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Oi-Yo Y, Yamamoto M, Urai S, Bando H, Ohmachi Y, Motomura Y, Kobatake M, Tsujimoto Y, Sasaki Y, Suzuki M, Yamamoto N, Takahashi M, Iguchi G, Ogawa W, Takahashi Y, Fukuoka H. Long-term metabolic effectiveness and safety of growth hormone replacement therapy in patients with adult growth hormone deficiency: a single-institution study in Japan. Pituitary 2024:10.1007/s11102-024-01459-z. [PMID: 39298061 DOI: 10.1007/s11102-024-01459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE To elucidate the long-term efficacy and safety of growth hormone replacement therapy (GHRT) in Japanese patients with adult growth hormone deficiency (AGHD). METHODS We conducted a retrospective study. A total of 110 patients with AGHD receiving GHRT were enrolled. Clinical and laboratory data were collected annually from the beginning of the study. Statistical analysis was performed using a linear mixed-effects model. RESULTS Of all patients, 46.4% were males, 70.9% had adult-onset GHD, and follow-up was up to 196 months, with a median of 68 months. The insulin-like growth factor-1 standard deviation score increased after the start of GHRT and remained constant for more than 11 years. Seventeen patients were followed up for more than 11 years. The body mass index increased. Waist circumference decreased in the short term but increased in the long term. The diastolic blood pressure decreased 1-5 years after the start of GHRT, and the systolic blood pressure increased 11 years after GHRT. Moreover, a long-term decrease in low-density lipoprotein cholesterol, an increase in high-density lipoprotein cholesterol, and a decrease in aspartate aminotransferase and alanine aminotransferase levels were observed. The glycosylated hemoglobin level increased after 3 years. The bone mineral density in the lumbar spine and total hip increased significantly 3 years after the start of GHRT. Finally, the number of adverse events was eight. CONCLUSION We demonstrated the metabolic effectiveness and safety of GHRT in Japanese patients with AGHD over a long follow-up period of 16 years.
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Affiliation(s)
- Yuka Oi-Yo
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan.
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Yuka Ohmachi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaki Kobatake
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yasutaka Tsujimoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yuriko Sasaki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Michiko Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Nutrition, Kobe University Hospital, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
- Faculty of Clinical Nutrition and Dietetics, Department of Clinical Nutrition and Dietetics, Konan Women's University, Kobe, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
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Tidblad A, Bottai M, Smedby KE, Albertsson-Wikland K, Sävendahl L. Long-term risk of neoplastic events after childhood growth hormone treatment: a population-based cohort study in Sweden. Front Endocrinol (Lausanne) 2024; 15:1360139. [PMID: 38505755 PMCID: PMC10948557 DOI: 10.3389/fendo.2024.1360139] [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: 12/22/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
Background Increased risk of neoplastic events after recombinant human growth hormone (rhGH) treatment in childhood has been an ongoing concern but long-term safety data are limited. Methods A nationwide population-based cohort study in Sweden of patients treated with rhGH during childhood between 1985-2010, due to isolated growth hormone deficiency (GHD), small for gestational age (SGA) and idiopathic short stature (ISS). The comparison group consisted of 15 age-, sex-, and region-matched controls per patient, randomly selected from the general population. Data on neoplastic events and covariates, such as gestational age, birth weight, birth length, socioeconomic status, and height at study start, were collected through linkage with population-based registers. The cohort was followed for neoplastic events until the end of 2020. Results 53,444 individuals (3,408 patients; 50,036 controls) were followed for up to 35 years, with a median follow-up of 19.8 years and a total of 1,050,977 person-years. Patients showed a moderately increased hazard ratio (HR) for neoplastic events overall compared to controls (HR 1.28, 95% CI: 1.12-1.46), but only significant for males (HR 1.39, 95% CI: 1.17-1.66) and not females (HR 1.15, 95% CI: 0.94-1.41). Longer treatment duration was associated with an increased HR, but no association was found between neoplastic events and mean or cumulative dose. No increased risk of malignant neoplasms was observed for the patients compared to matched controls (HR 0.91 95% CI: 0.66-1.26). Conclusion No association was found between rhGH treatment during childhood for GHD, SGA, or ISS and malignant neoplastic events in early to mid-adulthood. A moderate increase in overall neoplastic events was observed due to an increased number of events in male patients.
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Affiliation(s)
- Anders Tidblad
- Department of Women’s and Children’s Health, Karolinska Institutet and Division of Pediatric Endocrinology, Karolinska University Hospital, Solna, Sweden
| | - Matteo Bottai
- Unit of Biostatistics, Department of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Karin E. Smedby
- Division of Clinical Epidemiology (KEP), Department of Medicine Solna, Karolinska Institutet, and Department of Hematology, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Kerstin Albertsson-Wikland
- Department of Physiology/Endocrinology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Lars Sävendahl
- Department of Women’s and Children’s Health, Karolinska Institutet and Division of Pediatric Endocrinology, Karolinska University Hospital, Solna, Sweden
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Slagboom TNA, van Bunderen CC, van der Lely AJ, Drent ML. Sex Differences in Long-Term Safety and Tolerability of GH Replacement Therapy in GH Deficient Adults. J Clin Endocrinol Metab 2023; 108:e415-e424. [PMID: 36652411 DOI: 10.1210/clinem/dgad013] [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: 08/19/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
CONTEXT Previous studies report that outcomes of growth hormone (GH) replacement therapy (GHRT) might be less beneficial in growth hormone deficient (GHD) women compared with men. OBJECTIVE This study investigated possible contributing factors regarding this previously found sex difference. METHODS This retrospective cohort study, conducted at a nationwide outpatient clinic (the Dutch National Registry of GH Treatment in Adults), included Dutch adult GHD men (n = 1335) and women (n = 1251) treated with GHRT. The patients' baseline characteristics, details of GHRT, and the tolerability and long-term safety of GHRT were measured. RESULTS During treatment, sensitivity analysis showed that insulin-like growth factor-1 (IGF-1) SD scores remained subnormal more often in women (P < 0.001), while scores above normal were more frequent in men (P < 0.001). Women reported more adverse events (P < 0.001), especially symptoms related to fluid retention, and more often needed a dose reduction or temporary stop of GHRT (P = 0.001). In percentages, both sexes equally discontinued GHRT, as was also true for the risk in developing type 2 diabetes mellitus, benign neoplasms, and tumor recurrence. The risk of developing malignant neoplasms was higher in men (P = 0.012). CONCLUSION Data obtained from the Dutch National Registry of GH Treatment in Adults indicate that GHD women might be treated suboptimally, reflected as lower IGF-1 status and lower GHRT tolerability, leading to more frequent changes in treatment regimen but not discontinuation of GHRT. Regarding long-term safety, we found a higher risk for development of malignancies in GHD men.
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Affiliation(s)
- Tessa N A Slagboom
- Department of Internal Medicine, Section of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Christa C van Bunderen
- Department of Internal Medicine, Section of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Aart Jan van der Lely
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Madeleine L Drent
- Department of Internal Medicine, Section of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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Di Somma C, Scarano E, Arianna R, Romano F, Lavorgna M, Serpico D, Colao A. Long-Term Safety of Growth Hormone Deficiency Treatment in Cancer and Sellar Tumors Adult Survivors: Is There a Role of GH Therapy on the Neoplastic Risk? J Clin Med 2023; 12:jcm12020662. [PMID: 36675591 PMCID: PMC9861672 DOI: 10.3390/jcm12020662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Experimental studies support the hypothesis that GH/IGF-1 status may influence neoplastic tissue growth. Epidemiological studies suggest a link between GH/IGF-1 status and cancer risk. However, several studies regarding GH replacement safety in childhood cancer survivors do not show a prevalence excess of de novo cancers, and several reports on children and adults treated with GH have not shown an increase in observed cancer risk in these patients. The aim of this review is to provide an at-a-glance overview and the state of the art of long-term effects of GH replacement on neoplastic risk in adults with growth hormone deficiency who have survived cancer and sellar tumors.
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Affiliation(s)
- Carolina Di Somma
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, 80131 Naples, Italy
- Correspondence:
| | - Elisabetta Scarano
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Rossana Arianna
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Fiammetta Romano
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Mariarosaria Lavorgna
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Domenico Serpico
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Annamaria Colao
- Endocrinology, Diabetes and Andrology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, 80131 Naples, Italy
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Johannsson G, Touraine P, Feldt-Rasmussen U, Pico A, Vila G, Mattsson AF, Carlsson M, Korbonits M, van Beek AP, Wajnrajch MP, Gomez R, Yuen KCJ. Long-term Safety of Growth Hormone in Adults With Growth Hormone Deficiency: Overview of 15 809 GH-Treated Patients. J Clin Endocrinol Metab 2022; 107:1906-1919. [PMID: 35368070 PMCID: PMC9202689 DOI: 10.1210/clinem/dgac199] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Indexed: 01/16/2023]
Abstract
CONTEXT Data on long-term safety of growth hormone (GH) replacement in adults with GH deficiency (GHD) are needed. OBJECTIVE We aimed to evaluate the safety of GH in the full KIMS (Pfizer International Metabolic Database) cohort. METHODS The worldwide, observational KIMS study included adults and adolescents with confirmed GHD. Patients were treated with GH (Genotropin [somatropin]; Pfizer, NY) and followed through routine clinical practice. Adverse events (AEs) and clinical characteristics (eg, lipid profile, glucose) were collected. RESULTS A cohort of 15 809 GH-treated patients were analyzed (mean follow-up of 5.3 years). AEs were reported in 51.2% of patients (treatment-related in 18.8%). Crude AE rate was higher in patients who were older, had GHD due to pituitary/hypothalamic tumors, or adult-onset GHD. AE rate analysis adjusted for age, gender, etiology, and follow-up time showed no correlation with GH dose. A total of 606 deaths (3.8%) were reported (146 by neoplasms, 71 by cardiac/vascular disorders, 48 by cerebrovascular disorders). Overall, de novo cancer incidence was comparable to that in the general population (standard incidence ratio 0.92; 95% CI, 0.83-1.01). De novo cancer risk was significantly lower in patients with idiopathic/congenital GHD (0.64; 0.43-0.91), but similar in those with pituitary/hypothalamic tumors or other etiologies versus the general population. Neither adult-onset nor childhood-onset GHD was associated with increased de novo cancer risks. Neutral effects were observed in lipids/fasting blood glucose levels. CONCLUSION These final KIMS cohort data support the safety of long-term GH replacement in adults with GHD as prescribed in routine clinical practice.
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Affiliation(s)
- Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital & Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Sorbonne Université, Assistance Publique Hopitaux de Paris, Paris, France
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Rigshospitalet, and Department of Clinical Medicine, Faculty of Health and Clinical Science, Copenhagen University, Copenhagen, Denmark
| | - Antonio Pico
- Biomedical Research Networking Center in Rare Diseases (CIBERER), Institute of Health Carlos III (ISCIII), Madrid, Spain
- Hospital General Universitario de Alicante-Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Elche, Spain
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michael P Wajnrajch
- Rare Disease, Biopharmaceuticals, Pfizer, New York, NY, USA
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Roy Gomez
- European Medical Affairs, Pfizer, Brussels, Belgium
| | - Kevin C J Yuen
- Correspondence: Kevin CJ Yuen, MD, Barrow Pituitary Center, Barrow Neurological Institute, 124 West Thomas Road, Suite 300, Phoenix, AZ 85013, USA.
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He M, Deng X, Wang X, Wan Y, Huang J, Zhang Z, Niu W. Association Between Recombinant Growth Hormone Therapy and All-Cause Mortality and Cancer Risk in Childhood: Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:866295. [PMID: 35529328 PMCID: PMC9073080 DOI: 10.3389/fped.2022.866295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The safety of recombinant human growth hormone (rhGH) treatment in childhood and the role of rhGH therapy in promoting tumorigenesis and progression have been the subject of debate for decades. We aimed to systematically assess the relationship between rhGH therapy in children and adolescents and clinical outcomes, including all-cause mortality, cancer mortality, cancer incidence, and risk of the second neoplasm. METHODS Literature retrieval, study selection, and data extraction were completed independently and in duplicate. Effect-size estimates are expressed as standardized mortality ratios (SMRs), standardized incidence ratio (SIR), and relative risk (RR) with a 95% CI. RESULTS Data from 24 articles, involving 254,776 persons, were meta-analyzed. Overall analyses revealed the association of rhGH therapy was not statistically significant with all-cause mortality (SMR = 1.28; 95% CI: 0.58-2.84; P = 0.547; I 2 = 99.2%; Tau2 = 2.154) and cancer mortality (SMR = 2.59; 95% CI: 0.55-12.09; P = 0.228; I 2 = 96.7%; Tau2 = 2.361) and also cancer incidence (SIR = 1.54; 95% CI: 0.68-3.47; P = 0.229; I 2 = 97.5%; Tau2 = 2.287), yet statistical significance was observed for second neoplasm (RR = 1.77; 95% CI: 1.33-2.35; P = 0.001; I 2 = 26.7%; Tau2 = 0.055). Differences in the geographic region, gender, treatment duration, mean rhGH dose, overall rhGH exposure dose, and initial disease accounted for heterogeneity in the subgroup analyses. CONCLUSION Our findings indicate that the rhGH therapy is not related to all-cause mortality and cancer mortality and cancer incidence, yet it seems to trigger a second tumor risk. Future prospective studies are needed to confirm our findings and answer the more challenging question regarding the optimal dose of rhGH therapy in children and adolescents.
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Affiliation(s)
- Mengyang He
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xiangling Deng
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xuan Wang
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
| | - Yuxiang Wan
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Jinchang Huang
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
| | - Zhixin Zhang
- Department of International Medical, China-Japan Friendship Hospital, Beijing, China
| | - Wenquan Niu
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
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Johannsson G, Ragnarsson O. Growth hormone deficiency in adults with hypopituitarism-What are the risks and can they be eliminated by therapy? J Intern Med 2021; 290:1180-1193. [PMID: 34605087 DOI: 10.1111/joim.13382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Growth hormone (GH) deficiency develops early in patients with hypothalamic-pituitary disorders and is therefore common among these patients. GH deficiency in adults is associated with increased morbidity, increased body fat mass, abdominal obesity, dyslipidaemia, reduced exercise capacity, impaired cardiac function as well as reduced self-reported well-being and impaired quality of life. Since recombinant human GH became available as replacement therapy more than 25 years ago, randomised controlled trials and long-term studies, together with meta-analyses, have shown improved outcomes in adult patients with hypopituitarism receiving GH. Many of the features associated with GH deficiency in adults improve, or even normalize, and the safety profile is reassuring. The increased interest in GH deficiency in adults with hypothalamic-pituitary disorders has also contributed to the identification of other factors of importance for an outcome such as the replacement of other pituitary hormone deficiencies, and the management of the underlying hypothalamic-pituitary disease, most commonly a pituitary tumour. In this narrative review, we summarize the burden of GH deficiency in adults with hypopituitarism, the impact of GH replacement on the outcome, as well as safety. Based on currently available data, GH replacement should be considered routine management of adults with hypopituitarism.
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Affiliation(s)
- Gudmundur Johannsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Boguszewski MCS, Cardoso-Demartini AA, Boguszewski CL, Chemaitilly W, Higham CE, Johannsson G, Yuen KCJ. Safety of growth hormone (GH) treatment in GH deficient children and adults treated for cancer and non-malignant intracranial tumors-a review of research and clinical practice. Pituitary 2021; 24:810-827. [PMID: 34304361 PMCID: PMC8416866 DOI: 10.1007/s11102-021-01173-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/24/2022]
Abstract
Individuals surviving cancer and brain tumors may experience growth hormone (GH) deficiency as a result of tumor growth, surgical resection and/or radiotherapy involving the hypothalamic-pituitary region. Given the pro-mitogenic and anti-apoptotic properties of GH and insulin-like growth factor-I, the safety of GH replacement in this population has raised hypothetical safety concerns that have been debated for decades. Data from multicenter studies with extended follow-up have generally not found significant associations between GH replacement and cancer recurrence or mortality from cancer among childhood cancer survivors. Potential associations with secondary neoplasms, especially solid tumors, have been reported, although this risk appears to decline with longer follow-up. Data from survivors of pediatric or adult cancers who are treated with GH during adulthood are scarce, and the risk versus benefit profile of GH replacement of this population remains unclear. Studies pertaining to the safety of GH replacement in individuals treated for nonmalignant brain tumors, including craniopharyngioma and non-functioning pituitary adenoma, have generally been reassuring with regards to the risk of tumor recurrence. The present review offers a summary of the most current medical literature regarding GH treatment of patients who have survived cancer and brain tumors, with the emphasis on areas where active research is required and where consensus on clinical practice is lacking.
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Affiliation(s)
- Margaret C S Boguszewski
- Departamento de Pediatria, Universidade Federal do Paraná, Avenida Agostinho Leão Junior, 285 - Alto da Glória, Curitiba, PR, 80030-110, Brazil.
| | | | - Cesar Luiz Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Wassim Chemaitilly
- Departments of Pediatric Medicine-Endocrinology and Epidemiology-Cancer Control, St. Jude Children's Research Hospital, Memphis, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust and University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - 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, USA
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Doknic M, Gasic V, Stojanovic M, Pavlovic S, Marinkovic S, Miljic D, Pekic S, Manojlovic-Gacic E, Damjanovic D, Soldatovic I, Petakov M. Hypopituitarism in five PROP1 mutation siblings: long-lasting natural course and the effects of growth hormone replacement introduction in middle adulthood. Pituitary 2020; 23:400-408. [PMID: 32415500 DOI: 10.1007/s11102-020-01049-9] [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: 11/28/2022]
Abstract
Twenty years after the first description of combined hypopituitarism (CPHD) caused by PROP1 mutations, the phenotype of affected subjects is still challenging for clinicians. These patients suffer from pituitary hormone deficits ranging from IGHD to panhypopituitarism. ACTH deficiency usually develops later in life. Pituitary size is variable. PROP1 mutation is the most frequent in familial congenital hypopituitarism (CH). Reports on initiation of hormonal replacement including growth hormone (GH) in adults with CH are scarce. We identified 5 adult siblings with CPHD due to PROP1 mutation (301-302delAG), aged 36-51 years (4 females), never treated for hormone deficiencies. They presented with short stature (SD from - 3.7 to - 4.7), infantile sexual characteristic, moderate abdominal obesity and low bone mineral density in 3 of them. Complete hypopituituitarism was confirmed in three siblings, while two remaining demonstrated GH, TSH, FSH and LH deficiencies. Required hormonal replacement including rhGH was initiated in all patients. After several months necessity for hydrocortisone replacement developed in all patients. After 2 years of continual replacement therapy, BMD and body composition (measured by DXA-dual X-ray absorptiometry) improved in all subjects, most prominently in two younger females and the male sibling. Besides rhGH therapy, these three patients have received sex hormones contributing to the favorable effect. The male sibling was diagnosed with brain glioblastoma two years following complete hormonal replacement. This report provides important experience regarding hormonal replacement, particularly rhGH treatment, in adults with long-term untreated CH. Beneficial effect of such therapy are widely acknowledged, yet these subjects could be susceptible to certain risks of hormonal treatment initiated in adulthood. Careful and continual clinical follow-up is thus strongly advised.
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Affiliation(s)
- Mirjana Doknic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotic 13, 11000, Belgrade, Serbia.
- Faculty of Medicine, University Belgrade, Belgrade, Serbia.
| | - Vladimir Gasic
- Institute of Molecular Genetics and Genetic Engineering, University Belgrade, Belgrade, Serbia
| | - Marko Stojanovic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotic 13, 11000, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Sonja Pavlovic
- Institute of Molecular Genetics and Genetic Engineering, University Belgrade, Belgrade, Serbia
| | - Snezana Marinkovic
- Special Hospital for Thyroid Gland and Metabolism Diseases, Zlatibor, Serbia
| | - Dragana Miljic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotic 13, 11000, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Sandra Pekic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotic 13, 11000, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | | | - Dusan Damjanovic
- Center for Radiology Imaging - Magnetic Resonance and Gamma Knife, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Ivan Soldatovic
- Institute of Medical Statistics and Informatics, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
| | - Milan Petakov
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Dr Subotic 13, 11000, Belgrade, Serbia
- Faculty of Medicine, University Belgrade, Belgrade, Serbia
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Yuen KCJ, Biller BMK, Radovick S, Carmichael JD, Jasim S, Pantalone KM, Hoffman AR. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF GROWTH HORMONE DEFICIENCY IN ADULTS AND PATIENTS TRANSITIONING FROM PEDIATRIC TO ADULT CARE. Endocr Pract 2019; 25:1191-1232. [PMID: 31760824 DOI: 10.4158/gl-2019-0405] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPG). Methods: Recommendations are based on diligent reviews of clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2019 updated guideline contains 58 numbered recommendations: 12 are Grade A (21%), 19 are Grade B (33%), 21 are Grade C (36%), and 6 are Grade D (10%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 357 citations of which 51 (14%) are evidence level (EL) 1 (strong), 168 (47%) are EL 2 (intermediate), 61 (17%) are EL 3 (weak), and 77 (22%) are EL 4 (no clinical evidence). Conclusion: This CPG is a practical tool that practicing endocrinologists and regulatory bodies can refer to regarding the identification, diagnosis, and treatment of adults and patients transitioning from pediatric to adult-care services with growth hormone deficiency (GHD). It provides guidelines on assessment, screening, diagnostic testing, and treatment recommendations for a range of individuals with various causes of adult GHD. The recommendations emphasize the importance of considering testing patients with a reasonable level of clinical suspicion of GHD using appropriate growth hormone (GH) cut-points for various GH-stimulation tests to accurately diagnose adult GHD, and to exercise caution interpreting serum GH and insulin-like growth factor-1 (IGF-1) levels, as various GH and IGF-1 assays are used to support treatment decisions. The intention to treat often requires sound clinical judgment and careful assessment of the benefits and risks specific to each individual patient. Unapproved uses of GH, long-term safety, and the current status of long-acting GH preparations are also discussed in this document. LAY ABSTRACT This updated guideline provides evidence-based recommendations regarding the identification, screening, assessment, diagnosis, and treatment for a range of individuals with various causes of adult growth-hormone deficiency (GHD) and patients with childhood-onset GHD transitioning to adult care. The update summarizes the most current knowledge about the accuracy of available GH-stimulation tests, safety of recombinant human GH (rhGH) replacement, unapproved uses of rhGH related to sports and aging, and new developments such as long-acting GH preparations that use a variety of technologies to prolong GH action. Recommendations offer a framework for physicians to manage patients with GHD effectively during transition to adult care and adulthood. Establishing a correct diagnosis is essential before consideration of replacement therapy with rhGH. Since the diagnosis of GHD in adults can be challenging, GH-stimulation tests are recommended based on individual patient circumstances and use of appropriate GH cut-points. Available GH-stimulation tests are discussed regarding variability, accuracy, reproducibility, safety, and contraindications, among other factors. The regimen for starting and maintaining rhGH treatment now uses individualized dose adjustments, which has improved effectiveness and reduced reported side effects, dependent on age, gender, body mass index, and various other individual characteristics. With careful dosing of rhGH replacement, many features of adult GHD are reversible and side effects of therapy can be minimized. Scientific studies have consistently shown rhGH therapy to be beneficial for adults with GHD, including improvements in body composition and quality of life, and have demonstrated the safety of short- and long-term rhGH replacement. Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AHSG = alpha-2-HS-glycoprotein; AO-GHD = adult-onset growth hormone deficiency; ARG = arginine; BEL = best evidence level; BMD = bone mineral density; BMI = body mass index; CI = confidence interval; CO-GHD = childhood-onset growth hormone deficiency; CPG = clinical practice guideline; CRP = C-reactive protein; DM = diabetes mellitus; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = Food and Drug Administration; FD-GST = fixed-dose glucagon stimulation test; GeNeSIS = Genetics and Neuroendocrinology of Short Stature International Study; GH = growth hormone; GHD = growth hormone deficiency; GHRH = growth hormone-releasing hormone; GST = glucagon stimulation test; HDL = high-density lipoprotein; HypoCCS = Hypopituitary Control and Complications Study; IGF-1 = insulin-like growth factor-1; IGFBP = insulin-like growth factor-binding protein; IGHD = isolated growth hormone deficiency; ITT = insulin tolerance test; KIMS = Kabi International Metabolic Surveillance; LAGH = long-acting growth hormone; LDL = low-density lipoprotein; LIF = leukemia inhibitory factor; MPHD = multiple pituitary hormone deficiencies; MRI = magnetic resonance imaging; P-III-NP = procollagen type-III amino-terminal pro-peptide; PHD = pituitary hormone deficiencies; QoL = quality of life; rhGH = recombinant human growth hormone; ROC = receiver operating characteristic; RR = relative risk; SAH = subarachnoid hemorrhage; SDS = standard deviation score; SIR = standardized incidence ratio; SN = secondary neoplasms; T3 = triiodothyronine; TBI = traumatic brain injury; VDBP = vitamin D-binding protein; WADA = World Anti-Doping Agency; WB-GST = weight-based glucagon stimulation test.
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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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12
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Cianfarani S. Risk of cancer in patients treated with recombinant human growth hormone in childhood. Ann Pediatr Endocrinol Metab 2019; 24:92-98. [PMID: 31261472 PMCID: PMC6603614 DOI: 10.6065/apem.2019.24.2.92] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022] Open
Abstract
Recombinant human growth hormone (GH) has been in use for over 30 years, and its indications have gradually expanded from the classical replacement therapy in GH deficiency (GHD) to pharmacological therapy in patients with normal GH secretion. The insulin-like growth factor-I (IGF-I ) is closely GH dependent and is the effector of GH biological actions in peripheral tissues. Since IGF-I has potent mitogenic and antiapoptotic effects, the use of GH, especially outside GHD, has raised safety concern regarding cancer risk. The results of experimental, epidemiological and observational studies are not univocal and a number of biases and confounders affect the interpretation of data. The aim of this review is to critically review the data linking GH therapy during childhood with cancer risk, highlighting strengths and weaknesses of the available evidence.
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Affiliation(s)
- Stefano Cianfarani
- Dipartimento Pediatrico Universitario Ospedaliero, “Bambino Gesù” Children’s Hospital – Tor Vergata University, Rome, Italy,Department of Women’s and Children’s Health, Karolinska Institutet and University Hospital, Stockholm, Sweden,Address for correspondence: Stefano Cianfarani, MD, PhD Dipartimento Pediatrico Universitario Ospedaliero, “Bambino Gesù” Children’s Hospital–Tor Vergata University, Piazza S. Onofrio 4, 00165-Rome, Italy Tel: +39-06-6859-3074 Fax: +39-06-6859-2508 E-mail:
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13
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Boguszewski CL, Boguszewski MCDS. Growth Hormone's Links to Cancer. Endocr Rev 2019; 40:558-574. [PMID: 30500870 DOI: 10.1210/er.2018-00166] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
Several components of the GH axis are involved in tumor progression, and GH-induced intracellular signaling has been strongly associated with breast cancer susceptibility in genome-wide association studies. In the general population, high IGF-I levels and low IGF-binding protein-3 levels within the normal range are associated with the development of common malignancies, and components of the GH-IGF signaling system exhibit correlations with clinical, histopathological, and therapeutic parameters in cancer patients. Despite promising findings in preclinical studies, anticancer therapies targeting the GH-IGF signaling system have led to disappointing results in clinical trials. There is substantial evidence for some degree of protection against tumor development in several animal models and in patients with genetic defects associated with GH deficiency or resistance. In contrast, the link between GH excess and cancer risk in acromegaly patients is much less clear, and cancer screening in acromegaly has been a highly controversial issue. Recent studies have shown that increased life expectancy in acromegaly patients who attain normal GH and IGF-I levels is associated with more deaths due to age-related cancers. Replacement GH therapy in GH deficiency hypopituitary adults and short children has been shown to be safe when no other risk factors for malignancy are present. Nevertheless, the use of GH in cancer survivors and in short children with RASopathies, chromosomal breakage syndromes, or DNA-repair disorders should be carefully evaluated owing to an increased risk of recurrence, primary cancer, or second neoplasia in these individuals.
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Affiliation(s)
- Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), University Hospital, Federal University of Parana, Curitiba, Brazil
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14
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Hammarstrand C, Ragnarsson O, Bengtsson O, Bryngelsson IL, Johannsson G, Olsson DS. Comorbidities in patients with non-functioning pituitary adenoma: influence of long-term growth hormone replacement. Eur J Endocrinol 2018; 179:229-237. [PMID: 30299891 DOI: 10.1530/eje-18-0370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with hypopituitarism have an increased mortality. The aim of this study was to investigate comorbidities including cerebral infarction, type 2 diabetes mellitus (T2DM) and malignant tumors in patients with non-functioning pituitary adenomas (NFPA) with and without growth hormone replacement therapy (GHRT). METHODS Observational cohort study in patients with NFPA within the western region of Sweden. Subjects were identified through the National Patient Registry and followed between 1987 and 2014. Patient records were reviewed and standardized incidence ratios (SIRs) with 95% CIs for comorbidities were calculated. RESULTS In total, 426 patients were included, 206 with GHRT and 219 without. Median (range) follow-up time for patients with and without GHRT was 12.2 (0–24) and 8.2 (0–27) years, respectively. Mean ± s.d. BMI was 28.5 ± 4.5 and 26.5 ± 4.4 for patients with and without GHRT, respectively (P < 0.001). Incidence of cerebral infarction was increased (SIR: 1.39; 95% CI: 1.03–1.84; P = 0.032), with no difference between patients with and without GHRT. SIR for T2DM in patients not receiving GHRT was increased (1.65; 1.06–2.46; P = 0.018), whereas the incidence in patients receiving GHRT was not (0.99; 0.55–1.63; P = 0.99). The incidence of malignant tumors was not increased, either in patients with or without GHRT. CONCLUSION The incidence of cerebral infarction is increased in patients with NFPA irrespective of GHRT. Patients without GHRT had an increased risk of T2DM, whereas patients with GHRT had a normal incidence of T2DM, despite having higher BMI. Incidence of malignant tumors was not increased. Thus, long-term GHRT seems to be safe regarding risk of comorbidities.
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Affiliation(s)
- Casper Hammarstrand
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Olivia Bengtsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Ing-Liss Bryngelsson
- Department of Occupational and Environmental Medicine, Örebro University Hospital, Örebro, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Daniel S Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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15
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Tamhane S, Sfeir JG, Kittah NEN, Jasim S, Chemaitilly W, Cohen LE, Murad MH. GH Therapy in Childhood Cancer Survivors: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:2794-2801. [PMID: 29982555 DOI: 10.1210/jc.2018-01205] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 02/10/2023]
Abstract
BACKGROUND GH deficiency (GHD) is common among childhood cancer survivors (CCSs) with history of tumors, surgery, and/or radiotherapy involving the hypothalamus-pituitary region. We aimed to evaluate the effects of GH therapy (GHT) in CCSs on adult height, risk of diabetes mellitus, abnormal lipids, metabolic syndrome, quality of life, secondary tumors, and disease recurrence. METHODS We searched multiple databases for randomized and observational studies. Pairs of reviewers independently selected studies and collected data. Random effects meta-analysis was used to pool outcomes across the studies. RESULTS We included 29 observational studies at moderate to high risk of bias. Sixteen studies compared CCSs on GHT with those not on GHT (512 patients, GH dose: 0.3 to 0.9 IU/kg/week). GHT was significantly associated with height gain [standard deviation score, 0.61; 95% CI, 0.08 to 1.13] and was not significantly associated with the occurrence of secondary tumors [odds ratio (OR), 1.10; 95% CI, 0.72 to 1.67] or tumor recurrence (OR, 0.57; 95% CI, 0.31 to 1.02). Thirteen studies compared CCSs on GHT with normal age- or sex-matched controls or controls with idiopathic GHD or short stature. GHT was associated with either improved or unchanged risk of diabetes, lipid profiles, and metabolic syndrome. GHT was associated with improvements in quality of life. CONCLUSION CCSs treated with GHT gain height compared with the untreated controls. GHT may improve lipid profiles and quality of life and does not appear to increase the risk of diabetes or the development of secondary tumors, although close monitoring for such complications remains warranted due to uncertainty in the current evidence.
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Affiliation(s)
- Shrikant Tamhane
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Jad G Sfeir
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | | | - Sina Jasim
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Wassim Chemaitilly
- Department of Pediatric Medicine, Division of Endocrinology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Laurie E Cohen
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
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Stochholm K, Kiess W. Long-term safety of growth hormone-A combined registry analysis. Clin Endocrinol (Oxf) 2018; 88:515-528. [PMID: 29055168 DOI: 10.1111/cen.13502] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 10/03/2017] [Accepted: 10/17/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Preliminary data from the French cohort of the Safety and Appropriateness of Growth hormone treatments in Europe (SAGhE) study raised concerns regarding the safety of recombinant human GH, suggesting that GH may increase mortality and incidence of stroke in patients treated during childhood for GH deficiency or short stature. We evaluated published safety data, focusing on mortality, neoplasms, cerebrovascular events and diabetes across a number of large-scale pharmaceutical company GH registries. DESIGN A literature review was conducted using PubMed, EMBASE and Google Scholar to identify all relevant safety data from manufacturers' GH registries published between 1988 and April 2016. Results were hand-sorted to exclude nonrelevant publications; bibliographic references from retrieved articles were evaluated for any additional references. RESULTS The published data do not support an increased risk of mortality in children or adults treated with GH. There was no evidence of an increased risk of stroke, new malignancy, leukaemia, nonleukaemic extracranial tumours or recurrence of intracranial malignancy in patients without risk factors. The risk of a second neoplasm is increased, particularly if patients have received radiation therapy for a central nervous system tumour. There may be an increased risk of type 2 diabetes in GH-treated patients, but this appears to be confined to those with pre-existing risk factors. CONCLUSIONS Patients with risk factors for malignancy or type 2 diabetes should be treated with caution and monitored during follow-up, but current published data provide reassurance on the long-term safety profile of GH in patients receiving GH treatment.
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Affiliation(s)
- Kirstine Stochholm
- Department of Internal Medicine and Diabetes, Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Pediatrics, Center of Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Wieland Kiess
- Department of Women and Child Health, Hospital for Children and Adolescents, University Hospitals, University of Leipzig, Leipzig, Germany
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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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18
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Li Z, Zhou Q, Li Y, Fu J, Huang X, Shen L. Growth hormone replacement therapy reduces risk of cancer in adult with growth hormone deficiency: A meta-analysis. Oncotarget 2018; 7:81862-81869. [PMID: 27835910 PMCID: PMC5348436 DOI: 10.18632/oncotarget.13251] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023] Open
Abstract
The risk of growth hormone on cancer in adult with growth hormone deficiency remains unclear. We carried out a meta-analysis to evaluate the risk of cancer in adult with and without growth hormone replacement therapy. We searched PubMed, Web of Science, China National Knowledge Infrastructure, and WanFang databases up to 31 July 2016 for eligible studies. Pooled risk ratio (RR) with 95% confidence interval (CI) was calculated using fixed-or random-effects models if appropriate. The Newcastle-Ottawa Scale was used to assess the study quality. Two retrospective and seven prospective studies with a total of 11191 participants were included in the final analysis. The results from fixed-effects model showed this therapy was associated with the deceased risk of cancer in adult with growth hormone deficiency (RR=0.69, 95%CI: 0.59-0.82), with low heterogeneity within studies (I2=39.0%, P=0.108). We performed sensitivity analyses by sequentially omitting one study each time, and the pooled RRs did not materially change, indicating that our results were statistically stable. Begger's and Egger's tests suggested that there was no publication bias (Z=-0.63, P=0.520; t=0.16, P=0.874). Our study suggests that growth hormone replacement therapy could reduce risk of cancer in adult with growth hormone deficiency.
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Affiliation(s)
- Zhanzhan Li
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
| | - Qin Zhou
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
| | - Yanyan Li
- Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
| | - Jun Fu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
| | - Xinqiong Huang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
| | - Liangfang Shen
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan Province 410008, China
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Krzyzanowska-Mittermayer K, Mattsson AF, Maiter D, Feldt-Rasmussen U, Camacho-Hübner C, Luger A, Abs R. New Neoplasm During GH Replacement in Adults With Pituitary Deficiency Following Malignancy: A KIMS Analysis. J Clin Endocrinol Metab 2018; 103:523-531. [PMID: 29228199 DOI: 10.1210/jc.2017-01899] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/30/2017] [Indexed: 01/27/2023]
Abstract
CONTEXT Data on the association between growth hormone (GH) replacement in patients with GH deficiency (GHD) after malignancies and new neoplasms show conflicting results. OBJECTIVE To clarify the incidence of new malignant neoplasm in childhood-onset (CO) and adult-onset (AO) adult cancer survivors (CSs). DESIGN Retrospective comparison of CO-CS and AO-CS with CO idiopathic GHD (IGHD) and AO nonfunctioning pituitary adenoma (NFPA) patients and with the general population [standardized incidence ratio (SIR)]. SETTING Data from the Pfizer International Metabolic Database study (KIMS). PATIENTS CO-CS [n = 349; 50.4% females; mean baseline (MBL) IGF-I standard deviation score (SDS), -2.4], IGHD (n = 619; 35.7% females; MBL IGF-I SDS, -3.4), AO-CS (n = 174; 42.5% females; MBL IGF-I SDS, -1.4), and NFPA (n = 2449; 38.1% females; MBL IGF-I SDS, -1.0). MAIN OUTCOME MEASURES SIRs of malignant neoplasms. RESULTS After a median follow-up of 5.9 years (2192 patient-years), 15 CO-CS (4.3%) had developed 16 new neoplasms. The SIR was 10.4 [95% confidence interval (CI), 5.9 to 16.9] and 6.5 (95% CI, 3.0 to 12.4) after exclusion of seven patients with skin cancers. In IGHD, three malignant neoplasms (0.5%) were observed after a median follow-up of 5.4 years (3908 patient-years; SIR, 0.47; 95% CI, 0.09 to 1.37). New malignant neoplasms occurred in three AO-CS (1.7%; SIR, 1.1; 95% CI, 0.2 to 3.2) and 146 NFPA patients (153 cases, 6.0%; SIR, 1.1; 95% CI, 0.9 to 1.2) after a median follow-up of 4.9 (1024 patient-years) and 5.6 years (15,215 patient-years). CONCLUSIONS The risk of second malignant neoplasms was increased in CO-CS but not in AO-CS, which illustrates the need to closely follow patients on GH replacement because of a prior malignancy.
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Affiliation(s)
| | | | - Dominique Maiter
- UCL St Luc Hospital, Department of Endocrinology and Nutrition, Brussels, Belgium
| | - Ulla Feldt-Rasmussen
- Copenhagen University, Rigshospitalet, Department of Endocrinology, Copenhagen, Denmark
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University and General Hospital of Vienna, Vienna, Austria
| | - Roger Abs
- Antwerp Centre for Endocrinology, Antwerp, Belgium
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Shimatsu A, Ishii H, Nishinaga H, Murai O, Chihara K. Safety and effectiveness of long-term growth hormone therapy in Japanese patients with adult growth hormone deficiency: a postmarketing, multicenter, observational study. Endocr J 2017; 64:651-662. [PMID: 28529275 DOI: 10.1507/endocrj.ej16-0604] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We aimed to evaluate the long-term safety and effectiveness of growth hormone (GH) therapy in Japanese patients with adult growth hormone deficiency (AGHD). In this observational, multicenter study, Norditropin® (Novo Nordisk A/S, Bagsvaerd, Denmark) was administered as injections of 0.021 mg/kg/week as a starting dose divided into 6-7 doses/week. The dose was increased according to clinical response. Patients' data were obtained from medical records. Measurements (lipids, glucose metabolism, and body composition) taken at baseline; 3, 6, and 12 months; and yearly until the end of the study were collected. Adverse drug reactions (ADRs), serious ADRs, and serious adverse events (SAEs) were evaluated. Of 387 registered patients, 334 were eligible for safety. After GH treatment initiation, a marked decrease in total cholesterol was observed earlier in the child-onset group than in the adult-onset group. LDL-cholesterol also decreased, but no significant differences in changes in LDL-cholesterol between adult-onset and child-onset groups were found. A significant increase in HDL-cholesterol starting 1 year after GH treatment initiation was found in the adult-onset group. There was no effect of GH treatment on glucose metabolism. Because of the small number of dual-energy X-ray absorptiometry data, the overall assessment of changes of body composition was difficult. Fifty-six (16.8%), 12 (3.6%), and 35 (10.5%) patients experienced ADRs, serious ADRs, and SAEs, respectively. This study demonstrated a favorable long-term safety and effectiveness profile of GH therapy in AGHD patients in the real-life Japanese clinical practice setting.
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Affiliation(s)
- Akira Shimatsu
- National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | | | | | - Osamu Murai
- Novo Nordisk Pharma Ltd., Tokyo 100-0005, Japan
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Kann PH, Bergmann S, Stalla GK, Dimopoulou C, Weber MM, Pedersen BT, Meckes-Ferber S. Gender-, age- and time-dependent dosing of growth hormone in adults - real-world data from a decade of clinical practice in Germany. Gynecol Endocrinol 2017; 33:564-569. [PMID: 28277107 DOI: 10.1080/09513590.2017.1296130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We evaluated treatment patterns and gender-dependent dosing of growth hormone (GH) substitution in adults with GH deficiency (AGHD). Data on GH dose were collected (2003-2013) from 509 GH-treated patients (mean age: 48.9 years; 47% female) enroled in the observational German NordiWin study (NCT01543880). The impact of gender, age, treatment duration and calendar year on GH treatment patterns was evaluated by multiple regression analysis. Mean (SD) baseline GH dose (mg/day) was similar between females (0.25 [0.19] and males (0.24 [0.15]), but increased with treatment duration (at year 10, 0.55 [0.48] and 0.31 [0.09] in females and males, respectively), reflecting patient dose titration. GH dose increased more in females than males during treatment; this was statistically significant in years 2-6 (p < 0.05). Over the 10-year study period, a time trend of an overall estimated GH dose increase by 0.06 mg/day (females) and decrease by 0.07 mg/day (males) was shown; this interaction of gender and calendar year was significant (p < 0.0001). In both genders, overall GH dose decreased with increasing age (p < 0.0001). Our study confirms that females and younger patients require higher GH doses compared with males and older patients.
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Affiliation(s)
- Peter H Kann
- a Division of Endocrinology and Diabetology, Philipp's University Hospital , Marburg , Germany
| | - Simona Bergmann
- a Division of Endocrinology and Diabetology, Philipp's University Hospital , Marburg , Germany
| | - Günter K Stalla
- b Department of Neuroendocrinology, Max-Planck-Institute for Psychiatry , Munich , Germany
| | - Christina Dimopoulou
- b Department of Neuroendocrinology, Max-Planck-Institute for Psychiatry , Munich , Germany
| | - Matthias M Weber
- c Department of Endocrinology and Metabolism, Johannes Gutenberg University Hospital , Mainz , Germany
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22
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Ferone D, Profka E, Gasco V, Ambrosio MR, Colao A, Di Somma C, Puxeddu E, Arnaldi G, Pagano C, Zecchi E, Pietropoli A, Beck-Peccoz P. Long-term safety and efficacy of Omnitrope ® in adults with growth hormone deficiency: Italian interim analysis of the PATRO Adults study. J Endocrinol Invest 2017; 40:669-678. [PMID: 28161880 PMCID: PMC5443881 DOI: 10.1007/s40618-016-0604-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/23/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the long-term effectiveness and safety of the recombinant human growth hormone Omnitrope®, a somatropin biosimilar to Genotropin®, in Italian patients with growth hormone deficiency (GHD) enrolled in the PATRO Adults study. METHODS The PATRO Adults study is an ongoing observational, longitudinal, non-interventional global post-marketing surveillance study, conducted in several European countries. The primary endpoint is long-term safety; secondary endpoints include the effectiveness of Omnitrope®, which was assessed using serum insulin-like growth factor-1 levels, body composition, bone mineral density and lipid levels. Here we report the data from the Italian patients enrolled in the study. RESULTS Sixty-seven patients (mean age 50.4 years, 61.2% male) have been enrolled and have received a mean 45.4 ± 24.3 months of Omnitrope®. A total of 55.2% of patients were reported to have experienced adverse events (AEs), including arthralgia, myalgia, abdominal distension and hypoaesthesia, and 4.5% had adverse drug reactions. Fourteen serious AEs have been recorded; none of these are considered related to the study drug. The effectiveness of Omnitrope® was similar to other available somatropin preparations. CONCLUSIONS This study confirms the effectiveness and safety of Omnitrope® in adult patients with GHD in Italy. However, due to the limited size of the study population, these results need to be further confirmed by the global PATRO Adults study.
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Affiliation(s)
- D Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research (CEBR), IRCCS AOU San Martino-IST, University of Genova, Viale Benedetto XV, 6, 16132, Genova, Italy.
| | - E Profka
- Endocrinology and Metabolic Diseases Unit, Department of Clinical Sciences and Community Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milan, Italy
| | - V Gasco
- Endocrinology, Diabetes and Metabolism, Department of Medical Science, Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - M R Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - A Colao
- Department of Clinical Medicine and Surgery, University Federico II of Napoli, Naples, Italy
| | - C Di Somma
- Institute of Diagnostic and Nuclear Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico SDN, Naples, Italy
| | - E Puxeddu
- Veterinary and Forensic Biotechnological Sciences Department of Medicine Section, Internal Medicine, Endocrine and Metabolic Sciences, University of Perugia, Perugia, Italy
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - C Pagano
- Department of Medicine, Internal Medicine 3, University of Padova, Padua, Italy
| | - E Zecchi
- Sandoz S.p.A., Origgio, VA, Italy
| | | | - P Beck-Peccoz
- Endocrinology and Diabetology Unit, Medical Sciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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23
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Subramani R, Nandy SB, Pedroza DA, Lakshmanaswamy R. Role of Growth Hormone in Breast Cancer. Endocrinology 2017; 158:1543-1555. [PMID: 28379395 DOI: 10.1210/en.2016-1928] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/28/2017] [Indexed: 12/19/2022]
Abstract
Breast cancer is one of the most common cancers diagnosed in women. Approximately two-thirds of all breast cancers diagnosed are classified as hormone dependent, which indicates that hormones are the key factors that drive the growth of these breast cancers. Ovarian and pituitary hormones play a major role in the growth and development of normal mammary glands and breast cancer. In particular, the effect of the ovarian hormone estrogen has received much attention in regard to breast cancer. Pituitary hormones prolactin and growth hormone have also been associated with breast cancer. Although the role of these pituitary hormones in breast cancers has been studied, it has not been investigated extensively. In this review, we attempt to compile basic information from most of the currently available literature to understand and demonstrate the significance of growth hormone in breast cancer. Based on the available literature, it is clear that growth hormone plays a significant role in the development, progression, and metastasis of breast cancer by influencing tumor angiogenesis, stemness, and chemoresistance.
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Affiliation(s)
- Ramadevi Subramani
- Center of Emphasis in Cancer Research, Department of Biomedical Sciences MSB1, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas 79905
| | - Sushmita B Nandy
- Center of Emphasis in Cancer Research, Department of Biomedical Sciences MSB1, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas 79905
| | - Diego A Pedroza
- Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center El Paso, El Paso, Texas 79905
| | - Rajkumar Lakshmanaswamy
- Center of Emphasis in Cancer Research, Department of Biomedical Sciences MSB1, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas 79905
- Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center El Paso, El Paso, Texas 79905
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24
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Swerdlow AJ, Cooke R, Beckers D, Borgström B, Butler G, Carel JC, Cianfarani S, Clayton P, Coste J, Deodati A, Ecosse E, Gausche R, Giacomozzi C, Hokken-Koelega ACS, Khan AJ, Kiess W, Kuehni CE, Mullis PE, Pfaffle R, Sävendahl L, Sommer G, Thomas M, Tidblad A, Tollerfield S, Van Eycken L, Zandwijken GRJ. Cancer Risks in Patients Treated With Growth Hormone in Childhood: The SAGhE European Cohort Study. J Clin Endocrinol Metab 2017; 102:1661-1672. [PMID: 28187225 PMCID: PMC6061931 DOI: 10.1210/jc.2016-2046] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/26/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Growth hormone (GH) is prescribed for an increasing range of indications, but there has been concern that it might raise cancer risk. Published data are limited. OBJECTIVE To examine cancer risks in relation to GH treatment. DESIGN Cohort study. SETTING Population-based. PATIENTS Cohort of 23,984 patients treated with recombinant human GH (r-hGH) in eight European countries since this treatment was first used in 1984. Cancer expectations from country-specific national population statistics. MAIN OUTCOME MEASURES Cancer incidence and cancer mortality. RESULTS Incidence and mortality risks in the cohort were raised for several cancer sites, largely consequent on second primary malignancies in patients given r-hGH after cancer treatment. There was no clear raised risk in patients with growth failure without other major disease. Only for bone and bladder cancers was incidence significantly raised in GH-treated patients without previous cancer. Cancer risk was unrelated to duration or cumulative dose of r-hGH treatment, but for patients treated after previous cancer, cancer mortality risk increased significantly with increasing daily r-hGH dose (P trend < 0.001). Hodgkin lymphoma (HL) incidence increased significantly with longer follow-up (P trend = 0.001 for patients overall and 0.002 for patients without previous cancer). CONCLUSIONS Our results do not generally support a carcinogenic effect of r-hGH, but the unexplained trend in cancer mortality risk in relation to GH dose in patients with previous cancer, and the indication of possible effects on bone cancer, bladder cancer, and HL risks, need further investigation.
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Affiliation(s)
- Anthony J Swerdlow
- Division of Genetics and Epidemiology, Institute of Cancer Research, London SW7 3RP, United Kingdom
- Division of Breast Cancer Research, Institute of Cancer Research, London SW7 3RP, United Kingdom
| | - Rosie Cooke
- Division of Genetics and Epidemiology, Institute of Cancer Research, London SW7 3RP, United Kingdom
| | - Dominique Beckers
- Unité d'Endocrinologie Pédiatrique, CHU NAMUR, Université Catholique de Louvain, 5530 Yvoir, Belgium
- Belgian Society for Pediatric Endocrinology and Diabetology, 1200 Brussels, Belgium
| | - Birgit Borgström
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, SE-141 86 Stockholm, Sweden
| | - Gary Butler
- University College London, Great Ormond Street Institute for Child Health, London WC1N 1EH, United Kingdom
- University College London Hospitals, National Health Service Foundation Trust, London NW1 2PG, United Kingdom
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Robert-Debré, Department of Pediatric Endocrinology and Diabetology, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France
- PROTECT, Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris Diderot, Sorbonne Paris Cité, F-75019 Paris, France
| | - Stefano Cianfarani
- Dipartimento Pediatrico Universitario Ospedaliero "Bambino Gesù" Children's Hospital-Tor Vergata University, 00165 Rome, Italy
- Department of Women's and Children's Health, Karolinska Institutet, SE-141 86 Stockholm, Sweden
| | - Peter Clayton
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, United Kingdom
- School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester M13 9PL, United Kingdom
| | - Joël Coste
- Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, 1 Parvis Notre-Dame, 75004 Paris, France
- Equipe d'accueil 4360, University Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France
| | - Annalisa Deodati
- Dipartimento Pediatrico Universitario Ospedaliero "Bambino Gesù" Children's Hospital-Tor Vergata University, 00165 Rome, Italy
| | - Emmanuel Ecosse
- Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, 1 Parvis Notre-Dame, 75004 Paris, France
- Equipe d'accueil 4360, University Paris Descartes, Sorbonne Paris Cité, 75005 Paris, France
| | - Ruth Gausche
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Liebigstr. 20a, D-04103 Leipzig, Germany
| | - Claudio Giacomozzi
- Centre for Pediatric Endocrinology and Diabetes, Pediatric Unit, Carlo Poma Hospital, 46100 Mantua, Italy
| | - Anita C S Hokken-Koelega
- Dutch Growth Research Foundation, Westzeedijk 106, 3016 AH Rotterdam, The Netherlands
- Department of Pediatrics, Subdivision of Endocrinology, Erasmus Medical Center/Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Aysha J Khan
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, United Kingdom
- School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester M13 9PL, United Kingdom
| | - Wieland Kiess
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Liebigstr. 20a, D-04103 Leipzig, Germany
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - Primus-E Mullis
- Division of Paediatric Endocrinology, Diabetology and Metabolism, University Children's Hospital Bern, Inselspital, 3010 Bern, Switzerland
| | - Roland Pfaffle
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Liebigstr. 20a, D-04103 Leipzig, Germany
| | - Lars Sävendahl
- Department of Women's and Children's Health, Karolinska Institutet, SE-141 86 Stockholm, Sweden
| | - Grit Sommer
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| | - Muriel Thomas
- Belgian Society for Pediatric Endocrinology and Diabetology, 1200 Brussels, Belgium
| | - Anders Tidblad
- Department of Women's and Children's Health, Karolinska Institutet, SE-141 86 Stockholm, Sweden
| | - Sally Tollerfield
- University College London, Great Ormond Street Institute for Child Health, London WC1N 1EH, United Kingdom
| | - Liesbet Van Eycken
- Belgian Cancer Registry, Department Research, Koningsstraat 215, Box 7-B-1210 Brussels, Belgium
| | - Gladys R J Zandwijken
- Dutch Growth Research Foundation, Westzeedijk 106, 3016 AH Rotterdam, The Netherlands
- Department of Pediatrics, Subdivision of Endocrinology, Erasmus Medical Center/Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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25
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Olsson DS, Hammarstrand C, Bryngelsson IL, Nilsson AG, Andersson E, Johannsson G, Ragnarsson O. Incidence of malignant tumours in patients with a non-functioning pituitary adenoma. Endocr Relat Cancer 2017; 24:227-235. [PMID: 28274953 DOI: 10.1530/erc-16-0518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 03/08/2017] [Indexed: 11/08/2022]
Abstract
Whether patients with non-functioning pituitary adenoma (NFPA) are at increased risk of developing malignant tumours has been sparsely studied and is a matter of debate. In this study, we have investigated the incidence of malignant tumours in a large and unselected group of patients with NFPA. The study was nationwide and included all patients diagnosed with NFPA between 1987 and 2011 (n = 2795) in Sweden, identified in the National Patient Register. Malignant tumours, occurring after the NFPA diagnosis, were identified in the Swedish Cancer Register between 1987 and 2014. Standardised incidence ratios (SIRs) for malignant tumours with 95% confidence intervals (CI) were calculated using the Swedish population as reference. In total, 448 malignant tumours were detected in 386 patients with NFPA, as compared to 368 expected malignancies in the general population (SIR 1.22 (95% CI 1.11-1.33)). The incidence of neoplasms of the brain was increased (SIR 5.83 (95% CI 4.03-8.14)). When analysing the total incidence of malignancies excluding neoplasms of the brain, the overall SIR was still increased (SIR 1.14 (95% CI 1.03-1.26)). The incidence of malignant neoplasm of skin other than malignant melanoma (SIR 1.99 (95% CI 1.55-2.52)) and malignant melanoma (SIR 1.62 (95% CI 1.04-2.38)) were increased, whereas the incidence of breast cancer (SIR 0.65 (95% CI 0.42-0.97)) was decreased. The incidence of other types of malignancies did not differ significantly from the expected incidence in the general population. In conclusion, patients with NFPA have an increased overall risk of developing malignancies. To what extent these findings are due to more frequent medical surveillance, genetic predisposition or endocrine changes, remains unknown.
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Affiliation(s)
- Daniel S Olsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Casper Hammarstrand
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ing-Liss Bryngelsson
- Department of Occupational and Environmental MedicineÖrebro University Hospital, Örebro, Sweden
| | - Anna G Nilsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Andersson
- Department of Occupational and Environmental MedicineInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
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26
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Gasco V, Caputo M, Lanfranco F, Ghigo E, Grottoli S. Management of GH treatment in adult GH deficiency. Best Pract Res Clin Endocrinol Metab 2017; 31:13-24. [PMID: 28477728 DOI: 10.1016/j.beem.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Growth hormone (GH) replacement therapy in adults with GH deficiency is still a challenge for the clinical endocrinologist and its implementation has still numerous difficulties and uncertainties. The decision to treat GH deficient adults requires a thoughtful and individualized evaluation of risks and benefits. Benefits have been found in body composition, bone health, cardiovascular risk factors, and quality of life. However, evidences for a reduction in cardiovascular events and mortality are still lacking, and treatment costs remain high. It is advisable to start treatment with low doses of GH, the goals being an appropriate clinical response, an avoidance of side effects, and IGF-I levels in the age-adjusted reference range. Although treatment appears to be overall safe, certain areas continue to require long-term surveillance, such as risks of glucose intolerance, pituitary/hypothalamic tumor recurrence, and cancer.
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Affiliation(s)
- Valentina Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy.
| | - Marina Caputo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Fabio Lanfranco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
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27
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Abstract
Growth hormone (GH) replacement in GH deficient (GHD) children secures normal linear growth, while in GHD adults it improves metabolic status, body composition and quality of life. Safety of GH treatment is an important issue in particular concerning the controversy of potential cancer risk. Unlike in congenital IGF-1 deficiency, there is no complete protection against cancer in GHD patients. Important modifiable risk factors in GHD patients are obesity, insulin resistance, sedentary behavior, circadian rhythm disruption, chronic low grade inflammation and concomitant sex hormone replacement. Age, family history, hereditary cancer predisposition syndromes or cranial irradiation may present non-modifiable risk factors. Quantifying the risk of cancer in relation to GH therapy in adult GHD patients is complex. There is evidence that links GH to cancer occurrence or promotion, but the evidence is progressively weaker when moving from in vitro studies to in vivo animal studies to epidemiological studies and finally to studies on GH treated patients. GH-IGF inhibition in experimental animals leads to decreased cancer incidence and progression. Epidemiological studies suggest an association of high normal circulating IGF-1 or GH to cancer incidence in general population. Data regarding cancer incidence in acromegaly are inconsistent but thyroid and colorectal neoplasias are the main source of concern. Replacement therapy with rhGH for GHD is generally safe. Overall the rate of de novo cancers was not increased in studies of GH-treated GHD patients. Additional caution is mandated in patients with history of cancer, strong family history of cancer and with advancing age. Childhood cancer survivors may be at increased risk for secondary neoplasms compared with general population. In this subgroup GH therapy should be used cautiously and with respect to other risk factors (cranial irradiation etc). We believe that the benefits of GH therapy against the morbidity of untreated GH deficiency outweigh the theoretical cancer risk. Proper monitoring of GH treatment with diligent cancer surveillance remains essential.
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Affiliation(s)
- Sandra Pekic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Marko Stojanovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Vera Popovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia.
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28
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Abstract
Hypopituitarism refers to deficiency of one or more hormones produced by the anterior pituitary or released from the posterior pituitary. Hypopituitarism is associated with excess mortality, a key risk factor being cortisol deficiency due to adrenocorticotropic hormone (ACTH) deficiency. Onset can be acute or insidious, and the most common cause in adulthood is a pituitary adenoma, or treatment with pituitary surgery or radiotherapy. Hypopituitarism is diagnosed based on baseline blood sampling for thyroid stimulating hormone, gonadotropin, and prolactin deficiencies, whereas for ACTH, growth hormone, and antidiuretic hormone deficiency dynamic stimulation tests are usually needed. Repeated pituitary function assessment at regular intervals is needed for diagnosis of the predictable but slowly evolving forms of hypopituitarism. Replacement treatment exists in the form of thyroxine, hydrocortisone, sex steroids, growth hormone, and desmopressin. If onset is acute, cortisol deficiency should be replaced first. Modifications in replacement treatment are needed during the transition from paediatric to adult endocrine care, and during pregnancy.
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Affiliation(s)
- Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephen M Shalet
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, UK; Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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29
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Sävendahl L, Pournara E, Pedersen BT, Blankenstein O. Is safety of childhood growth hormone therapy related to dose? Data from a large observational study. Eur J Endocrinol 2016; 174:681-91. [PMID: 26903552 DOI: 10.1530/eje-15-1017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/22/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Concerns have been raised of increased mortality risk in adulthood in certain patients who received growth hormone treatment during childhood. This study evaluated the safety of growth hormone treatment in childhood in everyday practice. DESIGN NordiNet(®) International Outcome Study (IOS) is a noninterventional, observational study evaluating safety and effectiveness of Norditropin(®) (somatropin; Novo Nordisk A/S, Bagsvaerd, Denmark). METHODS Long-term safety data (1998-2013) were collected on 13 834 growth hormone treated pediatric patients with short stature. Incidence rates (IRs) of adverse events (AEs) defined as adverse drug reactions (ADRs), serious ADRs (SADRs), and serious AEs (SAEs) were calculated by mortality risk group (low/intermediate/high). The effect of growth hormone dose on IRs and the occurrence of cerebrovascular AEs were investigated by the risk group. RESULTS We found that 61.0% of patients were classified as low-risk, 33.9% intermediate-risk, and 5.1% high-risk. Three hundred and two AEs were reported in 261 (1.9%) patients during a mean (s.d.) treatment duration of 3.9 (2.8) years. IRs were significantly higher in the high- vs the low-risk group (high risk vs low risk-ADR: 9.11 vs 3.14; SAE: 13.66 vs 1.85; SADR: 4.97 vs 0.73 events/1000 patient-years of exposure; P < 0.0001 for all). Except for SAEs in the intermediate-risk group (P = 0.0486) in which an inverse relationship was observed, no association between IRs and growth hormone dose was found. No cerebrovascular events were reported. CONCLUSIONS We conclude that safety data from NordiNet(®) IOS do not reveal any new safety signals and confirm a favorable overall safety profile in accordance with other pediatric observational studies. No association between growth hormone dose and the incidence of AEs during growth hormone treatment in childhood was found.
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Affiliation(s)
- Lars Sävendahl
- Department of Women's and Children's HealthKarolinska Institutet and Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Effie Pournara
- Global Medical AffairsNovo Nordisk Health Care AG, 8050 Zurich, Switzerland
| | | | - Oliver Blankenstein
- Institute for Experimental Pediatric EndocrinologyCharité-University Medicine Berlin, 13353 Berlin, Germany
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30
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Yuen KCJ, Heaney AP, Popovic V. Considering GH replacement for GH-deficient adults with a previous history of cancer: a conundrum for the clinician. Endocrine 2016; 52:194-205. [PMID: 26732039 DOI: 10.1007/s12020-015-0840-2] [Citation(s) in RCA: 8] [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] [Received: 10/05/2015] [Accepted: 12/18/2015] [Indexed: 11/30/2022]
Abstract
Previous studies have shown that GH and IGF-I may enhance tumorigenesis, metastasis, and cell proliferation in humans and animals. Evidence supporting this notion is derived from animal model studies, epidemiological studies, experience from patients with acromegaly, molecular therapeutic manipulation of GH and IGF-I actions, and individuals with GH receptor and congenital IGF-I deficiencies. Prior exposure to radiation therapy, aging, family history of cancer, and individual susceptibility may also contribute to increase this risk. Therefore, the use of GH replacement in patients with a history of cancer raises hypothetical safety concerns for patients, caregivers, and providers. Studies of GH therapy in GH-deficient adults with hypopituitarism and childhood cancer survivors have not convincingly demonstrated an increased cancer risk. Conversely, the risk of occurrence of a second neoplasm (SN) in childhood cancer survivors may be increased, with meningiomas being the most common tumor; however, this risk appears to decline over time. In light of these findings, if GH replacement is to be considered in patients with a previous history of cancer, we propose this consideration to be based on each individual circumstance and that such therapy should only be initiated at least 2 years after cancer remission is achieved with the understanding that in some patients (particularly those with childhood cancers), GH may potentially increase the risk of SNs. In addition, close surveillance should be undertaken working closely with the patient's oncologist. More long-term data are thus needed to determine if GH replacement in GH-deficient adults with a history of cancer is associated with the development of de novo tumors and tumor recurrence.
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Affiliation(s)
- Kevin C J Yuen
- Department of Neurosurgery and Neurology, Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90073, USA
| | - Vera Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disease, University Clinical Center Belgrade, Faculty of Medicine, University of Belgrade, Dr Subotica 13, 11000, Belgrade, Serbia
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Growth Hormone Protects the Intestine Preserving Radiotherapy Efficacy on Tumors: A Short-Term Study. PLoS One 2015; 10:e0144537. [PMID: 26670463 PMCID: PMC4682900 DOI: 10.1371/journal.pone.0144537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
The efficacy of radiotherapy on tumors is hampered by its devastating adverse effects on healthy tissue, particularly that of the gastrointestinal tract. These effects cause acute symptoms that are so disruptive to patients that they can lead to interruption of the radiotherapy program. These adverse effects could limit the intensity of radiation received by the patient, resulting in a sublethal dose to the tumor, thus increasing the risk of tumor resistance. The lack of an effective treatment to protect the bowel during radiation therapy to allow higher radiation doses that are lethal to the tumor has become a barrier to implementing effective therapy. In this study, we present a comparative analysis of both intestinal and tumor tissue in regard to the efficacy and the preventive impact of a short-term growth hormone (GH) treatment in tumor-bearing rats as a protective agent during radiotherapy. Our data show that the exogenous administration of GH improved intestinal recovery after radiation treatment while preserving the therapeutic effect against the tumor. GH significantly increased proliferation in the irradiated intestine but not in the irradiated tumors, as assessed by Positron Emission Tomography and the proliferative markers Ki67, cyclin D3, and Proliferating Cell Nuclear Antigen. This proliferative effect was consistent with a significant increase in irradiated intestinal villi and crypt length. Furthermore, GH significantly decreased caspase-3 activity in the intestine, whereas GH did not produce this effect in the irradiated tumors. In conclusion, short-term GH treatment protects the bowel, inducing proliferation while reducing apoptosis in healthy intestinal tissue and preserving radiotherapy efficacy on tumors.
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Swerdlow AJ, Cooke R, Albertsson-Wikland K, Borgström B, Butler G, Cianfarani S, Clayton P, Coste J, Deodati A, Ecosse E, Gausche R, Giacomozzi C, Kiess W, Hokken-Koelega AC, Kuehni CE, Landier F, Maes M, Mullis PE, Pfaffle R, Sävendahl L, Sommer G, Thomas M, Tollerfield S, Zandwijken GR, Carel JC. Description of the SAGhE Cohort: A Large European Study of Mortality and Cancer Incidence Risks after Childhood Treatment with Recombinant Growth Hormone. Horm Res Paediatr 2015; 84:172-83. [PMID: 26227295 PMCID: PMC4611066 DOI: 10.1159/000435856] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/09/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The long-term safety of growth hormone treatment is uncertain. Raised risks of death and certain cancers have been reported inconsistently, based on limited data or short-term follow-up by pharmaceutical companies. PATIENTS AND METHODS The SAGhE (Safety and Appropriateness of Growth Hormone Treatments in Europe) study assembled cohorts of patients treated in childhood with recombinant human growth hormone (r-hGH) in 8 European countries since the first use of this treatment in 1984 and followed them for cause-specific mortality and cancer incidence. Expected rates were obtained from national and local general population data. The cohort consisted of 24,232 patients, most commonly treated for isolated growth failure (53%), Turner syndrome (13%) and growth hormone deficiency linked to neoplasia (12%). This paper describes in detail the study design, methods and data collection and discusses the strengths, biases and weaknesses consequent on this. CONCLUSION The SAGhE cohort is the largest and longest follow-up cohort study of growth hormone-treated patients with follow-up and analysis independent of industry. It forms a major resource for investigating cancer and mortality risks in r-hGH patients. The interpretation of SAGhE results, however, will need to take account of the methods of cohort assembly and follow-up in each country.
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Affiliation(s)
- Anthony J Swerdlow
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK,Division of Breast Cancer Research, Institute of Cancer Research, London, UK,*Prof. Anthony J. Swerdlow, DSc, Division of Genetics and Epidemiology, Institute of Cancer Research, Sir Richard Doll Building, Sutton, Surrey SM2 5NG (UK), E-Mail
| | - Rosi Cooke
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Kersti Albertsson-Wikland
- Institute of Neuroscience, Department of Physiology/Endocrinology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Birgi Borgström
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Gar Butler
- UCL Institute of Child Health, London, UK,University College London Hospitals NHS Foundation Trust, London, UK
| | - Stefan Cianfarani
- Dipartimento Pediatrico Universitario Ospedaliero ‘Bambino Gesù’ Children's Hospital, Tor Vergata University, Rome, Italy,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Pete Clayton
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK,Centre for Paediatrics and Child Health, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Joë Coste
- Biostatistics and Epidemiology Unit, and Approches Psychologiques et Epidémiologiques des Maladies Chroniques Equipe d'Accueil, Paris, France,Groupe Hospitalier Cochin-Saint Vincent de Paul and University Paris Descartes, Paris, France
| | - Annalis Deodati
- Dipartimento Pediatrico Universitario Ospedaliero ‘Bambino Gesù’ Children's Hospital, Tor Vergata University, Rome, Italy
| | - Emmanue Ecosse
- Biostatistics and Epidemiology Unit, and Approches Psychologiques et Epidémiologiques des Maladies Chroniques Equipe d'Accueil, Paris, France,Groupe Hospitalier Cochin-Saint Vincent de Paul and University Paris Descartes, Paris, France
| | - Rut Gausche
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Claudi Giacomozzi
- Dipartimento di Medicina Pediatrica ‘Bambino Gesù’ Children's Hospital, Rome, Italy
| | - Wielan Kiess
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Anita C.S Hokken-Koelega
- Dutch Growth Research Foundation, Rotterdam, The Netherlands,Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Fabienn Landier
- University Paris Diderot, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris,Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris,Institut National de la Santé et de la Recherche Médicale Unité CIE-5, Paris, France
| | - Mar Maes
- Division of Pediatric Endocrinology, Department of Pediatrics, Cliniques Universitaires St. Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Primus-E Mullis
- Division of Paediatric Endocrinology, Diabetology and Metabolism, University Children's Hospital Bern, Inselspital, Bern, Switzerland
| | - Rolan Pfaffle
- Hospital for Children and Adolescents and Centre of Pediatric Research, University of Leipzig, Leipzig, Germany
| | - Lar Sävendahl
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gri Sommer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Murie Thomas
- Belgian Study Group for Pediatric Endocrinology (BSGPE), Brussels, Belgium
| | | | | | - Jean-Claud Carel
- University Paris Diderot, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris,Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris,Institut National de la Santé et de la Recherche Médicale Unité CIE-5, Paris, France
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Stochholm K, Johannsson G. Reviewing the safety of GH replacement therapy in adults. Growth Horm IGF Res 2015; 25:149-157. [PMID: 26117668 DOI: 10.1016/j.ghir.2015.06.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 02/04/2023]
Abstract
CONTEXT Systematic data on safety of growth hormone (GH) replacement therapy in adult GH deficiency is lacking. OBJECTIVE To systematically describe safety of adult GH replacement therapy on glucose metabolism and long term safety. DESIGN A systematic web-based search of PubMed was performed guided by the Standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). OUTCOME Randomised controlled trials of ≥3 months and open trials for ≥12 months with more than 50 adult patients (50 patient years, prospective and retrospective) including adverse event reporting as well as articles on mortality primarily on adult onset patients, reporting mortality ratios on GH treated patients, were included for the review. RESULTS Based on the defined selection criteria 94 studies were included. The short-term early placebo controlled trials did not demonstrate an increased frequency of diabetes mellitus (DM) and the long-term open studies did not consistently show an increased incidence of DM during GH replacement. The concern that long-term GH replacement might increase the risk of primary cancer, secondary neoplasia after tumour treatment and recurrence of previous tumours was not evident in the study data. CONCLUSION Based on available data, short- and long-term adult GH replacement in patients with severe GH deficiency and hypopituitarism is safe. However, the small number of subjects, limitation of long-term of GH treatment data and absence of an adequate control population is still a limitation for the interpretation of these data.
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Affiliation(s)
- Kirstine Stochholm
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, 8000, Aarhus C, Denmark
| | - Gudmundur Johannsson
- Department of Endocrinology, Grstr 8, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden; Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Göteborg, Grstr 8, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden
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34
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Child CJ, Conroy D, Zimmermann AG, Woodmansee WW, Erfurth EM, Robison LL. Incidence of primary cancers and intracranial tumour recurrences in GH-treated and untreated adult hypopituitary patients: analyses from the Hypopituitary Control and Complications Study. Eur J Endocrinol 2015; 172:779-90. [PMID: 25810462 DOI: 10.1530/eje-14-1123] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/25/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Speculation remains that GH treatment is associated with increased neoplasia risk. Studies in GH-treated childhood cancer survivors suggested higher rates of second neoplasms, while cancer risk data for GH-treated and untreated hypopituitary adults have been variable. We present primary cancer risk data from the Hypopituitary Control and Complications Study (HypoCCS) with a focus on specific cancers, and assessment of recurrence rates for pituitary adenomas (PA) and craniopharyngiomas (CP). DESIGN Incident neoplasms during HypoCCS were evaluated in 8418 GH-treated vs 1268 untreated patients for primary malignancies, 3668 GH-treated vs 720 untreated patients with PA history, and 956 GH-treated vs 102 untreated patients with CP history. METHODS Using population cancer rates, standardised incidence ratios (SIRs) were calculated for all primary cancers, breast, prostate, and colorectal cancers. Neoplasm rates in GH-treated vs untreated patients were analysed after propensity score adjustment of baseline treatment group imbalances. RESULTS During mean follow-up of 4.8 years, 225 primary cancers were identified in GH-treated patients, with SIR of 0.82 (95% CI 0.71-0.93). SIRs (95% CI) for GH-treated patients were 0.59 (0.36-0.90) for breast, 0.80 (0.57-1.10) for prostate, and 0.62 (0.38-0.96) for colorectal cancers. Cancer risk was not statistically different between GH-treated and untreated patients (relative risk (RR)=1.00 (95% CI 0.70-1.41), P=0.98). Adjusted RR for recurrence was 0.91 (0.68-1.22), P=0.53 for PA and 1.32 (0.53-3.31), P=0.55 for CP. CONCLUSIONS There was no increased risk for all-site cancers: breast, prostate or colorectal primary cancers in GH-treated patients during HypoCCS. GH treatment did not increase the risk of PA and CP recurrences.
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Affiliation(s)
- Christopher J Child
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
| | - Daniel Conroy
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
| | - Alan G Zimmermann
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
| | - Whitney W Woodmansee
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
| | - Eva Marie Erfurth
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
| | - Leslie L Robison
- Lilly Research LaboratoriesErl Wood Manor, Windlesham, Surrey GU20 6PH, UKinVentiv Health ClinicalBurlington, Massachusetts 01803 USALilly Research LaboratoriesIndianapolis, Indiana 46285, USADivision of EndocrinologyDiabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USADepartment of EndocrinologySkånes University Hospital, Lund 221 85, SwedenDepartment of Epidemiology and Cancer ControlSt Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA
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Raman S, Grimberg A, Waguespack SG, Miller BS, Sklar CA, Meacham LR, Patterson BC. Risk of Neoplasia in Pediatric Patients Receiving Growth Hormone Therapy--A Report From the Pediatric Endocrine Society Drug and Therapeutics Committee. J Clin Endocrinol Metab 2015; 100:2192-203. [PMID: 25839904 PMCID: PMC5393518 DOI: 10.1210/jc.2015-1002] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT GH and IGF-1 have been shown to affect tumor growth in vitro and in some animal models. This report summarizes the available evidence on whether GH therapy in childhood is associated with an increased risk of neoplasia during treatment or after treatment is completed. EVIDENCE ACQUISITION A PubMed search conducted through February 2014 retrieved original articles written in English addressing GH therapy and neoplasia risk. Subsequent searches were done to include additional relevant publications. EVIDENCE SYNTHESIS In children without prior cancer or known risk factors for developing cancer, the clinical evidence does not affirm an association between GH therapy during childhood and neoplasia. GH therapy has not been reported to increase the risk for neoplasia in this population, although most of these data are derived from postmarketing surveillance studies lacking rigorous controls. In patients who are at higher risk for developing cancer, current evidence is insufficient to conclude whether or not GH further increases cancer risk. GH treatment of pediatric cancer survivors does not appear to increase the risk of recurrence but may increase their risk for subsequent primary neoplasms. CONCLUSIONS In children without known risk factors for malignancy, GH therapy can be safely administered without concerns about an increased risk for neoplasia. GH use in children with medical diagnoses predisposing them to the development of malignancies should be critically analyzed on an individual basis, and if chosen, appropriate surveillance for malignancies should be undertaken. GH can be used to treat GH-deficient childhood cancer survivors who are in remission with the understanding that GH therapy may increase their risk for second neoplasms.
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Affiliation(s)
- Sripriya Raman
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Adda Grimberg
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Steven G Waguespack
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Bradley S Miller
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Charles A Sklar
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Lillian R Meacham
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
| | - Briana C Patterson
- Division of Pediatric Endocrinology (S.R.), Children's Mercy Hospital, University of Missouri, Kansas City, Missouri 64111; University of Kansas Medical Center (S.R.), Kansas City, Kansas 66160; Department of Pediatrics (A.G.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104; Division of Endocrinology and Diabetes (A.G.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Department of Endocrine Neoplasia and Hormonal Disorders (S.G.W.), University of Texas MD Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (B.S.M.), Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota 55455; Memorial Sloan Kettering Cancer Center (C.A.S.), New York, New York 10065; and Emory University/Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta (L.R.M., B.C.P.), Atlanta, Georgia 30322
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Yuen KC, Popovic V. Growth hormone replacement in patients with a history of malignancy: a review of the literature and best practice for offering treatment. Expert Rev Endocrinol Metab 2015; 10:319-326. [PMID: 30298774 DOI: 10.1586/17446651.2015.996130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Previous studies have implicated the growth hormone (GH)/IGF-I axis as an important mediator of cancer risk in humans and animals. Evidence supporting this notion is derived from animal studies, epidemiological observations, patients with acromegaly and from therapeutic manipulation of GH and IGF-I actions. Therefore, the use of GH therapy in patients with a history of malignancy raises hypothetical safety concerns. Reassuringly, GH therapy in childhood cancer survivors has not been confirmed to increase the cancer risk. Conversely, the risk of occurrence of a second neoplasm may be increased, with meningiomas being the most common tumor. In light of these findings, we propose considering GH therapy to be based on each individual's circumstance and commenced at least 2 years after cancer remission is achieved with close monitoring during therapy. More long-term data are needed on the safety of GH replacement therapy in GH-deficient adults with a history of malignancy.
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Affiliation(s)
- Kevin Cj Yuen
- a 1 Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA 98122, USA
| | - Vera Popovic
- b 2 Faculty of Medicine, University of Belgrade and Clinic for Endocrinology, Diabetes and Metabolic Disease, University Clinical Center Belgrade, Dr Subotica 13, 11000 Belgrade, Serbia
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37
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Mo D, Hardin DS, Erfurth EM, Melmed S. Adult mortality or morbidity is not increased in childhood-onset growth hormone deficient patients who received pediatric GH treatment: an analysis of the Hypopituitary Control and Complications Study (HypoCCS). Pituitary 2014; 17:477-85. [PMID: 24122237 PMCID: PMC4159575 DOI: 10.1007/s11102-013-0529-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The French Safety and Appropriateness of Growth Hormone treatments in Europe (SAGhE) cohort has raised concern of increased mortality risk during follow-up into adulthood in certain patients who had received growth hormone (GH) treatment during childhood. The Hypopituitary Control and Complications Study monitored mortality and morbidity of adult GH-deficient patients including those with childhood-onset GH deficiency (COGHD) who received GH treatment as children. PURPOSE Evaluate risk of mortality, cancer, myocardial infarction (MI) and stroke in a prospective observational study. METHODS COGHD patients [n = 1,204, including 389 diagnosed with idiopathic COGHD (ICOGHD)] had received pediatric GH treatment. Standardized mortality ratios (SMRs), and cancer standardized incidence ratios (SIRs) in patients without a prior cancer were estimated relative to reference populations. Crude incidence rates were estimated for MI and stroke. RESULTS No increased mortality or cancer incidence was observed, as compared with reference populations, during a follow-up of 3.7 ± 3.3 years (mean ± SD). The overall SMR for COGHD was 1.14 [95 % confidence interval (CI) 0.55-2.10], and for ICOGHD, 0.33 (0.01-1.84). The overall cancer SIR for COGHD was 0.27 (0.01-1.50), and for ICOGHD, 0.00 (0.00-2.45). No incident case of MI was reported. The crude stroke incidence rate [181.3 per 100,000 person-years] in COGHD patients was consistent with the rates reported in reference populations. No incident case of stroke was identified in ICOGHD patients who are presumed to have no increased stroke risk factors. CONCLUSIONS The results indicate no increased risk of mortality or incidence of cancer, stroke, or MI in adult GH-deficient patients who had previously received pediatric GH treatment.
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Affiliation(s)
- Daojun Mo
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285 USA
| | - Dana Sue Hardin
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285 USA
| | - Eva Marie Erfurth
- Department of Endocrinology, Skånes University Hospital, Lund, Sweden
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
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Deodati A, Ferroli BB, Cianfarani S. Association between growth hormone therapy and mortality, cancer and cardiovascular risk: systematic review and meta-analysis. Growth Horm IGF Res 2014; 24:105-111. [PMID: 24818783 DOI: 10.1016/j.ghir.2014.02.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/23/2014] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The potential involvement of growth hormone therapy in tumor promotion and progression has been of concern for several decades. Our aim was to assess systematically the association between growth hormone therapy and all-cause, cancer and cardiovascular mortality, cancer morbidity and risk of second neoplasm mainly in patients treated during childhood and adolescence. DESIGN A systematic review of all articles published until September 2013 was carried out. The primary efficacy outcome measures were the all-cause, cancer and cardiovascular standardized mortality ratios (SMR). The secondary efficacy outcome measures were the standardized incidence ratio (SIR) for cancer and the relative risk (RR) for second neoplasms. The global effect size was calculated by pooling the data. When the effect size was significant in a fixed model we repeated the analyses using a random model. RESULTS The overall all-cause SMR was 1.19 (95% CI 1.08-1.32, p<0.001). Malignancy and cardiovascular SMRs were not significantly increased. Both the overall cancer SIR 2.74 (95% CI 1.18-5.41), and RR for second neoplasms 1.99 (95% CI 1.28-3.08, p=0.002), were significantly increased. CONCLUSION The results of this meta-analysis may raise concern on the long-term safety of GH treatment. However, several confounders and biases may affect the analysis. Independent, long-term, well-designed studies are needed to properly address the issue of GH therapy safety.
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Affiliation(s)
- Annalisa Deodati
- D.P.U.O. "Bambino Gesù" Children's Hospital - "Tor Vergata" University, Rome, Italy
| | | | - Stefano Cianfarani
- D.P.U.O. "Bambino Gesù" Children's Hospital - "Tor Vergata" University, Rome, Italy; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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van Bunderen CC, van Varsseveld NC, Erfurth EM, Ket JCF, Drent ML. Efficacy and safety of growth hormone treatment in adults with growth hormone deficiency: a systematic review of studies on morbidity. Clin Endocrinol (Oxf) 2014; 81:1-14. [PMID: 24750271 DOI: 10.1111/cen.12477] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/19/2014] [Accepted: 04/15/2014] [Indexed: 11/27/2022]
Abstract
Due to the positive effects demonstrated in randomized clinical trials on cardiovascular surrogate markers and bone metabolism, a positive effect of growth hormone (GH) treatment on clinically relevant end-points seems feasible. In this review, we discuss the long-term efficacy and safety of GH treatment in adult patients with growth hormone deficiency (GHD) with emphasis on morbidity: fatal and nonfatal cardiovascular disease (CVD) and stroke, fractures, fatal and nonfatal malignancies and recurrences, and diabetes mellitus. A positive effect of GH treatment on CVD and fracture risk could be concluded, but study design limitations have to be considered. Stroke and secondary brain tumours remained more prevalent. However, other contributing factors have to be taken into account. Regrowth and recurrences of (peri)pituitary tumours were not increased in patients with GH treatment compared to similar patients without GH treatment. All fatal and nonfatal malignancies were not more prevalent in GH-treated adults compared to the general population. However, follow-up time is still relatively short. The studies on diabetes are difficult to interpret, and more evidence is awaited. In clinical practice, a more individualized assessment seems appropriate, taking into consideration the underlying diagnosis of GHD, other treatment regimens, metabolic profile and the additional beneficial effects of GH set against the possible risks. Large and thoroughly conducted observational studies are needed and seem the only feasible way to inform the ongoing debate on health care costs, drug safety and clinical outcomes.
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Affiliation(s)
- Christa C van Bunderen
- Section of Endocrinology, Department of Internal Medicine, Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Díez JJ, Cordido F. [Benefits and risks of growth hormone in adults with growth hormone deficiency]. Med Clin (Barc) 2014; 143:354-9. [PMID: 24485161 DOI: 10.1016/j.medcli.2013.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/31/2013] [Accepted: 11/14/2013] [Indexed: 11/17/2022]
Abstract
Adult growth hormone (GH) deficiency is a well-recognized clinical syndrome with adverse health consequences. Many of these may improve after replacement therapy with recombinant GH. This treatment induces an increase in lean body mass and a decrease in fat mass. In long-term studies, bone mineral density increases and muscle strength improves. Health-related quality of life tends to increase after treatment with GH. Lipid profile and markers of cardiovascular risk also improve with therapy. Nevertheless, GH replacement therapy is not without risk. According to some studies, GH increases blood glucose, body mass index and waist circumference and may promote long-term development of diabetes and metabolic syndrome. Risk of neoplasia does not appear to be increased in adults treated with GH, but there are some high-risk subgroups. Methodological shortcomings and difficulties inherent to long-term studies prevent definitive conclusions about the relationship between GH and survival. Therefore, research in this field should remain active.
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Affiliation(s)
- Juan J Díez
- Servicio de Endocrinología, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España.
| | - Fernando Cordido
- Servicio de Endocrinología, Complejo Hospitalario Universitario de A Coruña, Departamento de Medicina, Universidad de A Coruña, A Coruña, España
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Abstract
It has been difficult to identify factors that affect the risk of cancer, but we know that people are at higher risk as they get older, or if they have a strong family history of cancer. The potential influence of environmental and behavioral factors remains poorly understood. Early population-based and case-control studies suggested that higher serum levels of IGF1 could be associated with increased cancer risk. Since GH therapy increases IGF1 levels, concern has been raised regarding its potential role as a cancer initiation factor. Experimental evidence and some clinical studies showed that when GH/IGF1 secretion or action was inhibited, a decreased incidence and rate of progression of cancers occurred. However, human populations comprise a garden variety of genotypes that respond differently to the same kind of exposures. Human population studies frequently reveal only very small effects to these exposures. So, are GH and cancer guilty by association? After more than 20 years, leukemia, a major safety issue initially believed associated with GH treatment in children with GH deficiency (GHD), has not been confirmed but the risk of second malignancies in patients previously treated with irradiation has been detected or confirmed through the National Cooperative Growth Study. Overall, this large study confirmed the favorable overall safety profile of GH therapy in children with GHD, and also highlighted specific populations at potential risk. The risk of secondary malignancy following radiotherapy is surely related to radiotherapy more than GH therapy that may increase growth but is less likely to start the oncogenic process. In GH-deficient adults treated with GH, observational studies (KIMS, HypoCCS) have shown that when IGF1 levels were targeted within normal age-related reference ranges, the occurrence of malignancies was not higher than in the general population.
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Affiliation(s)
- Sandra Pekic
- Faculty of Medicine, University of Belgrade and Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade,
Dr Subotica 13, 11000 Belgrade, Serbia
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Abstract
The availability of synthetic recombinant human growth hormone (GH) in potentially unlimited quantities since the 1980s has improved understanding of the many nonstatural effects of GH on metabolism, body composition, physical and psychological function, as well as the consequences of GH deficiency in adult life. Adult GH deficiency is now recognized as a distinct if nonspecific syndrome with considerable adverse health consequences. GH replacement therapy in lower doses than those used in children can reverse many of these abnormalities and restore functional capacities toward or even to normal; if dosed appropriately, GH therapy has few adverse effects. Although some doubts remain about possible long-term risks of childhood GH therapy, most registries of adult GH replacement therapy, albeit limited in study size and duration, have not shown an increased incidence of cancers or of cardiovascular morbidity or mortality.
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Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 North West 10th Avenue, Suite 807, Miami, FL 33136, USA
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Woodmansee WW, Zimmermann AG, Child CJ, Rong Q, Erfurth EM, Beck-Peccoz P, Blum WF, Robison LL. Incidence of second neoplasm in childhood cancer survivors treated with GH: an analysis of GeNeSIS and HypoCCS. Eur J Endocrinol 2013; 168:565-73. [PMID: 23359434 DOI: 10.1530/eje-12-0967] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Childhood cancer survivors are commonly treated with GH for GH deficiency that develops either as a result of primary malignancy or its treatment. One study--the Childhood Cancer Survivor Study (CCSS)--demonstrated increased risk of second neoplasm (SN) in GH-treated childhood cancer survivors compared with non-GH treated, after adjusting for key risk factors. We assessed the incidence of SN in GH-treated childhood cancer survivors in outpatient observational studies of GH replacement. DESIGN Retrospective analysis of two prospective cohort studies that collected data on safety of GH replacement as prescribed in clinical practice. METHODS Childhood cancer survivors enrolled in Eli Lilly and Company's pediatric (Genetics and Neuroendocrinology of Short Stature International Study (GeNeSIS)) and adult (Hypopituitary Control and Complications Study (HypoCCS)) observational studies of GH treatment were assessed for incidence of SN. RESULTS The percentage of childhood cancer survivors treated with GH who developed a SN was 3.8% in pediatric GeNeSIS participants and 6.0% in adult HypoCCS participants. The estimated cumulative incidence of SN at 5 years of follow-up in these studies was 6.2 and 4.8% respectively. CONCLUSIONS The incidence of SN in GeNeSIS and HypoCCS GH-treated participants is similar to the published literature and is thus consistent with increased risk of SN in childhood cancer survivors treated with GH. As follow-up times were relatively short (<3 years), longer observation is recommended. Nevertheless, clinicians should be alerted to the possibility of increased risk of SN in childhood cancer survivors treated with GH and continue chronic surveillance.
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Affiliation(s)
- Whitney W Woodmansee
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Hartman ML, Xu R, Crowe BJ, Robison LL, Erfurth EM, Kleinberg DL, Zimmermann AG, Woodmansee WW, Cutler GB, Chipman JJ, Melmed S. Prospective safety surveillance of GH-deficient adults: comparison of GH-treated vs untreated patients. J Clin Endocrinol Metab 2013; 98:980-8. [PMID: 23345098 PMCID: PMC3677286 DOI: 10.1210/jc.2012-2684] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT In clinical practice, the safety profile of GH replacement therapy for GH-deficient adults compared with no replacement therapy is unknown. OBJECTIVE The objective of this study was to compare adverse events (AEs) in GH-deficient adults who were GH-treated with those in GH-deficient adults who did not receive GH replacement. DESIGN AND SETTING This was a prospective observational study in the setting of US clinical practices. PATIENTS AND OUTCOME MEASURES AEs were compared between GH-treated (n = 1988) and untreated (n = 442) GH-deficient adults after adjusting for baseline group differences and controlling the false discovery rate. The standardized mortality ratio was calculated using US mortality rates. RESULTS After a mean follow-up of 2.3 years, there was no significant difference in rates of death, cancer, intracranial tumor growth or recurrence, diabetes, or cardiovascular events in GH-treated compared with untreated patients. The standardized mortality ratio was not increased in either group. Unexpected AEs (GH-treated vs untreated, P ≤ .05) included insomnia (6.4% vs 2.7%), dyspnea (4.2% vs 2.0%), anxiety (3.4% vs 0.9%), sleep apnea (3.3% vs 0.9%), and decreased libido (2.1% vs 0.2%). Some of these AEs were related to baseline risk factors (including obesity and cardiopulmonary disease), higher GH dose, or concomitant GH side effects. CONCLUSIONS In GH-deficient adults, there was no evidence for a GH treatment effect on death, cancer, intracranial tumor recurrence, diabetes, or cardiovascular events, although the follow-up period was of insufficient duration to be conclusive for these long-term events. The identification of unexpected GH-related AEs reinforces the fact that patient selection and GH dose titration are important to ensure safety of adult GH replacement.
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Affiliation(s)
- Mark L Hartman
- Lilly Research Laboratories, Indianapolis, Indiana 46285, USA
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Abstract
The availability of recombinant human growth hormone (rGH) for treatment of growth disorders has provided an unlimited supply for replacement in patients with growth hormone insufficiency but also for short stature due to Turner syndrome, renal failure, Prader-Willi syndrome, small for gestational age and idiopathic short stature. Considering the potential for side effects in the use of a growth promoting agent, the community of physicians and pharmaceutical manufacturers developed systematic methods to survey for short and long term effects. Recently published data from the National Cooperative Growth Study (NCGS), managed by Genentech, concluded that GH has a 'favorable profile'. In 2012, results from the European Union's Safety and Appropriateness of GH treatment in Europe (EU SAGhE) study about the long term mortality in GH treated patients were published in two separate manuscripts. This review will examine the issue of safety of rGH in order that practitioners are informed as they consider initiation of therapy with patients.
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46
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Shimatsu A, Tai S, Imori M, Ihara K, Taketsuna M, Funai J, Tanaka T, Teramoto A, Irie M, Chihara K. Efficacy and safety of growth hormone replacement therapy in Japanese adults with growth hormone deficiency: a post-marketing observational study. Endocr J 2013; 60:1131-44. [PMID: 23823978 DOI: 10.1507/endocrj.ej13-0083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This large-scale observational study examined the long-term effectiveness and safety of growth hormone (GH) replacement therapy for adult GH deficiency (GHD) in Japanese clinical practice using the Hypopituitary Control and Complications Study database. The study included 402 GHD patients for safety analyses and a subset of 209 patients (149 adult-onset and 60 childhood-onset GHD patients) who had not previously received GH replacement therapy for the efficacy analyses. Data on clinical, metabolic, quality of life (QoL) characteristics, and all adverse events (AEs) were collected at baseline (start of GH treatment), 6 months, 1 year and 2 years. Over the observation period, there were improvements from baseline in insulin-like growth factor-I standard deviation scores (P<0.001), although the changes in metabolic parameters were minimal. QoL (Short Form-36) Z-scores significantly increased from baseline in both onset-type groups for several subscale domains (P<0.05). A total of 145 (36.1%) patients experienced ≥1 AE. Common AEs were hyperlipidaemia (2.7%) and hyperinsulinaemia (2.2%). Some patients experienced recurrent hypothalamic/pituitary tumour (events per 1000 patient-years: 2.78), new benign (0.93), malignant tumour (10.28) or other new tumour (0.93), new diabetes mellitus (7.45), and new stroke (3.71). Seven patients died during the observation period. Our safety findings are inconclusive about the associations between GH replacement and AEs, although the incidence of diabetes mellitus and cardiovascular events are similar to those reported in the Japanese general population. In conclusion, the key beneficial effects of GH replacement therapy for GHD are observed in routine clinical practice in Japan.
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Affiliation(s)
- Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Chemaitilly W, Robison LL. Safety of growth hormone treatment in patients previously treated for cancer. Endocrinol Metab Clin North Am 2012; 41:785-92. [PMID: 23099270 DOI: 10.1016/j.ecl.2012.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This review provides an overview of the safety of growth hormone replacement therapy in individuals previously treated for cancer. The review focuses on the risk of disease recurrence and second neoplasm occurrence with special attention to data on childhood cancer survivors.
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Affiliation(s)
- Wassim Chemaitilly
- Division of Endocrinology, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN 38105-3678, USA.
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Beck-Peccoz P, Minuto F, Leal-Cerro A, Zabransky M, Stalla G. Rationale and design of PATRO Adults, a multicentre, noninterventional study of the long-term efficacy and safety of Omnitrope(®) for the treatment of adult patients with growth hormone deficiency. Ther Adv Endocrinol Metab 2012; 3:85-91. [PMID: 23148199 PMCID: PMC3474653 DOI: 10.1177/2042018812444152] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe the rationale and design of PATRO Adults, a postmarketing surveillance study of the long-term efficacy and safety of somatropin (Omnitrope(®)) for the treatment of adult patients with growth hormone deficiency (GHD). METHODS PATRO Adults is an observational, multicentre, open, longitudinal, noninterventional study being conducted in hospitals and specialized endocrinology clinics across several European countries. The primary objective is to assess the safety and efficacy of Omnitrope(®) in adults treated in routine clinical practice. Eligible patients are male or female adults who are receiving treatment with Omnitrope(®) and who have provided informed consent. Patients who have been treated with another human growth hormone (hGH) product before starting Omnitrope(®) therapy will also be eligible for inclusion. Efficacy assessments will be based on the analysis of the following: insulin-like growth factor-1 levels within age- and gender-adjusted normal ranges; anthropometric measures (weight, waist circumference, total fat mass, lean body mass, total body water); bone mineral density; lipids; effects on cardiovascular risk factors such as glucose metabolism, blood pressure and inflammatory markers (e.g. C-reactive protein); and quality of life. All adverse events will be monitored and recorded. Particular emphasis will be placed on long-term safety, the recording of malignancies, the occurrence and clinical impact of antirecombinant hGH antibodies, the incidence, severity and duration of hyperglycaemia, and the development of diabetes during treatment with Omnitrope(®). CONCLUSIONS PATRO Adults is a large, long-term, postmarketing surveillance study that will extend the safety database for Omnitrope(®), as well as contributing to the available data for all recombinant hGH products. Of particular interest, the study will provide important data on the impact of long-term GH replacement therapy on the development of diabetes mellitus, the recurrence/regrowth of hypothalamic-pituitary tumours, and de novo malignancy or recurrence of other (non-hypothalamic-pituitary) tumours.
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Affiliation(s)
- Paolo Beck-Peccoz
- Endocrinology and Diabetology Unit, Medical Sciences Department, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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