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

Patients' Perception of the Use of the EasyPod™ Growth Hormone Injector Device and Impact on Injection Adherence: A Multi-Center Regional Study

OBJECTIVE

This study aimed to assess patient perceptions of the use of the EasyPod™ growth hormone delivery device and its association with compliance.

METHODS

This cross-sectional, multicenter study was conducted in six centers from three countries (United Arab Emirates, Oman, and Saudi Arabia,) between March 2020 and June 2020. Children and adolescents aged 3-18 years, diagnosed with growth disorders and receiving rhGH through the EasyPod™ device were enrolled. Patients and caregivers were given a pre-set questionnaire that evaluated patient satisfaction, preference for technical and personalized features, and device drawbacks. The results were analyzed using independent measures of analysis of variance to evaluate the association of higher satisfaction with device features and better compliance.

RESULTS

A total of 186 patients were enrolled in the study. Of these, 45.7% had GH deficiency. The mean age (±SD) of patients was 11.8 (±2.76) years; 117 (62.90%) were males. Average compliance was 87%. One hundred patients (53.76%) had injection compliance of ≥90%. Amongst these patients, 74%, 68%, and 77% top-scored (5/5) the technical features of hidden needle, skin sensor, and pre-set dosing, respectively, compared to top scores by 39%, 34%, and 51% patients in the <90% compliance group (p-value <0.05). Similarly, a statistically significant difference was observed between the groups (p-value <0.05) in the perception of the usefulness of the tracking features such as display of history of injected doses (78% vs. 47.7%), a reminder for medicine remaining (46% vs. 23.3%) and battery power indicator (48% vs. 20.9%). Personal screen messages were associated with higher compliance while the requirement to keep the device in the fridge was reported as the most inconvenient feature by 56% of patients in the higher compliance group as against 39.5% in the lower compliance group (p-value <0.05). There was no statistically significant difference in the intensity of pain reported in the two compliance groups.

CONCLUSION

Our study showed that there is a statistically significant association between better perception of device features and higher compliance.

Mothers' Experiences of Caring for Children Receiving Growth Hormone Treatment

PURPOSE

To achieve understanding of the meanings of mothers' experiences of caring for children receiving growth hormone treatment (GHT).

BACKGROUND

Children generally begin GHT at a very early age which means parents have significant responsibilities and often endure a complex and difficult pathway with GHT.

DESIGN AND METHODS

Hermeneutic interpretive phenomenology based on the approach of Gadamer that adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines. See Supplementary File 1. Data collected through interviews and diaries with mothers (n = 16).

RESULTS

Mothers' experiences were framed by three concepts: uncertainty, normalisation and stigma. These concepts were used to elaborate on the four major meanings encapsulating their experience of caring for their children receiving GHT: (1) "It's the right thing to do" (Striving for the security and the wellbeing of the child), (2) "Doubting yourself constantly" (Constant uncertainty), (3) "But then you just get used to it I suppose" (Adhering to GHT and lifestyle changes - the new normal), (4) "I hadn't been told anything about it" (Information behaviour; looking for normality and certainty).

CONCLUSION

Mothers experienced significant challenges coping with the uncertainties associated with GHT and needed more information and support. The felt stigma of restricted growth, rare medical condition and GHT appeared to hinder some mothers from seeking support.

PRACTICE IMPLICATIONS

Healthcare professionals and policy makers need to ensure that services for children receiving GHT include the necessary continuous practical and emotional support for parents along the treatment journey.

Adult growth hormone deficiency: clinical advances and approaches to improve adherence

Introduction: There have been significant clinical advances in the understanding of the diagnosis and benefits of long-term recombinant human growth hormone (rhGH) replacement in adults with GH deficiency (GHD) since its approval in 1996 by the United States Food and Drug Administration.Areas covered: We searched PubMed, Medline, CINAHL, EMBASE and PsychInfo databases between January 2000 and June 2019 for published studies evaluating adults with GHD. We reviewed the data of the oral macimorelin test compared to the GHRH plus arginine and the insulin tolerance tests that led to its approval by the United States FDA and European Medicines Agency for adult diagnostic testing. We summarize the clinical advances of long-term benefits of rhGH therapy and the potential effects of GH receptor polymorphisms on individual treatment responsiveness. We identify that non-adherence and discontinuation rates are high and recommend strategies to support patients to improve adherence. We also provide an overview of several long-acting GH (LAGH) preparations currently under development and their potential role in improving treatment adherence.Expert opinion: This article summarizes recent clinical advances in rhGH replacement therapy, the biological and molecular aspects that may influence rhGH action, and offers practical strategies to enhance adherence in adults with GHD.

Improved adherence and growth outcomes with jet-delivered growth hormone

Background We previously reported improved persistence and adherence to daily recombinant growth hormone (rGH) in children using jet transjection delivery compared to using needle-based devices. This study examines the relationship between improved adherence and medium-term growth outcomes in children receiving jet-delivered rGH (JrGH) at a single centre. Methods This was a retrospective longitudinal follow-up study of children (<16 years) treated with daily JrGH (somatropin; Ferring Pharmaceuticals) in the form of Zomacton® with the Zomajet® device. Delivery schedules of home distribution services were utilised to calculate adherence, quantified as the proportion of days covered (PDC) index (PDC > 0.8 adherent, PDC ≤ 0.8 less adherent). Demography, patient history, height standard deviation scores (HTSDS) and difference from mid-parental height SDS (MPHSDS - HTSDS) were extracted from hospital records for up to 3 years of treatment. Results Of 75 patients eligible for JrGH, 52 had PDC treatment and height data for at least 1 year and 22 for 3 years. A greater proportion of patients were classified as adherent in both 1- and 3-year treated cohorts (adherent 30 [57.7%] and 14 [63.6%], less adherent 22 [42.3%] and 8 [36.4%]). After 1 year of JrGH treatment, HTSDS was not significantly different in either adherence group. After 3 years, only adherent patients demonstrated sustained year-on-year increments in HTSDS and significant improvement in target HTSDS positions (by 1.32 SDS) compared to baseline (p = 0.0008). MPHSDS - HTSDS showed a similar significant improvement at 3 years in adherent patients only (p = 0.0043). Conclusions Patients adherent to JrGH demonstrate significant growth improvement compared to baseline over 3 years.

Improvement of treatment adherence with growth hormone by easypod™ device: experience of an Italian centre

BACKGROUND

One of the most important vulnerabilities falling the efficacy of recombinant human growth hormone (r-hGH) treatment is low adherence especially in young patients. This study was planned to describe the correlation between r-hGH treatment efficacy and adherence in real-life setting using easypod™.

METHODS

Forty patients younger than 18 years, affected by a clinical condition in which r-hGH is available and treated with r-hGH easypod™, were enrolled in a retrospective, observational, real-world data, monocentric trial. The study design provided the retrospective collection of records collected by a questionnaire proposed to the patients and their parents and compared with registered data by the new generation electronic device r-hGH easypod™. Number of injections and doses were collected and used to assess the percentage of administered GH doses to measure treatment adherence. The r-hGH treatment efficacy was evaluated comparing standard deviation score for height (SDS) between baseline and follow-up visit, according to clinical practice.

RESULTS

The mean treatment adherence was 92.20% and it was inversely related to patients' age (R = - 0.358, p = 0.023), and significantly higher in the sub-group of patients with age between 10 and 13 years. Treatment adherence showed an inverse correlation with the years of therapy (R = - 0.453, p = 0.003) and with the number of r-hGH administrations (R = - 0.392, p = 0.012). However, the height increase did not reach a significant correlation with treatment adherence (R = - 0.067, p = 0.683).

CONCLUSIONS

Children and adolescent patients with GH deficiency due to different clinical conditions show high adherence to r-hGH treatment tested by easypod™. Easypod™ could be used as an important device to control patients' adherence in daily treatment for chronic diseases with expensive drugs.

Pattern of Use of Biosimilar and Originator Somatropin in Italy: A Population-Based Multiple Databases Study During the Years 2009-2014

PURPOSE

Somatropin [recombinant growth hormone (rGH)] is approved in children and adults for several conditions involving growth disturbances and the corresponding biosimilar is available in Italy since 2006. No population-based data are available on the pattern of rGH use in Italian clinical practice. This study aimed at exploring the pattern of biosimilar and originator rGH use in six Italian centers, where different policy interventions promoted biosimilar use.

METHODS

This population-based, drug-utilization study was conducted in the years 2009-2014, using administrative databases of Umbria, Tuscany, and Lazio Regions and Local Health Units of Caserta, Treviso, and Palermo. Naïve rGH users were characterized, and prevalence of use and discontinuation were assessed over time.

RESULTS

Among 6,785 patients treated with rGH during the study years, 4,493 (66.2%) were naïve users (males/females = 1.3), mostly affected by GH deficiency. The prevalence of rGH use increased from 2009 to 2010, remaining stable thereafter, but it was heterogeneous across centers (twofold higher prevalence of use in center n.2 than centers n.4 and 1 in 2014). Biosimilar rGH uptake increased over time but was low (7.8% in 2014) and heterogeneous as well. Discontinuation of rGH therapy occurred in 54.0% of naïve users, more frequently in females than males (58.1 vs. 50.9%). During the first year of treatment, discontinuation was frequent (39.9%), but no statistically significant differences were observed in treatment persistence for biosimilar vs. originator rGH (p > 0.05).

CONCLUSION

Geographical heterogeneity in the prevalence of rGH use was observed. Similarly, the biosimilar rGH uptake was low and variable across centers. Post-marketing monitoring is required to continuously monitor the benefit-risk profile of rGH, thus guaranteeing greater savings than only promoting lowest cost rGH.

Patients' perceptions on the usability of the SurePal™ self-injection device for Omnitrope®: a questionnaire-based observational study conducted in paediatric patients in France

BACKGROUND

A questionnaire-based survey was conducted to evaluate attitudes towards a reusable self-injection system, SurePal™, among paediatric patients with growth disturbances who were prescribed treatment with somatropin (Omnitrope^®) as part of routine clinical practice.

METHODS

This cross-sectional survey was incorporated into the multinational, multi-centre, noninterventional PAtients TReated with Omnitrope^® (PATRO) Children study. Questions were mainly focused on five areas: the attractiveness of SurePal™; training received; use of the device; opinion of the low-drug wastage system; experience compared with previous devices used (among pretreated patients).

RESULTS

Final results from participants in France are reported. Completed questionnaires were returned by 409 participants. Most patients (55%) were male and 89% were recombinant human growth hormone (rhGH)-treatment naïve. Around 57% of children completed the questionnaire by themselves, while 43% had help from a family member/other person. The mean (standard deviation) age of all participants was 11.3 (3.6) years, and most patients were aged 10-12 years (n = 126) or 13-15 years (n = 117). Overall, 86% of patients reported that preparing SurePal™ for injection was easy/very easy. Similarly, 83% reported that performing injections with SurePal™ was easy/very easy. The attractiveness of SurePal™ was rated as good/excellent by the majority (85%) of patients; this proportion was similarly high (> 80%) across all age groups. The dose-memory function was rated as helpful/very helpful by 54% of patients. Of the 174 patients who reported using the low drug-waste feature, 90% found it to be helpful/very helpful. Among the 24 pretreated patients, 17 reported that SurePal™ was better/much better than their previous device.

CONCLUSIONS

This questionnaire-based survey conducted in a large cohort of paediatric patients with growth disturbances from France confirms the ease of use of SurePal™ to support daily administration of Omnitrope^® across all age groups. The demonstrated acceptability of the device may help to improve patient adherence to long-term daily treatment with rhGH.

Acceptance of a reusable self-injection device for recombinant human growth hormone: final data from a questionnaire-based, cross-sectional, international, multicenter, observational study in pediatric patients

Background

A questionnaire-based survey was conducted to assess attitudes toward a reusable self-injection system (SurePal™) among pediatric patients with growth disturbances who were prescribed treatment with Omnitrope^® within routine clinical practice.

Methods

This was a multicenter, observational study, incorporated into the noninterventional PAtients TReated with Omnitrope^® (PATRO) Children study. Included subjects, or their caregivers, completed a questionnaire on the following five main areas: attractiveness of SurePal™, training received, using the device, the low drug wastage system, and experience versus other devices used previously (pretreated patients). Responses were based on a 5-point scale, with 2 being the best possible outcome and −2 the worst possible outcome.

Results

In total, 550 patients were included in this study (338 from France, 169 from Germany, and 43 from the UK). The mean age ± standard deviation of participants was 10.8±3.5 years; the majority (57%) were male and growth hormone treatment naïve (88%). Almost half (49.8%) of children prepared their SurePal™ for injection themselves and 45.5% performed injections themselves. As patients progressed into their teens, the majority (≥75%) favored preparing SurePal™ and performing injections themselves, rather than seeking assistance. The attractiveness of SurePal™ was rated as excellent/good by 84.7% of patients overall; this rating was similarly high (≥79%) across countries and age-groups. Preparing (88.8%) and using (83.3%) SurePal™ were rated as very easy/easy by most patients; these ratings were similarly high, irrespective of country or age-group. The dose-memory function was rated as very helpful/helpful by 66.2% of patients. Among 246 patients who reported using the low drug-waste feature, 87.4% found it helpful. Among pretreated patients (n=64), 78.2% reported that SurePal™ was much better/better than their previous device.

Conclusion

These data confirm the ease of use and patient preference for SurePal™ among pediatric patients with growth disturbances.

Acceptability of the reusable SurePal™ self-injection device for Omnitrope(®) among pediatric patients: results from a questionnaire-based, cross-sectional, multicenter observational study

Background

SurePal™ is a reusable self-injection system that has been developed to support daily administration of Omnitrope^® (Sandoz, Kundl, Austria). A questionnaire-based cross-sectional survey was conducted to evaluate acceptability of, and preference for, SurePal™ in pediatric patients who were prescribed treatment with Omnitrope^® within routine clinical care.

Methods

This multicenter, observational study was incorporated into the ongoing non-interventional PATRO (PAtients TReated with Omnitrope^®) Children study. Patients (or caregivers) were provided with a questionnaire that included five main topics; attractiveness of the device, training received, using SurePal™, the low drug wastage system, and experience versus other devices used previously (where applicable). Questions were scored on a 5-point scale, with −2 being the worst possible outcome (eg, very hard/very poor) and 2 being the best possible outcome (eg, very easy/excellent).

Results

A total of 186 patients were included in this study (Germany, n=154; UK, n=32). The attractiveness of SurePal™ was rated as excellent/good by 87.1% of patients. Overall, 86.5% of patients found that using their SurePal™ was very easy/easy. Almost all patients (96.2%) found that preparing their SurePal™ for injection was very easy/easy, and 89.2% found that injecting with SurePal™ was very easy/easy. 85.5% of patients recorded that the dose memory function was helpful, and 87.6% that taking their SurePal™ apart after an injection was very easy/easy. Of the 88 patients who recorded that they had used the low drug waste feature, 89.8% found the feature to be helpful. Among pre-treated patients (n=42), 81% recorded that SurePal™ was much better/better than their previously used device.

Conclusion

This questionnaire-based cross-sectional survey in pediatric patients confirms the ease of use and patient preference for SurePal™, a reusable self-injection system that has been developed to support daily administration of Omnitrope^®.

Validation and ease of use of a new pen device for self-administration of recombinant human growth hormone: results from a two-center usability study

Close adherence to the recommended treatment regimen is important for the success of recombinant human growth hormone therapy, although nonadherence can be common. Ease of use and safety during use/storage are among several important factors in the design of a growth hormone injection device intended for long-term use. This study was performed to validate the usability and assess the ease of use of a new pen device (SurePal™) that has been developed to support daily administration of the recombinant human growth hormone product, Omnitrope® (somatropin). The primary objectives of the study were to assess if study participants, representing intended users of the pen in clinical practice, were able to perform an injection procedure into an injection pad effectively and safely and disassemble the pen without receiving a needlestick injury. A total of 106 participants (61 adults and 45 children/adolescents) were enrolled at two study centers (one in the US, one in Germany). Results for both primary usability tasks met the predefined acceptance criteria, with >85% of participants successfully performing each task. All of the other tasks/handling steps assessed were also successfully performed by most participants, with high success rates reflected in the high proportion of participants who classified each task as “very easy” or “easy”. After a second use of the device, 87%–97% of participants rated it as “very easy” or “easy” to use. In summary, the new pen device is safe and easy to use for both adults and children, and will help to support effective, long-term daily administration of the recombinant human growth hormone product, Omnitrope®.