoporosis.

Lipid profile during rhGH therapy in pediatric renal transplant patients

To evaluate the effect of recombinant human growth hormone (rhGH) treatment on the lipid profile of pediatric renal transplant patients, we studied nine children treated with rhGH for 1 yr and a control group of 12 untreated patients matched in terms of age, renal transplant function and post-transplant follow-up. The levels of lipoprotein (a [Lp(a)], cholesterol, triglycerides, apolipoprotein A (APO A) and apolipoprotein B (APO B), and the APO B/APO A ratio, were determined at baseline and after 6 and 12 months of follow-up. RhGH therapy had no effect on cholesterol, triglycerides or apolipoproteins. Mean serum Lp(a) levels increased from 6.7 +/- 5.7 mg/dL at baseline to 11.8 +/- 10.7 after 6 months (p = 0.018) and 13.6 +/- 15.1 after 12 months of rhGH treatment (p = 0.04), but did not change in the control group. Lp(a) is a risk factor for cardiovascular morbidity, and increased Lp(a) levels may be a side-effect of rhGH treatment in renal transplant patients. Although long-term follow-up of a large number of patients is needed to establish the duration and extent of the effects of rhGH treatment on Lp(a) levels in transplanted children, serum Lp(a) levels should be carefully monitored in those receiving rhGH therapy.