Inhaled growth hormone (GH) compared with subcutaneous GH in children with GH deficiency: pharmacokinetics, pharmacodynamics, and safety

Strategies for transportation of peptides across the skin for treatment of multiple diseases

An established view in genetic engineering dictates an increase in the discovery of therapeutic peptides to enable the treatment of multiple diseases. The use of hypodermic needle for delivery of proteins and peptides occurs due to the hydrophilic nature, sensitivity toward proteolytic enzymes and high molecular weight. The non-invasive nature of the transdermal delivery technique offers multiple advantages over the invasive route to release drugs directly into the systemic circulation to enhance bioavailability, better patient compliance, reduced toxicity and local irritability. The transdermal route seems highly desirable from the pharmaco-therapeutic and patient compliance point of view, however, the lipophilic barrier of skin restricts the application. The use of several techniques like electrical methods (iontophoresis, sonophoresis etc.), chemical penetration enhancers (e.g. protease inhibitors, penetration enhancers, etc.) and nanocarriers (dendrimers, lipid nanocapsules, etc.) are utilized to improve the passage of drug molecules across the biomembranes. Additionally, such clinical interventions facilitate the physicochemical characteristics of peptides, to enable effective preservation, conveyance and release of therapeutic agents. Moreover, strategies ensure the attainment of the intended targets and enhance treatment outcomes for multiple diseases. This review article focuses on the techniques of peptide transportation across the skin to advance the delivery approaches and therapeutic efficiency.

Tackling access and payer barriers for growth hormone therapy in Saudi Arabia: a consensus statement for the Saudi Working Group for Pediatric Endocrinology

Prompt diagnosis and early treatment are key goals to optimize the outcomes of children with growth hormone deficiency (GHD) and attain the genetically expected adult height. Nonetheless, several barriers can hinder prompt diagnosis and treatment of GHD, including payer-related issues. In Saudi Arabia, moderate-to-severe short stature was reported in 13.1 and 11.7 % of healthy boys and girls, respectively. Several access and payer barriers can face pediatric endocrinologists during the diagnosis and treatment of GHD in Saudi Arabia. Insurance coverage policies can restrict access to diagnostic tests for GHD and recombinant human growth hormone (rhGH) due to their high costs and lack of gold-standard criteria. Some insurance policies may limit the duration of treatment with rhGH or the amount of medication covered per month. This consensus article gathered the insights of pediatric endocrinologists from Saudi Arabia to reflect the access and payer barriers to the diagnostic tests and treatment options of children with short stature. We also discussed the current payer-related challenges endocrinologists face during the investigations of children with short stature. The consensus identified potential strategies to overcome these challenges and optimize patient management.

Performance of Cell-Penetrating Peptides Anchored to Polysaccharide Platforms Applied via Various Mucosal Routes as an Absorption Enhancer

We have been investigating the potential of cell-penetrating peptides anchored to polymeric platforms as a novel absorption enhancer which delivers biologics into systemic circulation via mucosal routes. Our previous mouse experiments demonstrated that hyaluronic acid modified with l-octaarginine, a typical cell-penetrating peptide, via a tetraglycine spacer significantly enhanced the mucosal absorption of protein drugs applied into the nasal cavities, irrespective of the molecular weights (M_w) of the drugs. The present study evaluated the performance of tetraglycine-l-octaarginine-linked hyaluronic acid applied via various mucosal routes. Somatropin (M_w: ca. 22.1 kDa) was moderately absorbed from the lung mucosa, and the mean absolute bioavailability (BA) reached 19% under enhancer-free conditions; nevertheless, its BA under intranasal administration was approximately 1% or less. Its BA significantly elevated to 46% on average through intrapulmonary coadministration with tetraglycine-l-octaarginine-linked hyaluronic acid. When the administration site was replaced with the oral cavities, an extreme reduction in somatropin absorption was observed with a mean BA of 0.056% under enhancer-free conditions. Intraoral coadministration with tetraglycine-l-octaarginine-linked hyaluronic acid resulted in a 6.3-fold elevation of somatropin absorption with statistical significance. A similar enhancement was observed under intrarectal administration with a further reduction in BA. On the other hand, the hyaluronic acid derivative did not exhibit the absorption-enhancing ability under intragastric administration, probably due to the lack of stabilization effects against enzyme-susceptible biologics. The results indicated that the intrapulmonary route was suitable for maximizing the mucosal absorption of biologics, and that there was a likelihood of the intraoral route with user convenience. When somatropin was substituted with fluorescein isothiocyanate-conjugated dextran with an average M_w range of 4-70 kDa, similar phenomena were observed under intrapulmonary and intranasal administration. BA decreased with an increase in the M_w of dextran; however, the ratio of BA under enhancer-present conditions to that under enhancer-free conditions was consistently around 3, indicating that the performance of the hyaluronic acid derivative was M_w-independent, irrespective of the administration route.

New insight into the importance of formulation variables on parenteral growth hormone preparations: potential effect on the injection-site pain

Reducing injection-site pain (ISP) in patients with chronic conditions such as growth hormone deficiency is a valuable strategy to improve patient compliance and therapeutic efficiency. Thus understanding different aspects of pain induction following subcutaneous injection of biotherapeutics and identifying the responsible factors are vital. Here we have discussed the effects of formulation's viscosity, concentration, osmolality, buffering agents, pH, and temperature as well as injection volume, dosing frequency, and different excipients on ISP following subcutaneous injection of commercially available recombinant human growth hormone products. Our literature review found limited available data on the effects of different components of parenteral rhGH products on ISP. This may be due to high cost associated with conducting various clinical trials to assess each excipient in the formulation or to determine the complex interactions of different components and its impact on ISP. Recently, conducting molecular dynamics simulation studies before formulation design has been recommended as an alternative and less-expensive approach. On the other hand, the observed inconsistencies in the available data is mainly due to different pain measurement approaches used in each study. Moreover, it is difficult to translate data obtained from animal studies to human subjects. Despite all these limitations, our investigation showed that components of parenteral rhGH products can significantly contribute to ISP. We suggest further investigation is required for development of long acting, buffer-free, preservative-free formulations. Besides, various excipients are currently being investigated for reducing ISP which can be used as alternatives for common buffers, surfactants or preservatives in designing future rhGH formulations.

Population Pharmacokinetics and Pharmacodynamics of Once-Daily Growth Hormone Norditropin® in Children and Adults

Background and Objective

Once-daily injectable recombinant human growth hormone (GH) formulations (e.g. Norditropin^®; Novo Nordisk A/S) are used to treat GH deficiency in children and adults, with much of the therapeutic effect mediated via the insulin-like growth factor-I (IGF-I) response. Despite a long history of use, there are few data on the pharmacokinetics and pharmacodynamics (serum IGF-I response) of this therapy, or of potential differences in the relationship of GH pharmacokinetic/pharmacodynamic (PK/PD) effects between children and adults. This study aimed to characterise the GH pharmacokinetics and IGF-I profile following daily subcutaneous GH in adults and children with GH deficiency.

Methods

A model was developed based on a population PK/PD modelling meta-analysis of data from three phase I clinical trials (two using Norditropin^® as a comparator with somapacitan, and one as a comparator with a pegylated GH product). Sequential model building was performed, first developing a model that could describe GH pharmacokinetics. A PD model of IGF-I data was then developed using PK and PD data, and where all PK parameters were kept fixed to those estimated in the PK model.

Results

The model developed accurately describes and predicts GH pharmacokinetics and IGF-I response. Body weight was shown to have an important inversely correlated influence on GH exposure (and IGF-I standard deviation score), and this largely explained differences between adults and children.

Conclusions

The pharmacokinetics/pharmacodynamics developed here can inform expectations about the PD effects of different doses of GH in patients with GH deficiency of different body weights, regardless of their age.

Clinical Trial Registration

Pooled modelling analysis of data from ClinicalTrials.gov identifiers NCT01973244, NCT00936403 and NCT01706783.

Dates of registration

NCT01973244: 22 October, 2013; NCT00936403: 9 July, 2009; NCT01706783: 11 October, 2012.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-021-01011-3.

Dosing considerations for inhaled biologics

The number of biologics in the therapeutic development pipeline is increasing including those delivered though inhalation (Morales, 2017; Fathe, 2016). Biologics comprise a broad variety of complex macromolecules with unique physicochemical characteristics. These distinctive characteristics control their pharmacological mechanisms of action, stability, and ultimately affect their processing, formulation, and delivery requirements. This review systematically covers crucial aspects of biologic powders formulations and dry powder inhalers which need to be taken into consideration to establish the drug loading and the payload to be delivered to reach the desired clinical dose.

Nano-Therapeutics for the Lung: State-of-the-Art and Future Perspectives

Inhalation of aerosolized compounds is a popular, non-invasive route for the targeted delivery of therapeutic molecules to the lung. Various types of nanoparticles have been used as carriers to facilitate drug uptake and intracellular action in order to treat lung diseases and/or to facilitate lung repair and growth. These include polymeric nanoparticles, liposomes, and dendrimers, among many others. In addition, nanoparticles are sometimes used in combination with small molecules, cytokines, growth factors, and/or pluripotent stem cells. Here we review the rationale and state-of-the-art nanotechnology for pulmonary drug delivery, with particular attention to new technological developments and approaches as well as the challenges associated with them, the emerging advances, and opportunities for future development in this field.

Intranasal Human Growth Hormone (hGH) Induces IGF-1 Levels Comparable With Subcutaneous Injection With Lower Systemic Exposure to hGH in Healthy Volunteers

CONTEXT

The development of an improved, efficacious human GH (hGH) product administered by a noninjectable route of delivery such as the nasal route is highly desirable. We have developed a novel nasal hGH product (CP024) that showed excellent nasal absorption in animal models; however, the translation of these results into the clinical setting is essential because past attempts to develop such formulations by other groups have been unable to induce IGF-1 in man.

OBJECTIVE

The objective of the study was to assess the pharmacokinetics, pharmacodynamics, and tolerability of CP024 compared with a sc hGH injection.

DESIGN

This was a single-center, nonrandomized placebo-controlled, open-label, five-way crossover study in eight healthy volunteers.

SETTING

The study was carried out at a contract research organization, Quotient Bioresearch.

VOLUNTEERS

Eight healthy male volunteers, given an iv infusion of octreotide to suppress the endogenous GH secretion during the study period, participated in the study. No volunteers were withdrawn due to side effects.

MAIN OUTCOME MEASURES

Measurement of hGH and IGF-1 levels and tolerability of the drug product was performed.

RESULTS

No serious adverse events were reported and no subjects withdrawn from study due to the treatment. After the nasal administration of CP024, 3-fold higher hGH blood levels were obtained as compared with hGH nasal control. The relative bioavailability was about 3%. CP024 (given twice daily) induced a significant increase in IGF-1 levels up to 19 hours after administration, with no significant difference to those obtained after the sc injection of hGH.

CONCLUSIONS

The study indicates that CP024 is a promising candidate for an efficacious nasal product for the treatment of GH deficiency due to induction of IGF-1 similar to that after a sc injection, despite the lower plasma hGH concentration obtained. A dose-response study is needed to evaluate the optimal nasal dose.

Protein stability in pulmonary drug delivery via nebulization

Protein inhalation is a delivery route which offers high potential for direct local lung application of proteins. Liquid formulations are usually available in early stages of biopharmaceutical development and nebulizers are the device of choice for atomization avoiding additional process steps like drying and enabling fast progression to clinical trials. While some proteins were proven to remain stable throughout aerosolization e.g. DNase, many biopharmaceuticals are more susceptible towards the stresses encountered during nebulization. The main reason for protein instability is unfolding and aggregation at the air-liquid interface, a problem which is of particular challenge in the case of ultrasound and jet nebulizers due to recirculation of much of the generated droplets. Surfactants are an important formulation component to protect the sensitive biomolecules. A second important challenge is warming of ultrasound and vibrating mesh devices, which can be overcome by overfilling, precooled solutions or cooling of the reservoir. Ultimately, formulation development has to go hand in hand with device evaluation.

Growth hormone dose-dependent pubertal growth: a randomized trial in short children with low growth hormone secretion

BACKGROUND/AIMS

Growth hormone (GH) treatment regimens do not account for the pubertal increase in endogenous GH secretion. This study assessed whether increasing the GH dose and/or frequency of administration improves pubertal height gain and adult height (AH) in children with low GH secretion during stimulation tests, i.e. idiopathic isolated GH deficiency.

METHODS

A multicenter, randomized, clinical trial (No. 88-177) followed 111 children (96 boys) at study start from onset of puberty to AH who had received GH 33 µg/kg/day for ≥1 year. They were randomized to receive 67 µg/kg/day (GH(67)) given as one (GH(67×1); n = 35) or two daily injections (GH(33×2); n = 36), or to remain on a single 33 µg/kg/day dose (GH(33×1); n = 40). Growth was assessed as heightSDSgain for prepubertal, pubertal and total periods, as well as AHSDS versus the population and the midparental height.

RESULTS

Pubertal heightSDSgain was greater for patients receiving a high dose (GH(67), 0.73) than a low dose (GH(33×1), 0.41, p < 0.05). AHSDS was greater on GH(67) (GH(67×1), -0.84; GH(33×2), -0.83) than GH(33) (-1.25, p < 0.05), and heightSDSgain was greater on GH(67) than GH(33) (2.04 and 1.56, respectively; p < 0.01). All groups reached their target heightSDS.

CONCLUSION

Pubertal heightSDSgain and AHSDS were dose dependent, with greater growth being observed for the GH(67) than the GH(33) randomization group; however, there were no differences between the once- and twice-daily GH(67) regimens. © 2014 S. Karger AG, Basel.

Lipid-based carriers for pulmonary products: preclinical development and case studies in humans

A number of lipid-based technologies have been applied to pharmaceuticals to modify their drug release characteristics, and additionally, to improve the drug loading for poorly soluble drugs. These technologies, including solid-state lipid microparticles, many of which are porous in nature, liposomes, solid lipid nanoparticles and nanostructured lipid carriers, are increasingly being developed for inhalation applications. This article provides a review of the rationale for the use of these technologies in the pulmonary delivery of drugs, and summarizes the manufacturing processes and their limitations, the in vitro and in vivo performance of these systems, the safety of these lipid-based systems in the lung, and their promise for commercialization.

Developments in human growth hormone preparations: sustained-release, prolonged half-life, novel injection devices, and alternative delivery routes

Since the availability of recombinant human growth hormone (rhGH) enabled the application of human growth hormone both in clinical and research use in the 1980s, millions of patients were prescribed a daily injection of rhGH, but noncompliance rates were high. To address the problem of noncompliance, numerous studies have been carried out, involving: sustained-release preparations, prolonged half-life derivatives, new injectors that cause less pain, and other noninvasive delivery methods such as intranasal, pulmonary and transdermal deliveries. Some accomplishments have been made and launched already, such as the Nutropin Depot^® microsphere and injectors (Zomajet^®, Serojet^®, and NordiFlex^®). Here, we provide a review of the different technologies and illustrate the key points of these studies to achieve an improved rhGH product.

A high-affinity peptide for nicotinic acetylcholine receptor-α1 and its potential use in pulmonary drug delivery

In pulmonary drug delivery, the ability of an affinity molecule to bind to lung epithelium may prolong retention of therapeutic molecules within the lung and consequently yield higher overall bioavailability. To this end, we screened a library of structurally constrained peptides ('aptides') using phage-display technology and identified a high-affinity aptide for the mouse nicotinic acetylcholine receptor-α1 (nAChR-α1). The isolated aptide (APTnAChR-α1) bound to its target protein with high affinity (Kd=47nM). Alexa 488-labeled APTnAChR-α1 showed preferential binding to nAChR-α1-positive mouse lung epithelial cells and mouse muscle cells. Furthermore, the aptide exhibited substantial binding in nAChR-α1-positive tissue sections of muscle, trachea and lung, but not in liver, kidney or spleen tissues, which are nAChR-α1-negative. In an in vivo experiment, a high-intensity fluorescence signal was observed in the entire lung up to 50h after tracheal injection of Cy5.5-APTnAChR-α1, whereas most of the fluorescence signal from a Cy5.5-labeled scrambled peptide washed out within 20h after injection. Taken together, these results indicate that the high-affinity peptide for nAChR-α1 identified here bound tightly to lung epithelium and thus exhibited a long residence time in this tissue, suggesting that the peptide could be used for pulmonary delivery of active pharmaceuticals.

Targeting inhaled therapy beyond the lungs

Pulmonary disease has been the primary target of inhaled therapeutics for over 50 years. During that period, increasing interest has arisen in the use of this route of administration to gain access to the systemic circulation for the treatment of a number of diseases beyond the airways. In order to effectively employ this route, the barriers to transport from the lungs following deposition of aerosols must be considered, including the nature of the disease (whether proximal, as in pulmonary hypertension, or distal, as in diabetes). Delivery to the systemic circulation begins with the efficiency of aerosol generation and subsequent deposition in the airways and proceeds to the influence of mechanisms of clearance, including absorption, metabolism, and mucociliary and cell-mediated transport, on the residence time of the drugs in the lungs. The nature of the drug (small or large molecules/low or high molecular weight), susceptibility to degradation and general physicochemical properties play a role in the chemistry of its formulation, physics of aerosol delivery and biology of disposition.

Lung vascular targeting through inhalation delivery: insight from filamentous viruses and other shapes

Systemic delivery of therapeutic agents via inhalation of particulates remains an attractive, noninvasive means of administration due to the possibilities of high bioavailability and high patient compliance. Optimization of particle shapes and particle properties for deep lung deposition after inhalation continues to be one of the key challenges. Here, we review several aspects of nanoparticle design for deep lung deposition as well as the nature and extent of translocation through the air-blood barrier for local or systemic vascular targeting. We describe filamentous influenza virus in comparison to worm-like "filomicelle" polymers as one example of a nature inspired design.

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

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

Transmembrane delivery and biological effect of human growth hormone via a phage displayed peptide in vivo and in vitro

For a long time, people have been looking forward to being able to clinically deliver bio-drugs systemically by a noninvasive method. Here, we show that a synthetic peptide, TD (ACSSSPSKHCG) was efficient in transferring human growth hormone (GH) across various kinds of membranes and the blood-brain barrier (BBB) in vivo via rectal administration, resulting in elevation of GH level in serum, acetylcholine and O-choline acetyltransferase activities and GH /IGF-1 contents in brain tissues, manifesting great therapeutic effects on chronic age-related dementia in mice and ameliorating neuronal damage in the brain. Furthermore, the effects of Aβ and TD/GH on LDH release, apoptosis and its relevant gene expression, involving bcl-2 and bax/caspase-3, were observed in a human neuroblastoma cell line (SH-SY5Y). Results indicated that GH decreased LDH release, apoptosis, and bax/caspase-3 activity, and increased bcl-2 expression compared with Aβ treatment, moreover, TD/GH may enhance the effects due to existence of TD, which might be dependent on TD assisted cross-membrane delivery of GH. The transdermal/transmembrane-enhancing activity of the TD peptide was also manifested on porcine abdominal skin in vivo and the murine embryonic fibroblast cell line (3T3 cell) in vitro, which was further shown through interaction between TD and lecithin (one constituent of the cell membrane) by ESI-MS. In conclusion, TD/GH counteracted brain defects in aged mice in vivo and cell apoptosis induced by Aβ in vitro might explain several underlying mechanisms by which GH could ameliorate learning and memory deficits in aged mice. Mixed TD/GH transmembrane delivery might be a promising therapy of Alzheimer's disease.

Biotherapeutic bioanalysis: a multi-indication case study review

A thorough understanding of the structure and biology of a biotherapeutic is crucial to defining a suitable strategy for pharmacokinetic characterization in proof-of-concept disease models, toxicology species as well as the healthy and disease indication patient populations. This manuscript summarizes parameters that impact bioanalytical strategy for over 50 biotherapeutics indicated for the treatment of oncology, rheumatoid arthritis, allergy, multiple sclerosis, hematology, metabolism and infectious disease. We have addressed numerous therapeutic modalities including chimeric, humanized and fully human monoclonal antibodies, replacement proteins, peptides and fusion proteins, including polyethylene glycol and Fc fusions, as well as antibody–drug conjugates. With the rapid evolution of biotherapeutics over the last 20 years and the contraction of the pharmaceutical and biotechnology labor force, efficient workflow management becomes a crucial bioanalytical component. Thus, we have also addressed new technologies that have demonstrated either increased throughput or enhanced characterization, including Meso Scale Discovery, Gyrolab and affinity MS.

Dissolving microneedle patch for transdermal delivery of human growth hormone

The clinical impact of biotechnology has been constrained by the limitations of traditional hypodermic injection of biopharmaceuticals. Microneedle patches have been proposed as a minimally invasive alternative. In this study, the translation of a dissolving microneedle patch designed for simple, painless self-administration of biopharmacetucials that generates no sharp biohazardous waste is assessed. To study the pharmacokinetics and safety of this approach, human growth hormone (hGH) was encapsulated in 600 μm-long dissolving microneedles composed of carboxymethylcellulose and trehalose using an aqueous, moderate-temperature process that maintained complete hGH activity after encapsulation and retained most activity after storage for up to 15 months at room temperature and humidity. After manual insertion into the skin of hairless rats, hGH pharmacokinetics were similar to conventional subcutaneous injection. After patch removal, the microneedles had almost completely dissolved, leaving behind only blunt stubs. The dissolving microneedle patch was well tolerated, causing only slight, transient erythema. This study suggests that a dissolving microneedle patch can deliver hGH and other biopharmaceuticals in a manner suitable for self-administration without sharp biohazardous waste.

Pediatric Dosing and Body Size in Biotherapeutics

Although pediatric doses for biotherapeutics are often based on patients' body weight (mg/kg) or body surface area (mg/m²), linear body size dose adjustment is highly empirical. Growth and maturity are also important factors that affect the absorption, distribution, metabolism and excretion (ADME) of biologics in pediatrics. The complexity of the factors involved in pediatric pharmacokinetics lends to the reconsideration of body size based dose adjustment. A proper dosing adjustment for pediatrics should also provide less intersubject variability in the pharmacokinetics and/or pharmacodynamics of the product compared with no dose adjustment. Biological proteins and peptides generally share the same pharmacokinetic principle with small molecules, but the underlying mechanism can be very different. Here, pediatric and adult pharmacokinetic parameters are compared and summarized for selected biotherapeutics. The effect of body size on the pediatric pharmacokinetics for these biological products is discussed in the current review.

Differential effects of insufflated, subcutaneous, and intravenous growth hormone on bone growth, cognitive function, and NMDA receptor subunit expression

The objective of this study was to characterize the effect of inhalable growth hormone (GH) delivered by an insufflator to the lungs of hypophysectomized Sprague Dawley rats. In the first cohort, the safety and efficacy of the insufflated GH were evaluated. Three experimental groups (n = 7 per group) were treated with GH for 15 d: One group received sc injection of GH daily at 200 microg/kg (SC200). Two other groups received GH by insufflation daily: 200 microg/kg (INS 200) and 600 microg/kg (INS 600). In the second set of experiments, GH was administered in three routes [SC200, INS200, intravenous (IV200)] (n=10) for 5 d, and escape latency and N-methyl D-aspartate (NMDA) receptor expression were evaluated. In the first cohort, INS200 showed similar bioactivity as SC200 in growth promotion, tibial growth, as well as escape latency on the 12th day of treatment. Insufflated GH was well tolerated without significant inflammatory responses. In the second cohort, expression of the NMDA receptor 1 and 2B in hippocampus measured after 3 or 6 d of daily treatments were significantly higher in INS200 as compared to IV200, consistent with the improvement of the escape latency. In summary, the inhalable form of GH delivered by intratracheal insufflation was safe, and its bioactivity was comparable to sc injection both in promotion of growth and acquisition of learning ability. If applied properly to human, inhalable GH would be effective for growth promotion and possibly for several disorders caused by underexpression of NMDA receptors.

Growth hormone deficiency: diagnosis and therapy in children

Growth hormone (GH) deficiency (GHD) represents a condition characterized by reduced GH secretion, isolated or associated with other pituitary hormone deficiencies. Diagnosis of GHD in childhood is achieved by secretagogs testing in combination with auxological parameters, such as height and growth velocity and biochemical and radiological findings. Only after excluding other causes of growth failure should a careful assessment of the pituitary-IGF-1 axis be undertaken, using GH-provocative tests and basal serum IGF-I values. As recommended by the GH Research Society, patients with GHD should be treated with recombinant human GH in order to normalize height during childhood and, ultimately, attain a normal adult height.