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Robilliard R, Lee PA, Swartz Topor L. Diagnosis, Treatment, and Outcomes of Males with Central Precocious Puberty. Endocrinol Metab Clin North Am 2024; 53:239-250. [PMID: 38677867 DOI: 10.1016/j.ecl.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Central precocious puberty (CPP) among males is less frequent than among females but more likely to have an underlying pathologic cause. Diagnosis of CPP is often straightforward among males because increased testicular volume, the first sign of puberty, can be verified although careful central nervous system (CNS) assessment is generally necessary. Treatment with gonadotropin-releasing hormone agonist (GnRHa) is indicated, given in conjunction with any therapy needed for CNS lesions. Monitoring of treatment usually can consist of evaluating growth and physical puberty and with testosterone levels as the only lab data. Short-term and long-term outcome data indicate efficacy and safety, although data are limited. Such data need to be reported.
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Affiliation(s)
- Renée Robilliard
- Division of Pediatric Endocrinology and Diabetes, Hasbro Children's Hospital, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter A Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA.
| | - Lisa Swartz Topor
- Division of Pediatric Endocrinology and Diabetes, Hasbro Children's Hospital, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
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Klein KO, Miller BS, Mauras N. Unstimulated Luteinizing Hormone for Assessment of Suppression during Treatment of Central Precocious Puberty with 6-Month Subcutaneous Leuprolide Acetate: Correlations with Clinical Response. Horm Res Paediatr 2024:1-10. [PMID: 38684152 DOI: 10.1159/000539110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/25/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Phase 3 trial of 6-month subcutaneous leuprolide acetate (SC-LA) in children with central precocious puberty (CPP) demonstrated efficacy and safety. The aims of this secondary analysis were to evaluate unstimulated luteinizing hormone (LH) as efficacy measure, assess clinical suppression metrics, and present biochemical and clinical data for subgroups not achieving hormone suppression. METHODS Sixty-two children with treatment-naïve CPP received 2 doses of 45 mg SC-LA at 24-week intervals. Unstimulated and GnRH-stimulated LH, E2, and T concentrations were measured. Clinical measures included bone age (BA) and predicted adult height (PAH). RESULTS Eighty-four percentage and 86% of children achieved unstimulated LH <1 IU/L at weeks 24 and 48, respectively. Of 8 children not achieving unstimulated LH <1 IU/L at week 24 that completed the study, all showed a lack of pubertal stage progression and stable/decreased BA to chronological age ratio (BA/CA). Received operating characteristic (ROC) analyses suggested unstimulated LH is a good diagnostic predictor of GnRH-stimulated LH <4 IU/L at weeks 24 and 48 (AUC = 0.88). Across all children, mean BA/CA improved from 1.4 (screening) to 1.3 (week 48) and mean PAH increased by 3 cm. Of 7 girls not achieving stimulated LH <4 IU/L at week 24, all achieved E2 <10 pg/mL, showed a lack of pubertal stage progression, and had stable or decreased BA/CA by week 48. Additionally, 6/7 had increased PAH by week 48 and 4 had unstimulated LH <1 IU/L. CONCLUSION Unstimulated LH has value as an efficacy measure and concentrations <1 IU/L may be an adequate surrogate of treatment response in children with CPP. All children who completed the study had evidence of pubertal suppression.
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Affiliation(s)
- Karen O Klein
- Department of Pediatrics, Rady Children's Hospital and University of California, San Diego, California, USA
| | - Bradley S Miller
- Division of Pediatric Endocrinology, University of Minnesota Medical School, M Health Fairview Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children's Health, Jacksonville, Florida, USA
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Thaneetrakool T, Aroonparkmongkol S, Numsriskulrat N, Supornsilchai V, Wacharasindhu S, Srilanchakon K. Effectiveness of leuprolide acetate administered monthly compared to three-monthly in the treatment of central precocious puberty: evaluation at the end of treatment. Front Endocrinol (Lausanne) 2024; 15:1390674. [PMID: 38737553 PMCID: PMC11084664 DOI: 10.3389/fendo.2024.1390674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Gonadotropin-releasing hormone (GnRH) analogs are the standard treatment for central precocious puberty (CPP). Although there are numerous varieties of GnRH agonists, the effectiveness of 1-monthly compared with 3-monthly Leuprolide acetate is still restricted. The objective of this study was to evaluate the outcomes of CPP treatment with Leuprolide acetate at a 1-monthly dosage of 3.75 mg, in comparison to a dosage of 11.25 mg administered every 3 months. Method This retrospective cohort study involved 143 girls diagnosed with CPP with 72 of them receiving the monthly treatment regimen and 71 receiving the 3-monthly treatment regimen. Anthropometric measurements were compared at the start and end of the therapy. The rates and level of LH suppression were assessed six months after therapy. Results The regimen administered every 3 months showed more significant suppression of LH. The 3-monthly group showed lower actual height and degree of bone age advancement at the end of therapy. However, the predicted adult height (PAH) remained comparable in both groups. Conclusion The 3-monthly treatment showed greater hormonal and growth suppression effects, but there was no significant difference in PAH between the two groups.
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Affiliation(s)
- Thanaporn Thaneetrakool
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
| | - Suphab Aroonparkmongkol
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
| | - Nattakarn Numsriskulrat
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
- Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
| | - Vichit Supornsilchai
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
| | - Suttipong Wacharasindhu
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
| | - Khomsak Srilanchakon
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, ;Thailand
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Huang S, Zhang L, Gao C, Ou H, Hou L, Liu Z, Wang D, Xu Y, Liang L, Meng Z. Efficacy and safety of leuprorelin 3-month depot (11.25 mg) for idiopathic central precocious puberty treatment of Chinese girls: a single-center retrospective study. J Pediatr Endocrinol Metab 2024; 37:15-20. [PMID: 37975727 DOI: 10.1515/jpem-2023-0410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study aimed to evaluate the efficacy and safety of 3-month leuprorelin acetate (3-month LA, 11.25 mg) for the treatment of idiopathic central precocious puberty (ICPP) in Chinese girls. METHODS We conducted a single-center retrospective study in China on 28 girls with ICPP who received at least one year of 3-month LA treatment. Data from anthropometry, biochemistry, bone age (BA), and pelvic ultrasonography were assessed before and every 6 months during medication. RESULTS At CPP diagnosis, the mean chronological age (CA) was 7.8±0.8 years, with bone age advancement (BA-CA) of 1.5±0.8 years. After treatment initiation, growth velocity decreased significantly from 8.5±1.6 cm/year to 5.8±1.1 cm/year at month 12 (p<0.001). GnRH-stimulated peak LH ≤3IU/L, the primary efficacy criterion, was observed in 27 out of 28 (96.4 %) children at month 3. Basal estradiol <20 pg/mL was achieved by all 28 girls (100 %) at month 6 and remained stable at month 12. Basal follicle-stimulating hormone (FSH) decreased from 4.1±3.5 to 1.7±0.9 (p<0.001), and basal LH was also significantly reduced from 3.3±6.5 to 0.7±0.8 (p=0.035) at month 12. The mean predicted adult height (PAH) at treatment initiation was 152.7±5.8 cm, it increased significantly to 157.5±5.5 cm (p=0.007) after one-year treatment. Pubertal development was slowed in most patients, and in some cases, it was even reversed. Only one patient (3.6 %) reported local intolerance. CONCLUSIONS Three-month leuprorelin acetate is a safe and effective treatment for suppressing the pituitary-gonadal axis and restoring impaired adult height in Chinese girls.
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Affiliation(s)
- Siqi Huang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lina Zhang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chenchen Gao
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hui Ou
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lele Hou
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zulin Liu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dilong Wang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingying Xu
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liyang Liang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhe Meng
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Zevin EL, Eugster EA. Central precocious puberty: a review of diagnosis, treatment, and outcomes. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:886-896. [PMID: 37973253 DOI: 10.1016/s2352-4642(23)00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/23/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
Central precocious puberty (CPP) refers to early activation of the hypothalamic-pituitary-gonadal (HPG) axis and is manifested by breast development in girls or testicular enlargement in boys before the normal physiological age ranges. CPP can be precipitated by intracranial pathology, exposure to high levels of sex steroids, or environmental risk factors, but most cases are idiopathic. Monogenic causes have also been identified. In this Review, we summarise pathophysiology, risk factors, diagnosis, and management of CPP. Concern for CPP should prompt referral to paediatric endocrinology where diagnosis is confirmed by clinical, biochemical, radiological, and genetic testing. CPP is treated with a gonadotropin-releasing hormone analogue, the primary aims of which are to increase adult height and postpone development of secondary sexual characteristics to an age that is more commensurate with peers. Although long-term outcomes of treatment with gonadotropin-releasing hormone analogues are reassuring, additional research on the psychological effect of CPP is needed.
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Affiliation(s)
- Erika L Zevin
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Erica A Eugster
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Klein KO, Mauras N, Nayak S, Sunil B, Martinez-Placencia BM, Dragnic S, Ballina M, Zhou Q, Kansra AR. Efficacy and Safety of Leuprolide Acetate 6-Month Depot for the Treatment of Central Precocious Puberty: A Phase 3 Study. J Endocr Soc 2023; 7:bvad071. [PMID: 37334213 PMCID: PMC10274571 DOI: 10.1210/jendso/bvad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Indexed: 06/20/2023] Open
Abstract
Context Treatment options for central precocious puberty (CPP) are important for individualization of therapy. Objective We evaluated the efficacy and safety of 6-month 45-mg leuprolide acetate (LA) depot with intramuscular administration. Methods LA depot was administered at weeks 0 and 24 to treatment-naïve (n = 27) or previously treated (n = 18) children with CPP in a phase 3, multicenter, single-arm, open-label study (NCT03695237). Week 24 peak-stimulated luteinizing hormone (LH) suppression (<4 mIU/mL) was the primary outcome. Secondary/other outcomes included basal sex hormone suppression (girls, estradiol <20 pg/mL; boys, testosterone <30 ng/dL), suppression of physical signs, height velocity, bone age, patient/parent-reported outcomes, and adverse events. Results All patients (age, 7.8 ± 1.27 years) received both scheduled study doses. At 24 weeks, 39/45 patients (86.7%) had LH suppressed. Six were counted as unsuppressed; 2 because of missing data, 3 with LH of 4.35-5.30 mIU/mL and 1 with LH of 21.07 mIU/mL. Through 48 weeks, LH, estradiol, and testosterone suppression was achieved in ≥86.7%, ≥97.4%, and 100%, respectively (as early as week 4 for LH and estradiol and week 12 for testosterone). Physical signs were suppressed at week 48 (girls, 90.2%; boys, 75.0%). Mean height velocity ranged 5.0 to 5.3 cm/year post-baseline in previously treated patients and declined from 10.1 to 6.5 cm/year at week 20 in treatment-naïve patients. Mean bone age advanced slower than chronological age. Patient/parent-reported outcomes remained stable. No new safety signals were identified. No adverse event led to treatment discontinuation. Conclusion Six-month intramuscular LA depot demonstrated 48-week efficacy with a safety profile consistent with other GnRH agonist formulations.
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Affiliation(s)
- Karen O Klein
- University of California, San Diego, and Rady Children's Hospital San Diego, San Diego, CA 92121, USA
| | - Nelly Mauras
- Nemours Children's Health, Jacksonville, FL 32207, USA
| | - Sunil Nayak
- Pediatric Endocrine Associates, Greenwood Village, CO 80111, USA
| | - Bhuvana Sunil
- Mary Bridge Children's Hospital, Tacoma, WA 98403, USA
| | | | | | | | - Qing Zhou
- AbbVie, Inc., North Chicago, IL 60064, USA
| | - Alvina R Kansra
- Correspondence: Alvina R. Kansra, MD, Associate Medical Director, TAMD, Therapeutic Area, AbbVie, Inc., 1 North Waukegan Road, Bldg. AP31, North Chicago, IL 60064, USA.
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Trujillo MV, Lee PA, Reifschneider K, Backeljauw PF, Dragnic S, Van Komen S, Yu J, Klein KO. Using change in predicted adult height during GnRH agonist treatment for individualized treatment decisions in girls with central precocious puberty. J Pediatr Endocrinol Metab 2023; 36:299-308. [PMID: 36473097 DOI: 10.1515/jpem-2022-0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES It is important to understand what variables influence change in predicted adult height (PAH) throughout GnRHa treatment for central precocious puberty (CPP) to individualize treatment decisions and optimize care. METHODS Changes in PAH, chronological age (CA), bone age (BA), BA/CA, and height velocity (HV) were evaluated in girls with CPP throughout treatment with leuprolide acetate (n=77). A second analysis focused on changes in the 3 years preceding the first observed BA of ≥12 years. Relationships were characterized using plot inspection and linear mixed-effects analyses. Association between treatment duration and last assessed PAH was examined using multiple linear regression models. RESULTS BA/CA and HV showed a nonlinear change during treatment, with the largest changes and improvement in PAH observed in the first 6-18 months. Rate of BA advancement tended to decrease more slowly in girls initiating treatment at a younger BA. On-treatment change in PAH was predicted by concurrent BA/CA change, HV, and BA, as well as CA at treatment initiation. Last assessed PAH was positively associated with longer treatment durations (primary/exploratory models cut-offs of ≥33/≥55 months). CONCLUSIONS These findings support individualized monitoring during GnRHa treatment. Initial response should be interpreted with caution until 6-18 months after treatment initiation and failure should not be assumed based on continued bone maturation in girls starting therapy at a younger age. Treatment cessation should not be automatically based on a diminishing change in PAH or HV, as ongoing treatment may result in continued increase or maintenance of PAH.
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Affiliation(s)
- Marcela Vargas Trujillo
- Department of Pediatrics, University of California San Diego, and Rady Children's Hospital, San Diego, CA, USA
| | - Peter A Lee
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Philippe F Backeljauw
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | - Jun Yu
- AbbVie, North Chicago, IL, USA
| | - Karen O Klein
- Department of Pediatrics, University of California San Diego, and Rady Children's Hospital, San Diego, CA, USA
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Eitel KB, Hodax JK, DiVall S, Kidd KM, Salehi P, Sequeira GM. Leuprolide Acetate for Puberty Suppression in Transgender and Gender Diverse Youth: A Comparison of Subcutaneous Eligard Versus Intramuscular Lupron. J Adolesc Health 2023; 72:307-311. [PMID: 36404242 DOI: 10.1016/j.jadohealth.2022.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/24/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare the efficacy of intramuscular Lupron and subcutaneous Eligard, two formulations of leuprolide, for puberty suppression in transgender and gender diverse (TGD) youth. METHODS A retrospective chart review of TGD youth receiving Lupron or Eligard 22.5 mg every 3 months was conducted to determine hormone levels obtained 1 hour after an injection (1hrPost) and patient-reported clinical puberty suppression. RESULTS Forty eight patients were analyzed: 33% assigned female at birth of which 25% were premenarchal, mean age at first injection 13.7 years, and 50% received concurrent gender affirming hormones. Of these, 13% received Lupron, 52% Eligard, and 35% initially received Lupron then transitioned to Eligard due to drug shortages. There were 55 incidents of 1hrPost levels, 42 after Eligard and 13 after Lupron. Clinical puberty suppression occurred in all patients; however, biochemical suppression occurred in 90% of Eligard and 69% of Lupron (p = .06). DISCUSSION Eligard and Lupron were both effective in suppressing clinical puberty progression in our population of TGD youth, of which 50% were receiving concurrent gender affirming hormones.
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Affiliation(s)
- Kelsey B Eitel
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, Washington.
| | - Juanita K Hodax
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, Washington
| | - Sara DiVall
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, Washington
| | - Kacie M Kidd
- Division of Adolescent Medicine, Department of Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Parisa Salehi
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, Washington
| | - Gina M Sequeira
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle Children's, Seattle, Washington
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Popovic J, Geffner ME, Rogol AD, Silverman LA, Kaplowitz PB, Mauras N, Zeitler P, Eugster EA, Klein KO. Gonadotropin-releasing hormone analog therapies for children with central precocious puberty in the United States. Front Pediatr 2022; 10:968485. [PMID: 36268040 PMCID: PMC9577333 DOI: 10.3389/fped.2022.968485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
Gonadotropin-releasing hormone agonists (GnRHa's) are the standard treatment for children with central precocious puberty (CPP). We aim to present data on available GnRHa options with an easy-to-review table and discuss factors that influence treatment selection. Five GnRHa's are currently FDA-approved and prescribed in the US and published data suggest similar safety and efficacy profiles over the first year of treatment. One- and 3-month intramuscular (IM) leuprolide acetate (LA) have long-term safety and efficacy data and allow for flexible dosing. Six-month IM triptorelin pamoate offers a longer duration of treatment, but without long-term efficacy and outcome data. Six-month subcutaneous (SQ) LA combines a SQ route of injection and long duration of action but lacks long-term efficacy and outcome data. The 12-month SQ histrelin acetate implant avoids injections and offers the longest duration of action, but requires a minor surgical procedure with local or general anesthesia. Factors in treatment selection include route of administration, needle size, injection volume, duration of action, and cost. The current GnRHa landscape provides options with varying benefits and risks, allowing physicians and caregivers to select the most appropriate therapy based on the specific needs and concerns of the child and the caregiver. Agents have different advantages and disadvantages for use, with no one agent displaying superiority.
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Affiliation(s)
- Jadranka Popovic
- Department of Pediatric Endocrinology, Pediatric Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Mitchell E Geffner
- Department of Pediatric Endocrinology, Diabetes and Metabolism, The Saban Research Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Alan D Rogol
- Department of Pediatric Diabetes and Endocrinology, University of Virginia, Charlottesville, VA, United States
| | - Lawrence A Silverman
- Department of Pediatric Endocrinology, Goryeb Children's Hospital Atlantic Health, Morristown, NJ, United States
| | - Paul B Kaplowitz
- Department of Endocrinology, Children's National Hospital, Washington, DC, United States
| | - Nelly Mauras
- Department of Pediatrics, Nemours Children's Health System, Jacksonville, FL, United States
| | - Philip Zeitler
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Erica A Eugster
- Department of Pediatric Endocrinology, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
| | - Karen O Klein
- Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, San Diego, CA, United States
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Ramos CO, Canton APM, Seraphim CE, Faria AG, Tinano FR, Mendonca BB, Latronico AC, Brito VN. Anthropometric, metabolic, and reproductive outcomes of patients with central precocious puberty treated with leuprorelin acetate 3-month depot (11.25 mg). J Pediatr Endocrinol Metab 2021; 34:1371-1377. [PMID: 34298591 DOI: 10.1515/jpem-2021-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Longer-acting gonadotropin-releasing hormone analogs (GnRHa) have been widely used for central precocious puberty (CPP) treatment. However, the follow-up of patients after this treatment are still scarce. Our aim was to describe anthropometric, metabolic, and reproductive follow-up of CPP patients after treatment with leuprorelin acetate 3-month depot (11.25 mg). METHODS Twenty-two female patients with idiopathic CPP were treated with leuprorelin acetate 3-month depot (11.25 mg). Their medical records were retrospectively evaluated regarding clinical, hormonal, and imaging aspects before, during, and after GnRHa treatment until adult height (AH). RESULTS At the diagnosis of CPP, the mean chronological age (CA) was 8.2 ± 1.13 year, and mean bone age (BA) was 10.4 ± 1.4 year. Mean height SDS at the start and the end of GnRHa treatment was 1.6 ± 0.8 and 1.3 ± 0.9, respectively. The mean duration of GnRHa treatment was 2.8 ± 0.8 year. Mean predicted adult heights (PAH) at the start and the end of GnRH treatment was 153.2 ± 8.6 and 164.4 ± 7.3 cm, respectively (p<0.05). The mean AH was 163.2 ± 6.2 cm (mean SDS: 0.1 ± 1). All patients were within their target height (TH) range. There was a decrease in the percentage of overweight and obesity from the diagnosis until AH (39-19% p>0.05). At the AH, the insulin resistance and high LDL levels were identified in 3/17 patients (17.6%) and 2/21 patients (9.5%), respectively. The mean CA of menarche was 12.2 ± 0.5 years. At the AH, PCOS was diagnosed in one patient (4.8%). CONCLUSIONS Long-term anthropometric, metabolic, and reproductive follow-up of patients with CPP treated with longer-acting GnRHa revealed effectivity, safety, and favorable outcomes.
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Affiliation(s)
- Carolina O Ramos
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Ana P M Canton
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Carlos Eduardo Seraphim
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Aline Guimarães Faria
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Flavia Rezende Tinano
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Ana C Latronico
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
| | - Vinicius N Brito
- Unidade de Endocrinologia do Desenvolvimento, Disciplina de Endocrinologia e Metabologia da Faculdade de Medicina da Universidade de São Paulo e Laboratório de Hormônios e Genética Molecular LIM 42 do Hospital das Clínicas, São Paulo-SP, Brasil
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Jeon MJ, Choe JW, Chung HR, Kim JH. Short-term efficacy of 1-month and 3-month gonadotropin-releasing hormone agonist depots in girls with central precocious puberty. Ann Pediatr Endocrinol Metab 2021; 26:171-177. [PMID: 34015908 PMCID: PMC8505044 DOI: 10.6065/apem.2040134.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 04/27/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Gonadotropin-releasing hormone agonist (GnRHa) has been the mainstay of central precocious puberty (CPP) treatment for decades, but few reports have compared the efficacy of 1-month and 3-month depot GnRHa formulations. This study investigates the short-term efficacy of 1-month and 3-month GnRHa depots in girls with CPP. METHODS Overall, 150 girls with CPP were included in a retrospective review of medical records. Subjects in group 1 (n=105) were treated with 1-month GnRHa depots for ≥12 months, and those in group 2 (n=45) were treated with 1-month GnRHa depots for 6 months followed by 3-month GnRHa depots for ≥6 months. Anthropometric and biochemical data were compared between the groups at 3-time points (after 0, 6, and 12 months of GnRHa treatment). RESULTS Demographic and clinical characteristics did not differ between the groups at baseline or after 6 months of GnRHa treatment. After 12 months of GnRHa treatment, patients in the both groups showed no difference in bone age (BA), chronological age (CA), BA-CA difference, height standard deviation score (SDS) for CA and BA, or body mass index SDS for CA and BA. The sexual maturity rate of the breast was prepubertal at 12 months in most of subjects. GnRH-stimulated luteinizing hormone (LH) level was suppressed during GnRHa treatment in both groups at 6 and 12 months, although the LH level in group 2 was higher than that in group 1. CONCLUSION Treating CPP with a 3-month GnRHa depot showed short-term efficacy comparable to that with a 1-month depot in anthropometric parameters and pubertal suppression.
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Affiliation(s)
- Min Jin Jeon
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Jae Won Choe
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Address for correspondence: Jae Hyun Kim Department of Pediatrics, Seoul National Universit y Bundang Hospital, 82, Gumi-ro 173 Beongil, Bundang-gu, Seongnam 13620, Korea
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Klein KO, Freire A, Gryngarten MG, Kletter GB, Benson M, Miller BS, Dajani TS, Eugster EA, Mauras N. Phase 3 Trial of a Small-volume Subcutaneous 6-Month Duration Leuprolide Acetate Treatment for Central Precocious Puberty. J Clin Endocrinol Metab 2020; 105:5879679. [PMID: 32738042 PMCID: PMC7442270 DOI: 10.1210/clinem/dgaa479] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 11/26/2022]
Abstract
CONTEXT Gonadotropin-releasing hormone agonists (GnRHas) are standard of care for central precocious puberty (CPP). A 6-month subcutaneous injection has recently been approved by the Food and Drug Administration. OBJECTIVE Determine efficacy, pharmacokinetics, and safety of 6-month 45-mg subcutaneous leuprolide acetate for CPP. DESIGN Phase 3 multicenter, open-label, single-arm study. SETTING 25 sites in 6 countries. SUBJECTS 64 GnRHa-naïve children with CPP (age: 7.5 ± 0.1 years) received study drug: 59 completed the study. INTERVENTION(S) 2 doses of 45-mg subcutaneous leuprolide acetate (0.375 mL) at 0 and 24 weeks; children were followed for 48 weeks. MAIN OUTCOME MEASURE(S) Percentage of children with serum luteinizing hormone (LH) <4 IU/L 30 minutes following GnRHa stimulation at week 24. RESULTS 54/62 (87%) children achieved poststimulation LH <4 IU/L at week 24; 49/56 (88%) girls and 1/2 boys maintained peak LH <4 IU/L at week 48. Mean growth velocity decreased from 8.9 cm/year at week 4 to 6.0 cm/year at week 48. Mean bone age was advanced 3.0 years beyond chronological age at screening and 2.7 years at week 48. Breast pubertal stage regressed or was stable in 97% of girls and external genitalia development regressed in both boys. Adverse events were mild and did not cause treatment discontinuation. CONCLUSIONS A small volume of 45-mg subcutaneous leuprolide acetate administered at a 6-month interval effectively suppressed pubertal hormones and stopped or caused regression of pubertal progression. This long-acting GnRHa preparation of leuprolide acetate is a new, effective, and well-tolerated therapy for children with CPP.
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Affiliation(s)
- Karen O Klein
- Rady Children’s Hospital and University of California, San Diego, California
- Correspondence and Reprint Requests: Karen O. Klein, MD, Endocrinology/Diabetes, Institute/University/Hospital, Rady Children’s Hospital, 3020 Children’s Way, San Diego, CA 92123, USA. E-mail:
| | - Analía Freire
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Mirta Graciela Gryngarten
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE) CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Gad B Kletter
- MultiCare Institute for Research and Innovation, Tacoma, Washington
| | - Matthew Benson
- Nemours Children’s Hospital, Orlando, Florida
- Nemours Children’s Health System, Jacksonville, Florida
| | - Bradley S Miller
- University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Tala S Dajani
- School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona
| | - Erica A Eugster
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Nelly Mauras
- Nemours Children’s Health System, Jacksonville, Florida
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Klein KO, Soliman AM, Bonafede M, Nelson JK, Grubb E. Treatment patterns, health resource utilization and costs among central precocious puberty patients treated with leuprolide or histrelin: an examination of the commercial and Medicaid populations. J Med Econ 2020; 23:407-414. [PMID: 31766907 DOI: 10.1080/13696998.2019.1697700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aims: To compare treatment duration, healthcare resource utilization (HRU), and direct healthcare costs between patients with central precocious puberty (CPP) treated with leuprolide or histrelin, and between patients with Medicaid or commercial insurance. This information is important as it affects treatment choice and outcomes.Materials and methods: This retrospective cohort study identified commercial and Medicaid-insured CPP patients ≤12-years-old who were diagnosed between 1 January 2010 and 30 September 2014 and had ≥1 prescription for leuprolide or histrelin (first prescription = index date). Treatment patterns were measured for the duration of available data; whereas, all-cause and disease-monitoring HRU and all-cause costs were compared between treatment groups for the year following treatment initiation. Multivariable analysis was used to adjust healthcare costs for differences in baseline patient characteristics.Results: A total of 1,177 commercially-insured (907 leuprolide and 270 histrelin) and 658 Medicaid-insured (613 leuprolide and 45 histrelin) patients were identified. Mean age at treatment initiation ranged from 7.5-8.5-years-old, 11.1-20.5% of patients were male, and the mean treatment duration was over one year. Commercially-insured patients treated with histrelin used more services in general than those treated with leuprolide but had fewer office visits. Healthcare service utilization was similar between Medicaid-insured treatment groups. In both payer populations, costs were similar.Limitations: The number of Medicaid-insured patients who received a histrelin implant was low, and this may make the findings more sensitive to influence by outliers.Conclusions: Mean overall healthcare costs were similar between CPP patients treated with leuprolide and those treated with histrelin. Medicaid patients generally received less testing and were less likely to receive specialist care. Patients treated with histrelin had fewer office visits but also had a shorter overall treatment.
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Affiliation(s)
- Karen O Klein
- Rady Children's Hospital, San Diego, CA, USA
- Department of Pediatrics, Division of Endocrinology, University of California, San Diego, CA, USA
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Bangalore Krishna K, Fuqua JS, Rogol AD, Klein KO, Popovic J, Houk CP, Charmandari E, Lee PA, Freire AV, Ropelato MG, Yazid Jalaludin M, Mbogo J, Kanaka-Gantenbein C, Luo X, Eugster EA, Klein KO, Vogiatzi MG, Reifschneider K, Bamba V, Garcia Rudaz C, Kaplowitz P, Backeljauw P, Allen DB, Palmert MR, Harrington J, Guerra-Junior G, Stanley T, Torres Tamayo M, Miranda Lora AL, Bajpai A, Silverman LA, Miller BS, Dayal A, Horikawa R, Oberfield S, Rogol AD, Tajima T, Popovic J, Witchel SF, Rosenthal SM, Finlayson C, Hannema SE, Castilla-Peon MF, Mericq V, Medina Bravo PG. Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium. Horm Res Paediatr 2020; 91:357-372. [PMID: 31319416 DOI: 10.1159/000501336] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022] Open
Abstract
This update, written by authors designated by multiple pediatric endocrinology societies (see List of Participating Societies) from around the globe, concisely addresses topics related to changes in GnRHa usage in children and adolescents over the last decade. Topics related to the use of GnRHa in precocious puberty include diagnostic criteria, globally available formulations, considerations of benefit of treatment, monitoring of therapy, adverse events, and long-term outcome data. Additional sections review use in transgender individuals and other pediatric endocrine related conditions. Although there have been many significant changes in GnRHa usage, there is a definite paucity of evidence-based publications to support them. Therefore, this paper is explicitly not intended to evaluate what is recommended in terms of the best use of GnRHa, based on evidence and expert opinion, but rather to describe how these drugs are used, irrespective of any qualitative evaluation. Thus, this paper should be considered a narrative review on GnRHa utilization in precocious puberty and other clinical situations. These changes are reviewed not only to point out deficiencies in the literature but also to stimulate future studies and publications in this area.
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Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA,
| | - John S Fuqua
- Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Alan D Rogol
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Karen O Klein
- University of California, San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jadranka Popovic
- Division of Pediatric Endocrinology, Pediatric Alliance, Pittsburgh, Pennsylvania, USA
| | - Christopher P Houk
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Peter A Lee
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
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Wiromrat P, Panamonta O. Elevated Random Luteinizing Hormone is an Unreliable Indicator for Pubertal Suppression in Girls Treated with Monthly Leuprolide for Idiopathic Central Precocious Puberty. J Clin Res Pediatr Endocrinol 2019; 11:227-233. [PMID: 30592192 PMCID: PMC6745452 DOI: 10.4274/jcrpe.galenos.2018.2018.0213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/25/2018] [Indexed: 12/01/2022] Open
Abstract
Objective Longitudinal data regarding random luteinizing hormone (LH) concentrations in patients with idiopathic central precocious puberty (ICPP) during treatment are limited. Therefore, we sought to evaluate random LH and estradiol concentrations during monthly leuprolide injection and their associations with pubertal progression and final adult height (FAH) in girls with ICPP. Methods Medical records of 27 girls with ICPP who had attained FAH were reviewed. Patients’ height, weight, Tanner stage, growth rate (GR), bone age, random LH measured by both immunoradiometric and immunochemiluminescent methods, follicular-stimulating hormone (FSH) and estradiol levels were monitored until FAH. Results Treatment was started at a mean (±standard deviation) age of 8.1±0.6 years with mean duration of 3.9±0.2 years. At six months of follow-up, random LH (p=0.048), FSH (p<0.001) and estradiol (p=0.023) concentrations were decreased compared with baseline. Thereafter, random LHs were well suppressed. GRs gradually decreased to prepubertal norm by month 12. Seventeen patients (63%) exhibited pubertal LH concentrations at least once during treatment visits. Furthermore, 43 of a total 116 (37%) LH measurements were found elevated. However, those patients with elevated random LH did not show signs of pubertal progression. After treatment, mean FAH was greater than predicted adult height (p<0.0001) and target height (p=0.03). At no time points of treatment did random LH, FSH and estradiol correlate with GRs or FAH. Conclusion Elevated random LH is commonly found in ICPP girls during monthly leuprolide treatment. However, these elevations were not associated with clinical progression of puberty or decreased FAH, suggesting that it is not a reliable method for CPP monitoring.
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Affiliation(s)
- Pattara Wiromrat
- Khon Kaen University Faculty of Medicine, Department of Pediatrics, Division of Endocrinology, Khon Kaen, Thailand
| | - Ouyporn Panamonta
- Khon Kaen University Faculty of Medicine, Department of Pediatrics, Division of Endocrinology, Khon Kaen, Thailand
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Abstract
Precocious puberty is defined as the appearance of secondary sex characteristics before 8 years of age in girls and before 9 years of age in boys. Central precocious puberty (CPP) is diagnosed when activation of the hypothalamic-pituitary axis is identified. It is a rare disease with a clear female predominance. A background of international adoption increases its risk, with other environmental factors such as endocrine disruptors also being associated with CPP. The causes of CPP are heterogeneous, with alterations of the CNS being of special interest. Physical injuries of the CNS are more frequent in boys, while idiopathic etiology is more prevalent among girls. However, in the last decade the number of idiopathic cases has diminished thanks to the discovery of mutations in different genes, including KISS1, KISS1R, MKRN3, and DLK1 that cause CPP. For the diagnosis of CPP, hormone studies are needed in addition to the clinical data regarding signs of pubertal onset. For this purpose, the GnRH test continues to be the gold standard. Imaging analyses, such as bone age and brain MRI, are also very useful. Furthermore, genetic testing must be incorporated in the diagnosis of CPP, especially in familial cases. Early puberty has been related to various consequences in the medium and long term such as behavioral problems, breast cancer, obesity, and metabolic comorbidities. However, there are few studies that have exclusively analyzed patients with CPP. GnRH analogs are the most frequent treatment election with the main objective being to improve adult height. Currently, there are new formulations that are being investigated.
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Affiliation(s)
- Leandro Soriano-Guillén
- Department of Pediatrics, Universidad Autónoma de Madrid, Spain; Department of Pediatrics, Hospital Universitario Fundación Jiménez Díaz, Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain
| | - Jesús Argente
- Department of Pediatrics, Universidad Autónoma de Madrid, Spain; Department of Pediatrics & Pediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Madrid, Spain; Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; IMDEA Food Institute, CEIUAM+CSIC, Madrid, Spain.
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Abstract
Long-acting analogs of GnRH (GnRHas) have been the gold-standard treatment of central precocious puberty (CPP) worldwide and have an enviable track record of safety and efficacy. Recent years have witnessed much growth in the availability of longer-acting and sustained-release forms of GnRHas. Although all available agents appear promising, limited long-term follow-up and/or comparative data are available. In this review, important issues pertaining to the treatment of children with CPP are discussed. In addition to an assessment of the newer extended-release GnRHa formulations, a delineation of factors essential in determining which children should be treated is offered. Outstanding uncertainties in clinical management are highlighted and areas in need of future research identified. Literature searches for this review were performed in PubMed and OVID, with a focus on English-language publications using the terms "central precocious puberty" and "treatment."
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Affiliation(s)
- Erica A Eugster
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana
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Klein KO, Dragnic S, Soliman AM, Bacher P. Predictors of bone maturation, growth rate and adult height in children with central precocious puberty treated with depot leuprolide acetate. J Pediatr Endocrinol Metab 2018; 31:655-663. [PMID: 29750651 DOI: 10.1515/jpem-2017-0523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/16/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Children with central precocious puberty (CPP) are treated with gonadotropin-releasing hormone agonists (GnRHa) to suppress puberty. Optimizing treatment outcomes continues to be studied. The relationships between growth, rate of bone maturation (bone age/chronological age [ΔBA/ΔCA]), luteinizing hormone (LH), predicted adult stature (PAS), as well as variables influencing these outcomes, were studied in children treated with depot leuprolide (LA Depot) Methods: Subjects (64 girls, seven boys) with CPP received LA Depot every 3 months for up to 42 months. Multivariate regression analyses were conducted to examine the predictors affecting ΔBA/ΔCA, PAS and growth rate. RESULTS Ninety percent of subjects (18 of 20) were suppressed (LH levels <4 IU/L) at 42 months. Over 42 months, the mean growth rate declined 2 cm/year, the mean BA/CA ratio decreased 0.21 and PAS increased 8.90 cm for girls (n=64). PAS improved to mid-parental height (MPH) in 46.2% of children by 30 months of treatment. Regression analysis showed that only the Body Mass Index Standardized Score (BMI SDS) was significantly associated (β+0.378 and +0.367, p≤0.05) with growth rate. For PAS, significant correlations were with MPH (β+0.808 and +0.791, p<0.001) and ΔBA/ΔCA (β+0.808 and +0.791, p<0.001). For ΔBA/ΔCA, a significant association was found only with BA at onset of treatment (β-0.098 and -0.103, p≤0.05). Peak-stimulated or basal LH showed no significant influence on growth rate, ΔBA/ΔCA or PAS. CONCLUSIONS Growth rate and bone maturation rate normalized on treatment with LA Depot. LH levels were not significantly correlated with growth rate, ΔBA/ΔCA or PAS, suggesting that suppression was adequate and variations in gonadotropin levels were below the threshold affecting outcomes.
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Affiliation(s)
- Karen O Klein
- Clinical Professor of Pediatrics, Rady Children's Hospital San Diego, 3020 Children's Way, MC 5103, San Diego, CA 92123, USA, Phone: +(858) 966 4032.,University of California, San Diego, CA, USA
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Brito VN, Spinola-Castro AM, Kochi C, Kopacek C, Silva PCAD, Guerra-Júnior G. Central precocious puberty: revisiting the diagnosis and therapeutic management. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2017; 60:163-72. [PMID: 27191050 DOI: 10.1590/2359-3997000000144] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/10/2016] [Indexed: 11/22/2022]
Abstract
Clinical and laboratory diagnosis and treatment of central precocious puberty (CPP) remain challenging due to lack of standardization. The aim of this revision was to address the diagnostic and therapeutic features of CPP in Brazil based on relevant international literature and availability of the existing therapies in the country. The diagnosis of CPP is based mainly on clinical and biochemical parameters, and a period of follow-up is desirable to define the "progressive" form of sexual precocity. This occurs due to the broad spectrum of pubertal development, including isolated premature thelarche, constitutional growth and puberty acceleration, progressive and nonprogressive CPP, and early puberty. Measurement of basal and stimulated LH levels remains challenging, considering that the levels are not always in the pubertal range at baseline, short-acting GnRH is not readily available in Brazil, and the cutoff values differ according to the laboratory assay. When CPP is suspected but basal LH values are at prepubertal range, a stimulation test with short-acting or long-acting monthly GnRH is a diagnostic option. In Brazil, the treatment of choice for progressive CPP and early puberty is a long-acting GnRH analog (GnRHa) administered once a month or every 3 months. In Brazil, formulations of GnRHa (leuprorelin and triptorelin) are available and commonly administered, including 1-month depot leuprorelin 3.75 mg and 7.5 mg, 1-month depot triptorelin 3.75 mg, and 3-month depot leuprorelin 11.25 mg. Monthly or 3-month depot GnRHa are effective and safe to treat CPP. Arch Endocrinol Metab. 2016;60(2):163-72.
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Affiliation(s)
- Vinícius Nahime Brito
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Angela Maria Spinola-Castro
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Cristiane Kochi
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
| | - Cristiane Kopacek
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
| | - Paulo César Alves da Silva
- Departamento de Endocrinologia Pediátrica, Sociedade Brasileira de Endocrinologia e Metabologia, Rio de Janeiro, RJ, Brasil
| | - Gil Guerra-Júnior
- Departamento de Endocrinologia, Sociedade Brasileira de Pediatria, Rio de Janeiro, RJ, Brasil
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Liu J, Tang J. Effects of pomegranate extract in supplementing gonadotropin-releasing hormone therapy on idiopathic central precocious puberty in Chinese girls: a randomized, placebo-controlled, double-blind clinical trial. Food Funct 2017; 8:695-700. [PMID: 28091641 DOI: 10.1039/c6fo01616b] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Central precocious puberty (CPP) without organic abnormality is called idiopathic CPP (ICPP).
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Affiliation(s)
- Jinsheng Liu
- The First Affiliated Hospital of Anhui Medical University
- Hefei 230022
- China
- The Second People's Hospital of Hefei
- Hefei 230011
| | - Jiulai Tang
- The First Affiliated Hospital of Anhui Medical University
- Hefei 230022
- China
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Lee PA, Luce M, Bacher P. Monitoring treatment of central precocious puberty using basal luteinizing hormone levels and practical considerations for dosing with a 3-month leuprolide acetate formulation. J Pediatr Endocrinol Metab 2016; 29:1249-1257. [PMID: 27740929 DOI: 10.1515/jpem-2016-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 08/29/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Peak gonadotropin-releasing hormone or agonist (GnRHa) stimulated luteinizing hormone (LH) testing with leuprolide acetate (LA) is commonly used to document suppression during therapy for central precocious puberty (CPP). The objective of the study was to investigate suitability of using basal LH levels to monitor GnRHa treatment and to determine optimal transition from 1-month to 3-month LA formulations via a post hoc analysis of a randomized, open-label, 6-month study. METHODS A total of 42 children with CPP, pretreated with 7.5-, 11.25-, or 15-mg 1-month LA formulations were randomized to 11.25- or 30-mg 3-month LA. Basal LH/peak-stimulated LH levels were measured at weeks 0, 4, 8 and 12. Positive/negative predictive values and sensitivities/specificities were determined for basal LH vs. LH-stimulation results. RESULTS Pretreatment with any 1-month formulation for the most part did not affect continuation of suppression after transitioning to 3-month formulation (mean peak-stimulated LH levels remained < 4 IU/L). Basal LH predicted suppression escape (basal LH-level cutoff ≥ 0.6 IU/L predicted 70% of those failing suppression). Tolerability was similar, regardless of dose. CONCLUSIONS Our data indicate that a basal level of <0.60 IU/L is adequate for monitoring suppression approximately two-thirds of the time. Furthermore, the effectiveness and safety of 3-month LA treatments are not influenced by previous CPP therapies.
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Central precocious puberty: consider early treatment with gonadotropin-releasing hormone analogues to preserve maximum height. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0238-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Borges MDF, Franciscon PDM, Cambraia TC, Oliveira DM, Ferreira BP, Resende EAMRD, Palhares HMC. Evaluation of central precocious puberty treatment with GnRH analogue at the Triangulo Mineiro Federal University (UFTM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:515-22. [PMID: 26421668 DOI: 10.1590/2359-3997000000101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/27/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report our experience of treating central precocious puberty (CPP) with a GnRH analogue with respect to the final heights (FH) attained in patients who completed treatment. SUBJECTS AND METHODS Among 105 records of children diagnosed with precocious puberty, 62 cases (54 girls and 8 boys), who were treated with leuprolide acetate/3.75 mg/monthly, were selected, and divided into 4 groups: group 1 (G1), 25 girls who attained FH; group 2 (G2), 18 girls who completed treatment but did not reach FH; group 3 (G3), 11 girls still under treatment; and group 4 (G4), 8 boys, 5 of which attained FH. Treatment was concluded at a bone age of 12 years, and follow-up continued until FH was achieved. RESULTS In both G1 and G2 groups, height standard deviation score (SDS), weight-SDS and percentile of body mass index (PBMI) did not show intra/intergroup differences at the beginning and at interruption of treatment, but when added, G1+G2, height-SDS and weight-SDS differed significantly (p = 0.002 and 0.0001, respectively). In G1, 19 of 25 cases attained TH, and average height gain was 16.7 cm (7.7- 27.1); there was significant difference between FH and prediction of FH at the start (PFH at start) (p = 0.0001), as well as between PFH at interruption vs TH and vs FH (p = 0.007) with FH higher than TH (p = 0.004). Significant correlation was identified between FH and height gain after treatment. CONCLUSION As shown by some studies, GnRH analogue treatment was effective in children with CPP reaching FH near the genetic target.
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Abstract
Central precocious puberty (CPP) is characterized by the same biochemical and physical features as normally timed puberty but occurs at an abnormally early age. Most cases of CPP are seen in girls, in whom it is usually idiopathic. In contrast, ~50% of boys with CPP have an identifiable cause. The diagnosis of CPP relies on clinical, biochemical, and radiographic features. Untreated, CPP has the potential to result in early epiphyseal fusion and a significant compromise in adult height. Thus, the main goal of therapy is preservation of height potential. The gold-standard treatment for CPP is gonadotropin-releasing hormone (GnRH) analogs (GnRHa). Numerous preparations with a range of delivery systems and durations of action are commercially available. While the outcomes of patients treated for CPP have generally been favorable, more research about the psychological aspects, optimal monitoring, and long-term effects of all forms of GnRHa treatment is needed. Several potential therapeutic alternatives to GnRHa exist and await additional investigation.
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Postinjection Muscle Fibrosis from Lupron. Case Rep Pediatr 2015; 2015:938264. [PMID: 26101682 PMCID: PMC4458552 DOI: 10.1155/2015/938264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/13/2015] [Indexed: 11/17/2022] Open
Abstract
We describe the case of a 6.5-year-old girl with central precocious puberty (CPP), which signifies the onset of secondary sexual characteristics before the age of eight in females and the age of nine in males as a result of stimulation of the hypothalamic-pituitary-gonadal axis. Her case is likely related to her adoption, as children who are adopted internationally have much higher rates of CPP. She had left breast development at Tanner Stage 2, adult body odor, and mildly advanced bone age. In order to halt puberty and maximize adult height, she was prescribed a gonadotropin releasing hormone analog, the first line treatment for CPP. She was administered Lupron (leuprolide acetate) Depot-Ped (3 months) intramuscularly. After her second injection, she developed swelling and muscle pain at the injection site on her right thigh. She also reported an impaired ability to walk. She was diagnosed with muscle fibrosis. This is the first reported case of muscle fibrosis resulting from Lupron injection.
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Silverman LA, Neely EK, Kletter GB, Lewis K, Chitra S, Terleckyj O, Eugster EA. Long-Term Continuous Suppression With Once-Yearly Histrelin Subcutaneous Implants for the Treatment of Central Precocious Puberty: A Final Report of a Phase 3 Multicenter Trial. J Clin Endocrinol Metab 2015; 100:2354-63. [PMID: 25803268 PMCID: PMC4504932 DOI: 10.1210/jc.2014-3031] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE The histrelin implant has proven to be an effective method of delivering GnRH analog (GnRHa) therapy to children with central precocious puberty (CPP), yet there are limited data available regarding hormonal suppression and auxological changes during an extended course of therapy. DESIGN This was a phase 3, prospective, open-label study. SETTING AND PARTICIPANTS Thirty-six children with CPP who participated in a phase 3, open-label study and required further GnRHa therapy were eligible to continue treatment receiving a new implant upon removal of the prior 12-month histrelin implant during a long-term extension phase. OUTCOME MEASURES Hormone levels and auxologic parameters were measured periodically for up to 6 years of treatment and up to 1 year of posttreatment follow-up. RESULTS Hormonal suppression was maintained throughout the study in patients who had prior GnRHa therapy (n = 16) and in treatment-naive patients (n = 20). Bone age to chronological age ratio decreased from 1.417 (n = 20) at baseline to 1.18 (n = 8) at 48 months in treatment-naive children (P < .01). Predicted adult height in girls increased from 151.9 cm at baseline to 166.5 cm at month 60 (n = 6; P < .05), with a 10.7-cm height gain observed among treatment-naive children (n = 5). No adverse effect on growth or recovery of the hypothalamic-pituitary-gonadal axis was observed with hormonal suppression. The histrelin implant was generally well tolerated during long-term therapy. CONCLUSIONS Long-term histrelin implant therapy provided sustained gonadotropin suppression safely and effectively and improved predicted adult height in children with CPP.
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Affiliation(s)
- Lawrence A Silverman
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - E Kirk Neely
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - Gad B Kletter
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - Katherine Lewis
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - Surya Chitra
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - Oksana Terleckyj
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
| | - Erica A Eugster
- Division of Pediatric Endocrinology (L.A.S.), Goryeb Children's Hospital Atlantic Health, Morristown, New Jersey 07962; Division of Pediatric Endocrinology and Diabetes (E.K.N.), Stanford University, Stanford, California 94305-5208; Redmond (G.B.K.), Washington 98052; Division of Endocrinology, Diabetes, and Medical Genetics (K.L.), Charleston, South Carolina 29425; Endo Pharmaceuticals Inc (S.C., O.T.), Malvern, Pennsylvania 19355; and Riley Hospital for Children at Indiana University Health (E.A.E.), Indianapolis, Indiana 46202
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