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Kargi AY. Impact of long-acting growth hormone replacement therapy in adult growth hormone deficiency: Comparison between adolescent, adult, and elderly patients. Best Pract Res Clin Endocrinol Metab 2023; 37:101825. [PMID: 37802712 DOI: 10.1016/j.beem.2023.101825] [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] [Indexed: 10/08/2023]
Abstract
The predominant features of the adult growth hormone deficiency (GHD) syndrome may vary between patients of different age and age of onset of GHD. Evidence from clinical trials and long-term observational studies has informed our ability to understand the unique considerations regarding risks and benefits of daily growth hormone replacement therapy (GHRT) and specific dosing and monitoring strategies for these patient subgroups. High rates of nonadherence with daily GHRT presents a challenge to achieving optimal treatment outcomes and long-acting growth hormone (LAGH) formulations have been developed with the promise of improving treatment adherence resulting in improved therapeutic outcomes. While existing data from short-term studies have demonstrated noninferiority of efficacy and safety of LAGH compared to daily GHRT, long-term studies are needed to assess the full spectrum of outcomes of interest and long-term safety considerations specific to patients in adolescence, adulthood and the elderly GHD population. Since each LAGH formulation has a unique pharmacodynamic and pharmacokinetic profile optimal dosing and monitoring strategies will need to be developed to allow for the provision of individualized patient treatment.
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Affiliation(s)
- Atil Y Kargi
- Department of Neurosurgery, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA.
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Miller BS, Yuen KCJ. Spotlight on Lonapegsomatropin Once-Weekly Injection and Its Potential in the Treatment of Growth Hormone Deficiency in Pediatric Patients. Drug Des Devel Ther 2022; 16:2055-2066. [PMID: 35791404 PMCID: PMC9250779 DOI: 10.2147/dddt.s336285] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Lonapegsomatropin, a long-acting GH therapy (LAGH), was approved by the United States Food and Drug Administration in August 2021 for the treatment of pediatric growth hormone deficiency (GHD). Lonapegsomatropin is a prodrug consisting of unmodified GH transiently conjugated to methoxypolyethylene glycol which enables time-release of GH with a half-life of ~25 hours allowing for once-weekly administration. Clinical trials of lonapegsomatropin have demonstrated positive efficacy results in children (phase 2 and 3) and adults (phase 2) with GHD. The phase 3 trial in children with GHD established non-inferiority and statistical superiority of height velocity with lonapegsomatropin (11.2 cm/yr) compared to daily GH (10.3 cm/yr), with no concerning side effects with lonapegsomatropin. Similar growth responses have been reported in other LAGH products in phase 2 (somapacitan) and phase 3 (somatrogon) trials. Lonapegsomatropin is distributed in temperature-stable, prefilled cartridges at 9 different doses that can be prescribed based upon specific weight brackets designed to deliver approximately 0.24 mg/kg/wk. An electronic delivery device is required to combine the powdered medication with the diluent and deliver the medication subcutaneously through a small gauge needle to the recipient. The pharmacodynamic data from the clinical trials of lonapegsomatropin has been used to develop models to estimate an average IGF-1 value drawn at any time during the weekly injection interval. This average IGF-1 value may be used to for safety monitoring and/or to guide dose adjustment. New LAGH products, including lonapegsomatropin, may potentially improve patient adherence, quality of life and clinical outcomes, particularly in patients with poor adherence to daily GH injections in the future. With the availability of new LAGH products, clinicians will need to identify the best candidates for LAGH therapy and understand how to monitor and adjust therapy. Long-term surveillance studies are needed to demonstrate adherence, efficacy, cost-effectiveness and safety of LAGH preparations.
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Affiliation(s)
- Bradley S Miller
- Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kevin C J Yuen
- Department of Neuroendocrinology and Neurology, Barrow Pituitary Center, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
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Dos Santos JBR, da Silva MRR. TransCon human growth hormone for children with growth hormone deficiency: a technology evaluation. Expert Opin Drug Deliv 2022; 19:1-7. [PMID: 34996331 DOI: 10.1080/17425247.2022.2027365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Standard-of-care treatment for growth hormone deficiency consists of daily subcutaneous injections of recombinant human growth hormone, also known as somatropin. Although somatropin treatment is well established, the burden of daily injections can lead to poor adherence and quality of life. In this regard, a TransCon human growth hormone (lonapegsomatropin-tcgd) technology was developed to optimize the therapeutic effect of daily somatropin for the treatment of children with growth hormone deficiency. AREAS COVERED The authors reviewed the effects of lonapegsomatropin-tcgd in children with growth hormone deficiency. EXPERT OPINION Lonapegsomatropin-tcgd was found to be non-inferior to and superior to daily somatropin for annualized height velocity. In addition, the safety was comparable between them. As a result, the convenient dosing of lonapegsomatropin-tcgd has the potential to improve patient adherence, leading to increased efficacy and quality of life. Medication adherence, quality of life, long-term safety, and cost-effectiveness studies comparing lonapegsomatropin-tcgd and daily somatropin are required to confirm these possible benefits.
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Affiliation(s)
- Jéssica Barreto Ribeiro Dos Santos
- Health Assessment, Technology, and Economy Group; Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre , Espírito Santo, 29500-000, Brazil
| | - Michael Ruberson Ribeiro da Silva
- Health Assessment, Technology, and Economy Group; Center for Exact, Natural and Health Sciences, Federal University of Espírito Santo, Alto Universitário S/N, Guararema, Alegre , Espírito Santo, 29500-000, Brazil
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Abstract
Lonapegsomatropin (lonapegsomatropin-tcgd; SKYTROFA®), a long-acting prodrug of somatropin (human growth hormone), is in development by Ascendis Pharma as a treatment for growth hormone deficiency in pediatric and adult patients. Lonapegsomatropin received its first approval in August 2021 in the USA for the treatment of pediatric patients at least 1 year of age (and weighing ≥ 11.5 kg) with growth failure due to inadequate secretion of endogenous growth hormone. Lonapegsomatropin is administered as a once-weekly subcutaneous injection; the sustained release of somatropin from lonapegsomatropin eliminates the need for daily somatropin injections. This article summarizes the milestones in the development of lonapegsomatropin leading to this first pediatric approval for the treatment of growth hormone deficiency.
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Shi Y, Lu A, Wang X, Belhadj Z, Wang J, Zhang Q. A review of existing strategies for designing long-acting parenteral formulations: Focus on underlying mechanisms, and future perspectives. Acta Pharm Sin B 2021; 11:2396-2415. [PMID: 34522592 PMCID: PMC8424287 DOI: 10.1016/j.apsb.2021.05.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/03/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022] Open
Abstract
The need for long-term treatments of chronic diseases has motivated the widespread development of long-acting parenteral formulations (LAPFs) with the aim of improving drug pharmacokinetics and therapeutic efficacy. LAPFs have been proven to extend the half-life of therapeutics, as well as to improve patient adherence; consequently, this enhances the outcome of therapy positively. Over past decades, considerable progress has been made in designing effective LAPFs in both preclinical and clinical settings. Here we review the latest advances of LAPFs in preclinical and clinical stages, focusing on the strategies and underlying mechanisms for achieving long acting. Existing strategies are classified into manipulation of in vivo clearance and manipulation of drug release from delivery systems, respectively. And the current challenges and prospects of each strategy are discussed. In addition, we also briefly discuss the design principles of LAPFs and provide future perspectives of the rational design of more effective LAPFs for their further clinical translation.
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Key Words
- 2′-F, 2′-fluoro
- 2′-O-MOE, 2′-O-(2-methoxyethyl)
- 2′-OMe, 2′-O-methyl
- 3D, three-dimensional
- ART, antiretroviral therapy
- ASO, antisense oligonucleotide
- Biomimetic strategies
- Chemical modification
- DDS, drug delivery systems
- ECM, extracellular matrix
- ENA, ethylene-bridged nucleic acid
- ESC, enhanced stabilization chemistry
- EVA, ethylene vinyl acetate
- Fc/HSA fusion
- FcRn, Fc receptor
- GLP-1, glucagon like peptide-1
- GS, glycine–serine
- HA, hyaluronic acid
- HES, hydroxy-ethyl-starch
- HP, hypoparathyroidism
- HSA, human serum albumin
- Hydrogels
- ISFI, in situ forming implants
- IgG, immunoglobulin G
- Implantable systems
- LAFs, long-acting formulations
- LAPFs, long-acting parenteral formulations
- LNA, locked nucleic acid
- Long-acting
- MNs, microneedles
- Microneedles
- NDS, nanochannel delivery system
- NPs, nanoparticles
- Nanocrystal suspensions
- OA, osteoarthritis
- PCPP-SA, poly(1,3-bis(carboxyphenoxy)propane-co-sebacic-acid)
- PEG, polyethylene glycol
- PM, platelet membrane
- PMPC, poly(2-methyacryloyloxyethyl phosphorylcholine)
- PNAs, peptide nucleic acids
- PS, phase separation
- PSA, polysialic acid
- PTH, parathyroid hormone
- PVA, polyvinyl alcohol
- RBCs, red blood cells
- RES, reticuloendothelial system
- RNAi, RNA interference
- SAR, structure‒activity relationship
- SCID, severe combined immunodeficiency
- SE, solvent extraction
- STC, standard template chemistry
- TNFR2, tumor necrosis factor receptor 2
- hGH, human growth hormone
- im, intramuscular
- iv, intravenous
- mPEG, methoxypolyethylene glycol
- sc, subcutaneous
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Affiliation(s)
- Yujie Shi
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - An Lu
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Xiangyu Wang
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Zakia Belhadj
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Jiancheng Wang
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Qiang Zhang
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
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Yuen KCJ, Miller BS, Boguszewski CL, Hoffman AR. Usefulness and Potential Pitfalls of Long-Acting Growth Hormone Analogs. Front Endocrinol (Lausanne) 2021; 12:637209. [PMID: 33716988 PMCID: PMC7943875 DOI: 10.3389/fendo.2021.637209] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 11/18/2022] Open
Abstract
Daily recombinant human GH (rhGH) is currently approved for use in children and adults with GH deficiency (GHD) in many countries with relatively few side-effects. Nevertheless, daily injections can be painful and distressing for some patients, often resulting in non-adherence and reduction of treatment outcomes. This has prompted the development of numerous long-acting GH (LAGH) analogs that allow for decreased injection frequency, ranging from weekly, bi-weekly to monthly. These LAGH analogs are attractive as they may theoretically offer increased patient acceptance, tolerability, and therapeutic flexibility. Conversely, there may also be pitfalls to these LAGH analogs, including an unphysiological GH profile and differing molecular structures that pose potential clinical issues in terms of dose initiation, therapeutic monitoring, incidence and duration of side-effects, and long-term safety. Furthermore, fluctuations of peak and trough serum GH and IGF-I levels and variations in therapeutic efficacy may depend on the technology used to prolong GH action. Previous studies of some LAGH analogs have demonstrated non-inferiority compared to daily rhGH in terms of increased growth velocity and improved body composition in children and adults with GHD, respectively, with no significant unanticipated adverse events. Currently, two LAGH analogs are marketed in Asia, one recently approved in the United States, another previously approved but not marketed in Europe, and several others proceeding through various stages of clinical development. Nevertheless, several practical questions still remain, including possible differences in dose initiation between naïve and switch-over patients, methodology of dose adjustment/s, timing of measuring serum IGF-I levels, safety, durability of efficacy and cost-effectiveness. Long-term surveillance of safety and efficacy of LAGH analogs are needed to answer these important questions.
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Affiliation(s)
- Kevin C. J. Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, Departments of Neuroendocrinology and Neurosurgery, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, United States
- *Correspondence: Kevin C. J. Yuen,
| | - Bradley S. Miller
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Cesar L. Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Andrew R. Hoffman
- Department of Medicine, VA Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, CA, United States
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Sbardella E, Crocco M, Feola T, Papa F, Puliani G, Gianfrilli D, Isidori AM, Grossman AB. GH deficiency in cancer survivors in the transition age: diagnosis and therapy. Pituitary 2020; 23:432-456. [PMID: 32488760 DOI: 10.1007/s11102-020-01052-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Survival rates among childhood cancer survivors (CCSs) have significantly risen in the last 40 years due to substantial improvements in treatment protocols. However, this improvement has brought with it serious late effects that frequently involve the endocrine system. Of the endocrine disorders, GH deficiency (GHD) is the most common among CCSs as a consequence of a history of cancers, surgery, and/or radiotherapy involving the hypothalamo-pituitary region. METHODS A comprehensive search of English language articles regardless of age was conducted in the MEDLINE database between December 2018 and October 2019. We selected all studies on GH therapy in CCSs during the transition age regarding the most challenging topics: when to retest; which diagnostic tests and cut-offs to use; when to start GH replacement therapy (GHRT); what GH dose to use; safety; quality of life, compliance and adherence to GHRT; interactions between GH and other hormonal replacement treatments. RESULTS In the present review, we provide an overview of the current clinical management of challenges in GHD in cancer survivors in the transition age. CONCLUSIONS Endocrine dysfunction among CCSs has a high prevalence in the transition age and increase with time. Many endocrine disorders, including GHD, are often not diagnosed or under-diagnosed, probably due to the lack of specialized centers for the long-term follow-up. Therefore, it is crucial that transition specialized clinics should be increased in terms of number and specific skills in order to manage endocrine disorders in adolescence, a delicate and complex period of life. A multidisciplinary approach, also including psychological counseling, is essential in the follow-up and management of these patients in order to minimize their disabilities and maximize their quality of life.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Marco Crocco
- Department of Pediatrics, IRCCS Giannina Gaslini Institute, University of Genoa, Genoa, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Fortuna Papa
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK
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Bright GM, Fierro-Renoy JF. A rationale for the treatment of short stature in children with the combination of recombinant human growth hormone (rhGH) and recombinant human insulin-like growth factor-I (rhIGF-I). Growth Horm IGF Res 2020; 52:101318. [PMID: 32252003 DOI: 10.1016/j.ghir.2020.101318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Both rhGH and rhIGF-I are signaling molecules with the capacity to restore the rate of growth in certain subsets of slowly growing children. In some instances, heights attained at or near the time of cessation of linear growth are indistinguishable from the height distribution of the community as a whole or from the height distribution expected based on the heights of biological parents. The GH: IGF-I signaling system is sequential, forming a continuous loop wherein GH will stimulate production of IGF-I and IGF-I will inhibit production of GH. This feature suggests that a deficiency of GH will be accompanied by a deficiency of IGF-I and that treatment of GH deficiency with rhGH will restore IGF-I and the subnormal growth of combined GH: IGF-I deficiency. Although logical, this proposition is not always true. rhGH and rhIGF-I are distinct polypeptides, with distinct cell surface receptors and distinct intracellular signaling pathways both capable of amplifying distinct, yet overlapping, patterns of gene replication, protein synthesis and metabolic activities. These features suggest that neither treatment with rhGH nor rhIGF-I alone will invariably recapitulate the combined activities of the GH: IGF-I system, At the present time, this proposition appears both logical and true. The possibility that combined rhGH and rhIGF-I treatment can accomplish that which neither monotherapy can has been examined in gene knock-out experiments in animals and direct comparisons of GH, IGF-I and combined GH: IGF- treatments in animals and in children with short stature, normal GH and low IGF-I (primary IGF-I deficiency). In these experimental models, the growth rates with combined rhGH and rhIGF-I treatment exceed those of either monotherapy. The extent to which this proposition can be generalized to various short stature populations remains to be determined.
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Yuen KCJ, Llahana S, Miller BS. Adult growth hormone deficiency: clinical advances and approaches to improve adherence. Expert Rev Endocrinol Metab 2019; 14:419-436. [PMID: 31721610 DOI: 10.1080/17446651.2019.1689119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/01/2019] [Indexed: 12/17/2022]
Abstract
Introduction: There have been significant clinical advances in the understanding of the diagnosis and benefits of long-term recombinant human growth hormone (rhGH) replacement in adults with GH deficiency (GHD) since its approval in 1996 by the United States Food and Drug Administration.Areas covered: We searched PubMed, Medline, CINAHL, EMBASE and PsychInfo databases between January 2000 and June 2019 for published studies evaluating adults with GHD. We reviewed the data of the oral macimorelin test compared to the GHRH plus arginine and the insulin tolerance tests that led to its approval by the United States FDA and European Medicines Agency for adult diagnostic testing. We summarize the clinical advances of long-term benefits of rhGH therapy and the potential effects of GH receptor polymorphisms on individual treatment responsiveness. We identify that non-adherence and discontinuation rates are high and recommend strategies to support patients to improve adherence. We also provide an overview of several long-acting GH (LAGH) preparations currently under development and their potential role in improving treatment adherence.Expert opinion: This article summarizes recent clinical advances in rhGH replacement therapy, the biological and molecular aspects that may influence rhGH action, and offers practical strategies to enhance adherence in adults with GHD.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
| | - Sofia Llahana
- Division of Nursing, School of Health Sciences, City University of London, London, UK
| | - Bradley S Miller
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Lal RA, Hoffman AR. Perspectives on long-acting growth hormone therapy in children and adults. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:601-607. [PMID: 31939485 PMCID: PMC7237337 DOI: 10.20945/2359-3997000000190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/23/2019] [Indexed: 01/20/2023]
Abstract
Growth hormone therapy with daily injections of recombinant human growth hormone has been available since 1985, and is shown to be safe and effective treatment for short stature in children and for adult growth hormone deficiency. In an effort to produce a product that would improve patient adherence, there has been a strong effort from industry to create a long acting form of growth hormone to ease the burden of use. Technologies used to increase half-life include depot formulations, PEGylated formulations, pro-drug formulations, non-covalent albumin binding growth hormone and growth hormone fusion proteins. At present, two long acting formulations are on the market in China and South Korea, and several more promising agents are under clinical investigation at various stages of development throughout the world. Arch Endocrinol Metab. 2019;63(6):601-7.
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Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew R Hoffman
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Medical Service, Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California, USA
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11
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Holt RIG, Ho KKY. The Use and Abuse of Growth Hormone in Sports. Endocr Rev 2019; 40:1163-1185. [PMID: 31180479 DOI: 10.1210/er.2018-00265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/27/2019] [Indexed: 12/18/2022]
Abstract
GH is banned by the World Anti-Doping Agency as a performance-enhancing anabolic agent. Doping with GH likely began in the early 1980s and became more prevalent with the advent of recombinant technology well before any scientific evidence of benefit. The expectation that GH improves physical function stems from its anabolic and lipolytic properties. Athletic performance depends on muscle strength and the energy required to power muscle function. In recreational athletes, GH selectively improves anaerobic sprint capacity but has not been proven to significantly enhance muscle strength, power, or maximum rate of oxygen consumption. GH is secreted as a family of isoform peptides in a pulsatile manner reflecting intermittent secretion and rapid clearance. Its anabolic actions are largely mediated by IGF-I, which stimulates whole-body protein synthesis, including skeletal muscle and collagen proteins. Two methods have been validated for detecting GH abuse in athletes. The first (the isoform method) is based on distinguishing pure recombinant 22-kDa GH from the heterogeneous isoforms secreted from the pituitary. The second (the marker method) is based on measuring blood levels of GH-responsive proteins, specifically IGF-I and the N-terminal propeptide of type III collagen (P-III-NP). Only a handful of athletes have been caught since the implementation of GH doping tests in 2004. The low rate likely reflects the limitation of in-competition testing using current methods. Improved detection rates may be achieved by more out-of-competition testing, introducing athletes' biological passports, and the development of novel methods. Governance, operational, technical, and political factors influence the effectiveness of an anti-doping program.
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Affiliation(s)
- Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Ken K Y Ho
- Garvan Institute of Medical Research, St. Vincent's Hospital, University of New South Wales, Sydney, New South Wales, Australia
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12
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Lal RA, Hoffman AR. Long-Acting Growth Hormone Preparations in the Treatment of Children. PEDIATRIC ENDOCRINOLOGY REVIEWS : PER 2019; 16:162-167. [PMID: 30378794 DOI: 10.17458/per.vol16.2018.lh.longactingghpreparation] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Human growth hormone (hGH), which had been in use since 1958, was supplanted by recombinant human growth hormone (rhGH) in 1985 for those with growth hormone deficiency (GHD). Adherence to daily subcutaneous growth hormone is challenging for patients. Thus, several companies have pursued the creation of long acting rhGH. These agents can be divided broadly into depot formulations, PEGylated formulations, pro-drug formulations, non-covalent albumin binding GH and GH fusion proteins. Nutropin Depot is the only long acting rhGH ever approved by the U.S. Food and Drug Administration, and it was removed from the market in 2004. Of the approximately seventeen candidate drugs, only a handful remain under active clinical investigation or are commercially available.
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Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA, Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA, E-mail:
| | - Andrew R Hoffman
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA 3Medical Service, VA Palo Alto Health Care System, Palo Alto, California, USA
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Ku CR, Brue T, Schilbach K, Ignatenko S, Magony S, Chung YS, Kim BJ, Hur KY, Kang HC, Kim JH, Kim MS, Kowalska A, Bolanowski M, Ruchala M, Damjanovic S, Payer J, Choi YJ, Heo SJ, Kim TK, Heo M, Lee J, Lee EJ. Long-acting FC-fusion rhGH (GX-H9) shows potential for up to twice-monthly administration in GH-deficient adults. Eur J Endocrinol 2018; 179:169-179. [PMID: 29973375 DOI: 10.1530/eje-18-0185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/03/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hybrid Fc-fused rhGH (GX-H9) is a long-acting recombinant human growth hormone (GH) under clinical development for both adults and children with GH deficiency (GHD). We compared the safety, pharmacokinetics and pharmacodynamics of weekly and every other week (EOW) dosages of GX-H9 with those of daily GH administration in adult GHD (AGHD) patients. DESIGN This was a randomized, open-label, active-controlled and dose-escalation study conducted in 16 endocrinology centers in Europe and Korea. METHODS Forty-five AGHD patients with or without prior GH treatment were enrolled. Patients with prior GH treatments were required to have received the last GH administration at least 1 month prior to randomization. Subjects were sequentially assigned to treatment groups. Fifteen subjects were enrolled to each treatment group and randomly assigned to receive either GX-H9 or Genotropin (4:1 ratio). GX-H9 dosage regimens for Groups 1, 2 and 3 were 0.1 mg/kg weekly, 0.3 mg/kg EOW and 0.2 mg/kg EOW, respectively. All Genotropin-assigned subjects received 6 µg/kg Genotropin, regardless of treatment group. Main outcome analyses included measurements of serum insulin-like growth factor 1 (IGF-I), safety, pharmacokinetics, pharmacodynamics and immunogenicity. RESULTS Mean GX-H9 peak and total exposure increased with an increase in dose after a single-dose administration. The mean IGF-I response was sustained above baseline over the intended dose interval of 168 h for the weekly and 336 h for the EOW GX-H9 groups. Safety profiles and immunogenicity were not different across the treatment groups and with Genotropin. CONCLUSIONS GX-H9 has the potential for up to twice-monthly administration.
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Affiliation(s)
- Cheol Ryong Ku
- Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Thierry Brue
- Aix-Marseille Université, INSERM U1251, Marseille Medical Genetics, and AP-HM, Hôpital Conception, Marseille, France
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Sandor Magony
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Yoon-Sok Chung
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Byung-Joon Kim
- Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Kyu Yeon Hur
- Samsung Medical Center, Seoul, Republic of Korea
| | - Ho-Cheol Kang
- Chonnam National University Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Jung Hee Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Aldona Kowalska
- Endocrinology Clinic Holycross Cancer Centre, Swietokrzyskie, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Ruchala
- Poznan University of Medical Sciences Chair and Department of Endocrinology, Metabolism and Internal Medicine, Poznań, Poland
| | | | - Juraj Payer
- 5th Department of Internal Medicine, Comenius University Faculty of Medicine, University Hospital, Bratislava, Slovakia
| | | | | | | | - MinKyu Heo
- Genexine Inc., Seongnam, Republic of Korea
| | - Joan Lee
- Genexine Inc., Seongnam, Republic of Korea
| | - Eun Jig Lee
- Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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14
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Yuen KCJ, Miller BS, Biller BMK. The current state of long-acting growth hormone preparations for growth hormone therapy. Curr Opin Endocrinol Diabetes Obes 2018; 25:267-273. [PMID: 29746309 DOI: 10.1097/med.0000000000000416] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To discuss the rationale of developing long-acting growth hormone (LAGH) preparations, to describe the technologies designed to prolong GH action, and to address key issues regarding efficacy, safety, and monitoring while on treatment. REVIEW FINDINGS Recombinant human GH is currently approved for daily use and has been shown to restore longitudinal growth, and improve body composition with relatively few side-effects in children and adults with GH deficiency, respectively. However, daily injections can be inconvenient, painful and distressing for some patients, resulting in decreased adherence and efficacy. Over a dozen pharmaceutical companies have designed LAGH preparations that are at various stages of development using a number of different methods to prolong GH action. SUMMARY LAGH will represent an advancement over daily recombinant human GH injections because of fewer injections that may offer increased acceptance, tolerability, and therapeutic flexibility to patients that potentially can improve treatment outcomes. However, given the unphysiological profile of LAGH preparations, long-term surveillance of efficacy and safety are needed. This review summarizes recent developments of LAGH preparations, and highlights the importance of long-term surveillance registries to assess for efficacy and safety that will be essential for understanding the impact of prolonged exposure to these compounds.
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Affiliation(s)
- Kevin C J Yuen
- Department of Neuroendocrinology and Neurosurgery, Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine, Phoenix, Arizona
| | - Bradley S Miller
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Gilfoyle D, Mortensen E, Christoffersen ED, Leff JA, Beckert M. A first-in-man phase 1 trial for long-acting TransCon Growth Hormone. Growth Horm IGF Res 2018; 39:34-39. [PMID: 29273485 DOI: 10.1016/j.ghir.2017.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/30/2017] [Accepted: 12/03/2017] [Indexed: 11/23/2022]
Abstract
TransCon growth hormone (GH) is a sustained-release inactive prodrug consisting of unmodified GH transiently bound to an inert carrier molecule designed to release fully active GH over a one-week period. This was a first-in-man phase 1 randomized trial was to evaluate the safety, tolerability, immunogenicity, pharmacokinetics (PK), and pharmacodynamics (PD) of a single dose of TransCon GH as compared to equivalent doses of daily GH (Omnitrope) or placebo in healthy adults. Forty-four healthy male adults were randomized to 4 cohorts of 11 subjects, distributed in a 7:2:2 ratio (TransCon GH: Omnitrope: placebo). A single injection of 4 possible TransCon GH doses (i.e., 0.04, 0.08, 0.16, or 0.24mg GH/kg/wk) or two different Omnitrope doses (i.e., 0.08 or 0.16mg GH/kg/wk divided into 7 equal daily doses) were administered with subjects evaluated for adverse events, immunogenicity, and GH and insulin-like growth factor-1 (IGF-1) levels. TransCon GH was well tolerated; no serious adverse events occurred, no injection site reaction differences between TransCon GH, Omnitrope, or placebo were identified, no nodules or lipoatrophy were reported, and no anti-GH binding antibodies or ECG changes were detected. Overall, the exposure of GH (Cmax) and IGF-1 (AUC0-168h) following administration of equivalent doses of TransCon GH and Omnitrope were similar. GH and IGF-1 kinetics showed a dose-proportional increase following a single SC administration of TransCon GH and indicated that the prodrug is suitable for weekly administration. These results support advancement of TransCon GH to pediatric and adult GHD trials. Clinical trial registration numbers: NCT01010425 (clinicaltrials.gov).
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16
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Treatment with Growth Hormone for Adults with Growth Hormone Deficiency Syndrome: Benefits and Risks. Int J Mol Sci 2018; 19:ijms19030893. [PMID: 29562611 PMCID: PMC5877754 DOI: 10.3390/ijms19030893] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/07/2018] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Pharmacological treatment of growth hormone deficiency (GHD) in adults began in clinical practice more than 20 years ago. Since then, a great volume of experience has been accumulated on its effects on the symptoms and biochemical alterations that characterize this hormonal deficiency. The effects on body composition, muscle mass and strength, exercise capacity, glucose and lipid profile, bone metabolism, and quality of life have been fully demonstrated. The advance of knowledge has also taken place in the biological and molecular aspects of the action of this hormone in patients who have completed longitudinal growth. In recent years, several epidemiological studies have reported interesting information about the long-term effects of GH replacement therapy in regard to the possible induction of neoplasms and the potential development of diabetes. In addition, GH hormone receptor polymorphism could potentially influence GH therapy. Long-acting GH are under development to create a more convenient GH dosing profile, while retaining the excellent safety, efficacy, and tolerability of daily GH. In this article we compile the most recent data of GH replacement therapy in adults, as well as the molecular aspects that may condition a different sensitivity to this treatment.
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17
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Sprogøe K, Mortensen E, Karpf DB, Leff JA. The rationale and design of TransCon Growth Hormone for the treatment of growth hormone deficiency. Endocr Connect 2017; 6:R171-R181. [PMID: 28947559 PMCID: PMC5655688 DOI: 10.1530/ec-17-0203] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 01/09/2023]
Abstract
The fundamental challenge of developing a long-acting growth hormone (LAGH) is to create a more convenient growth hormone (GH) dosing profile while retaining the excellent safety, efficacy and tolerability of daily GH. With GH receptors on virtually all cells, replacement therapy should achieve the same tissue distribution and effects of daily (and endogenous) GH while maintaining levels of GH and resulting IGF-1 within the physiologic range. To date, only two LAGHs have gained the approval of either the Food and Drug Administration (FDA) or the European Medicines Agency (EMA); both released unmodified GH, thus presumably replicating distribution and pharmacological actions of daily GH. Other technologies have been applied to create LAGHs, including modifying GH (for example, protein enlargement or albumin binding) such that the resulting analogues possess a longer half-life. Based on these approaches, nearly 20 LAGHs have reached various stages of clinical development. Although most have failed, lessons learned have guided the development of a novel LAGH. TransCon GH is a LAGH prodrug in which GH is transiently bound to an inert methoxy polyethylene glycol (mPEG) carrier. It was designed to achieve the same safety, efficacy and tolerability as daily GH but with more convenient weekly dosing. In phase 2 trials of children and adults with growth hormone deficiency (GHD), similar safety, efficacy and tolerability to daily GH was shown as well as GH and IGF-1 levels within the physiologic range. These promising results support further development of TransCon GH.
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18
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Rautio J, Kärkkäinen J, Sloan KB. Prodrugs – Recent approvals and a glimpse of the pipeline. Eur J Pharm Sci 2017; 109:146-161. [DOI: 10.1016/j.ejps.2017.08.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 01/12/2023]
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19
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Ciresi A, Cicciò F, Radellini S, Guarnotta V, Calcaterra AM, Giordano C. More Favorable Metabolic Impact of Three-Times-Weekly versus Daily Growth Hormone Treatment in Naïve GH-Deficient Children. Int J Endocrinol 2017; 2017:8469680. [PMID: 28634491 PMCID: PMC5467351 DOI: 10.1155/2017/8469680] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/14/2017] [Accepted: 04/26/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate whether two different regimens of weekly injections could lead to similar auxological and metabolic effects in children with growth hormone deficiency (GHD). DESIGN 32 GHD children (25 males, mean age 10.5 ± 2.2 yr) were randomly assigned to receive daily (group A, 16 patients) or TIW (group B, 16 patients) GHT for 12 months. METHODS Auxological parameters, insulin-like growth factor-I (IGF-I), glucose and insulin during OGTT, glycosylated hemoglobin (HbA1c), lipid profile, the oral disposition index (DIo), the homeostasis model assessment estimate of insulin resistance (Homa-IR), and the insulin sensitivity index (ISI). RESULTS After 12 months, both groups showed a significant and comparable improvement in height (p < 0.001) and IGF-I (p < 0.001). As regards the metabolic parameters, in both groups, we found a significant increase in fasting insulin (p < 0.001 and p = 0.026) and Homa-IR (p < 0.001 and p = 0.019). A significant increase in fasting glucose (p = 0.001) and a decrease in ISI (p < 0.001) and DIo (p = 0.002) were only found in group A. CONCLUSIONS The TIW regimen is effective and comparable with the daily regimen in improving auxological parameters and has a more favorable metabolic impact in GHD children. This trial is registered with ClinicalTrials.gov NCT03033121.
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Affiliation(s)
- Alessandro Ciresi
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Floriana Cicciò
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Stefano Radellini
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Valentina Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Anna Maria Calcaterra
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Carla Giordano
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
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