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Song W, Zhao F, Liang S, Li G, Xue J. Is a Combination of a GnRH Agonist and Recombinant Growth Hormone an Effective Treatment to Increase the Final Adult Height of Girls with Precocious or Early Puberty? Int J Endocrinol 2018; 2018:1708650. [PMID: 30693027 PMCID: PMC6332953 DOI: 10.1155/2018/1708650] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/18/2018] [Accepted: 10/04/2018] [Indexed: 02/02/2023] Open
Abstract
The aim of treatment for idiopathic central precocious puberty (ICPP) is to increase final adult stature, for which gonadotropin-releasing hormone agonist (GnRHa) is the gold standard. Early puberty is frequently similar to ICPP, with pubertal onset only slightly advanced. Short stature may result from early pubertal onset. Some studies have suggested that recombinant human growth hormone (rhGH) should be combined with a GnRHa to improve adult height, while others have not. Here, the aim was to compare the efficacy of combined GnRHa and rhGH treatment with GnRHa or rhGH treatment alone, or no therapy, for the improvement of the final height of girls with ICPP or early puberty. Electronic databases of randomized and quasi-randomized controlled trials, in which the efficacy of GnRHa preparations was compared with that of rhGH for the treatment of children with precocious or early puberty, were searched and a meta-analysis conducted. Five studies of early puberty and four studies of ICPP were identified. There were no statistically significant differences between final adult height standard deviation score and initial height standard deviation score in the treatment of early puberty (GnRHa and rhGH versus rhGH alone or no treatment). The overall analysis of the data failed to indicate any benefit of combined therapy, while individual reports suggested that in specific instances combined therapy may be beneficial in preserving or reclaiming growth potential and improving adult height.
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Affiliation(s)
- Wei Song
- Department of Pediatrics, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Fei Zhao
- Department of Pediatrics, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Shuang Liang
- Department of Pediatrics, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Guimei Li
- Department of Pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Jiang Xue
- Department of Pediatrics, The Second Hospital of Shandong University, Jinan, Shandong Province, China
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Bereket A. A Critical Appraisal of the Effect of Gonadotropin-Releasing Hormon Analog Treatment on Adult Height of Girls with Central Precocious Puberty. J Clin Res Pediatr Endocrinol 2017; 9:33-48. [PMID: 29280737 PMCID: PMC5790330 DOI: 10.4274/jcrpe.2017.s004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 12/01/2022] Open
Abstract
Central precocious puberty (CPP) is a diagnosis that pediatric endocrinologists worldwide increasingly make in girls of age 6-8 years and is mostly idiopathic. Part of the reason for increasing referral and diagnosis is the perception among the doctors as well as the patients that treatment of CPP with long-acting gonadotropin-releasing hormon analogues (GnRHa) promote height of the child. Although, the timing and the tempo of puberty does influence statural growth and achieved adult height, the extent of this effect is variable depending on several factors and is modest in most cases. Studies investigating GnRHa treatment in girls with idiopathic CPP demonstrate that treatment is able to restore adult height compromised by precocious puberty. However, reports on untreated girls with precocious puberty demonstrate that some of these girls achieve their target height without treatment as well, thus, blurring the net effect of GnRHa treatment on height in girls with CPP. Clinical studies on treatment of girls with idiopathic CPP on adult stature suffers from the solid evidence-base due mainly to the lack of well-designed randomized controlled studies and our insufficiencies of predicting adult height of a child with narrow precision. This is particularly true for girls in whom age of pubertal onset is close to physiological age of puberty, which are the majority of cases treated with GnRHa nowadays. Heterogeneous nature of pubertal tempo (progressive vs. nonprogressive) leading to different height outcomes also complicates the interpretation of the results in both treated and untreated cases. This review will attemp to summarize and critically appraise available data in the field.
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Affiliation(s)
- Abdullah Bereket
- Marmara University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
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Bath KG, Russo SJ, Pleil KE, Wohleb ES, Duman RS, Radley JJ. Circuit and synaptic mechanisms of repeated stress: Perspectives from differing contexts, duration, and development. Neurobiol Stress 2017; 7:137-151. [PMID: 29276735 PMCID: PMC5736942 DOI: 10.1016/j.ynstr.2017.05.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/03/2017] [Accepted: 05/04/2017] [Indexed: 12/12/2022] Open
Abstract
The current review is meant to synthesize research presented as part of a symposium at the 2016 Neurobiology of Stress workshop in Irvine California. The focus of the symposium was "Stress and the Synapse: New Concepts and Methods" and featured the work of several junior investigators. The presentations focused on the impact of various forms of stress (altered maternal care, binge alcohol drinking, chronic social defeat, and chronic unpredictable stress) on synaptic function, neurodevelopment, and behavioral outcomes. One of the goals of the symposium was to highlight the mechanisms accounting for how the nervous system responds to stress and their impact on outcome measures with converging effects on the development of pathological behavior. Dr. Kevin Bath's presentation focused on the impact of disruptions in early maternal care and its impact on the timing of hippocampus maturation in mice, finding that this form of stress drove accelerated synaptic and behavioral maturation, and contributed to the later emergence of risk for cognitive and emotional disturbance. Dr. Scott Russo highlighted the impact of chronic social defeat stress in adolescent mice on the development and plasticity of reward circuity, with a focus on glutamatergic development in the nucleus accumbens and mesolimbic dopamine system, and the implications of these changes for disruptions in social and hedonic response, key processes disturbed in depressive pathology. Dr. Kristen Pleil described synaptic changes in the bed nuclei of the stria terminalis that underlie the behavioral consequences of allostatic load produced by repeated cycles of alcohol binge drinking and withdrawal. Dr. Eric Wohleb and Dr. Ron Duman provided new data associating decreased mammalian target of rapamycin (mTOR) signaling and neurobiological changes in the synapses in response to chronic unpredictable stress, and highlighted the potential for the novel antidepressant ketamine to rescue synaptic and behavioral effects. In aggregate, these presentations showcased how divergent perspectives provide new insights into the ways in which stress impacts circuit development and function, with implications for understanding emergence of affective pathology.
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Affiliation(s)
- Kevin G. Bath
- Department of Cognitive Linguistic and Psychological Sciences, Brown University, Providence, RI 02912, United States
| | - Scott J. Russo
- Fishberg Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Kristen E. Pleil
- Department of Pharmacology, Weill Cornell Medical College, New York, NY 10065, United States
| | - Eric S. Wohleb
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH 45237, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06508, United States
| | - Ronald S. Duman
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06508, United States
| | - Jason J. Radley
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA 52242, United States
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Wang M, Zhang Y, Lan D, Hill JW. The Efficacy of GnRHa Alone or in Combination with rhGH for the Treatment of Chinese Children with Central Precocious Puberty. Sci Rep 2016; 6:24259. [PMID: 27072597 PMCID: PMC4829831 DOI: 10.1038/srep24259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/23/2016] [Indexed: 11/19/2022] Open
Abstract
The addition of recombinant human growth hormone (rhGH) to GnRH agonist (GnRHa) to treat central precocious puberty (CPP) is controversial. We systemically reviewed and evaluated the efficacy and safety of the rhGH and GnRHa adjunctive therapy in Chinese children with CPP and assessed the influence of age and therapy duration on the efficacy of the combined treatment. A total of 464 patients were included from 14 studies. Compared with baseline, administration of GnRHa plus rhGH led to a significant increase in height, predicted adult height (PAH) and height standard deviation for bone age (HtSDS-BA), corresponding to a weighted mean difference (WMD) (95%CI) of 9.06 cm (6.41, 11.70), 6.5 cm (4.47, 8.52), and 0.86 (0.58, 1.14) respectively. Subgroup analysis showed the combined therapy had increased efficacy in subjects with initial treatment age younger than 10 years old or with treatment lasting over 12 months. Compared with GnRHa alone treatment, the combined treatment led to a significant increase in height, PAH and HtSDS-BA, corresponding to a WMD (95% CI) of 3.56 cm (2.54, 4.57), 3.76 cm (3.19, 4.34) and 0.56 (0.43, 0.69). The combined treatment exhibited no safety concerns. Our findings may aid clinicians in making treatment decisions for children with CPP.
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Affiliation(s)
- Mengjie Wang
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio 43614
| | - Youjie Zhang
- Center for Hypertension and Personalized Medicine, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio 43614
| | - Dan Lan
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Jennifer W Hill
- Center for Diabetes and Endocrine Research, Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio 43614.,Department of Obstetrics-Gynecology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, 43614
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Li P, Li Y, Yang CL. Gonadotropin releasing hormone agonist treatment to increase final stature in children with precocious puberty: a meta-analysis. Medicine (Baltimore) 2014; 93:e260. [PMID: 25501098 PMCID: PMC4602779 DOI: 10.1097/md.0000000000000260] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In the setting of central precocious puberty (CPP), the motivation for hormonal intervention is to help the child to reach a taller adult stature than she would achieve otherwise. While gonadotropin-releasing hormone analogs (GnRHa) constitute an established treatment for improving adult stature in girls presenting with CPP up to age 6 (true precocious puberty), it is not yet clear whether or not the same is true in the setting of CPP presented in girls beyond age 6 (advance puberty). GnRHa may slow growth velocity, offsetting the anticipated improvement in final height that should have resulted from the increased time before growth plate fusion. Consequently, it's been suggested that growth hormone (GH) should be combined with GnRHa to improve the results.Few controlled prospective studies have been performed with GnRHa in children and many conclusions rely in part on collective expert opinion. Therefore, the literature was searched and relevant studies were selected using the search terms "gonadotropin releasing hormone agonist," "precocious puberty/early puberty," and "GnRH analogue." After selected articles were screened for relevance, the process yielded 8 studies, the results of which were then pooled in a meta-analysis aimed at evaluating the effects of GnRHa therapy both with and without added GH in the setting of early puberty. A significant difference was elucidated in final height and predicted adult height comparing GnRHa and combined GnRHa/GH groups. However, no significant difference was elucidated in final height standard deviation scores (SDS) and initial height SDS when comparing GnRHa and control groups. At the same time, the final analysis revealed no significant difference in final height SDS and initial height SDS when GnRHa and combined GnRHa/GH groups were compared.The results suggest GnRHa therapy may have a positive effect on final adult height in girls with early puberty, while adding GH to the treatment may suggest more advantage. Interpretation of the results requires extreme caution, given the complexity of the outcome analysis. Final height gain may prove to be a more appropriate measure of treatment efficacy in any case.
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Affiliation(s)
- Pin Li
- From the Department of Endocrinology, Shanghai Children's Hospital, Shanghai JiaoTong University, Shanghai, P.R. China (PL); Department of Endocrinology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China (YL); Department of First Clinical Medical College, Nanjing Medical University, Jiangsu, China (YL); and Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan, ROC (CL-Y)
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