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Roth CL, Scimia C, Shoemaker AH, Gottschalk M, Miller J, Yuan G, Malhotra S, Abuzzahab MJ. Setmelanotide for the treatment of acquired hypothalamic obesity: a phase 2, open-label, multicentre trial. Lancet Diabetes Endocrinol 2024; 12:380-389. [PMID: 38697184 DOI: 10.1016/s2213-8587(24)00087-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Hypothalamic obesity resulting from hypothalamic damage might affect melanocortin signalling. We investigated the melanocortin-4 receptor agonist setmelanotide for treatment of hypothalamic obesity. METHODS This phase 2, open-label, multicentre trial was done in five centres in the USA. Eligible patients were aged between 6 and 40 years with obesity and history of hypothalamic injury or diagnosis of a non-malignant tumour affecting the hypothalamus that was treated with surgery, chemotherapy, or radiation. Setmelanotide was titrated up to a dose of 3·0 mg and administered subcutaneously once a day for a total duration of 16 weeks. The primary endpoint was the proportion of patients with a reduction in BMI of at least 5% from baseline after 16 weeks, compared with a historic control rate of less than 5% in this population. The primary endpoint was analysed using the full analysis set, which includes all patients with baseline data who received at least one dose of setmelanotide. Safety was assessed in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT04725240) and is complete. FINDINGS Between June 6, 2021, and Jan 13, 2022, 19 patients were screened for inclusion. One patient was excluded, and 18 were enrolled and received at least one dose of setmelanotide. Patients were primarily White (n=14 [78%]) and male (n=11 [61%]). Enrolled patients had a mean age of 15·0 years (SD 5·3) and a mean BMI of 38·0 kg/m2 (SD 6·5). Of 18 patients enrolled, 16 (89%) of 18 patients completed the study and met the primary endpoint of reduction in BMI of at least 5% from baseline after 16 weeks (p<0·0001). The mean reduction in BMI across all patients was 15% (SD 10). A composite proportion of patients had a clinically meaningful change (89%, 90% CI 69-98%; p<0·0001), comprising a reduction in BMI Z score of at least 0·2 points for patients younger than 18 years (92%, 68-100%; p<0·0001) and reduction in bodyweight of at least 5% for patients aged 18 years or older (80%, 34-99%; p<0·0001). Patients aged 12 years or older had a mean reduction in hunger score of 45%. Frequent adverse events included nausea (61%), vomiting (33%), skin hyperpigmentation (33%), and diarrhoea (22%). Of 14 patients who continued treatment in a long-term extension study (NCT03651765), 12 completed at least 12 months of treatment at the time of publication and had a mean change in BMI of -26% (SD 12) from index trial baseline. INTERPRETATION These findings support setmelanotide as a novel effective treatment of hypothalamic obesity. FUNDING Rhythm Pharmaceuticals.
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Affiliation(s)
- Christian L Roth
- Seattle Children's Research Institute, Seattle, WA, USA; Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | | | - Ashley H Shoemaker
- Ian Burr Division of Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Gottschalk
- Pediatric Endocrinology, University of California San Diego/Rady Children's Hospital, San Diego, CA, USA
| | - Jennifer Miller
- Pediatric Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Sonali Malhotra
- Rhythm Pharmaceuticals, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Gan HW, Cerbone M, Dattani MT. Appetite- and Weight-Regulating Neuroendocrine Circuitry in Hypothalamic Obesity. Endocr Rev 2024; 45:309-342. [PMID: 38019584 PMCID: PMC11074800 DOI: 10.1210/endrev/bnad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 10/25/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
Since hypothalamic obesity (HyOb) was first described over 120 years ago by Joseph Babinski and Alfred Fröhlich, advances in molecular genetic laboratory techniques have allowed us to elucidate various components of the intricate neurocircuitry governing appetite and weight regulation connecting the hypothalamus, pituitary gland, brainstem, adipose tissue, pancreas, and gastrointestinal tract. On a background of an increasing prevalence of population-level common obesity, the number of survivors of congenital (eg, septo-optic dysplasia, Prader-Willi syndrome) and acquired (eg, central nervous system tumors) hypothalamic disorders is increasing, thanks to earlier diagnosis and management as well as better oncological therapies. Although to date the discovery of several appetite-regulating peptides has led to the development of a range of targeted molecular therapies for monogenic obesity syndromes, outside of these disorders these discoveries have not translated into the development of efficacious treatments for other forms of HyOb. This review aims to summarize our current understanding of the neuroendocrine physiology of appetite and weight regulation, and explore our current understanding of the pathophysiology of HyOb.
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Affiliation(s)
- Hoong-Wei Gan
- Department of Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
- Genetics & Genomic Medicine Research & Teaching Department, University College London Great Ormond Street Institute for Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Manuela Cerbone
- Department of Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
- Genetics & Genomic Medicine Research & Teaching Department, University College London Great Ormond Street Institute for Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Mehul Tulsidas Dattani
- Department of Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
- Genetics & Genomic Medicine Research & Teaching Department, University College London Great Ormond Street Institute for Child Health, 30 Guilford Street, London WC1N 1EH, UK
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Roth CL, McCormack SE. Acquired hypothalamic obesity: A clinical overview and update. Diabetes Obes Metab 2024; 26 Suppl 2:34-45. [PMID: 38450938 DOI: 10.1111/dom.15530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
Hypothalamic obesity (HO) is a rare and complex disorder that confers substantial morbidity and excess mortality. HO is a unique subtype of obesity characterized by impairment in the key brain pathways that regulate energy intake and expenditure, autonomic nervous system function, and peripheral hormonal signalling. HO often occurs in the context of hypothalamic syndrome, a constellation of symptoms that follow from disruption of hypothalamic functions, for example, temperature regulation, sleep-wake circadian control, and energy balance. Genetic forms of HO, including the monogenic obesity syndromes, often impact central leptin-melanocortin pathways. Acquired forms of HO occur as a result of tumours impacting the hypothalamus, such as craniopharyngioma, surgery or radiation to treat those tumours, or other forms of hypothalamic damage, such as brain injury impacting the region. Risk for severe obesity following hypothalamic injury is increased with larger extent of hypothalamic damage or lesions that contain the medial and posterior hypothalamic nuclei that support melanocortin signalling pathways. Structural damage in these hypothalamic nuclei often leads to hyperphagia, central insulin and leptin resistance, decreased sympathetic activity, low energy expenditure, and increased energy storage in adipose tissue, the collective effect of which is rapid weight gain. Individuals with hyperphagia are perpetually hungry. They do not experience fullness at the end of a meal, nor do they feel satiated after meals, leading them to consume larger and more frequent meals. To date, most efforts to treat HO have been disappointing and met with limited, if any, long-term success. However, new treatments based on the distinct pathophysiology of disturbed energy homeostasis in acquired HO may hold promise for the future.
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Affiliation(s)
- Christian L Roth
- Centre for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, DC, USA
- Department of Paediatrics, University of Washington, School of Medicine, Seattle, Washington, DC, USA
| | - Shana E McCormack
- Neuroendocrine Centre, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Paediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Roth CL, Zenno A. Treatment of hypothalamic obesity in people with hypothalamic injury: new drugs are on the horizon. Front Endocrinol (Lausanne) 2023; 14:1256514. [PMID: 37780616 PMCID: PMC10533996 DOI: 10.3389/fendo.2023.1256514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Hypothalamic obesity (HO) is a complex and rare disorder affecting multiple regulatory pathways of energy intake and expenditure in the brain as well as the regulation of the autonomic nervous system and peripheral hormonal signaling. It can be related to monogenic obesity syndromes which often affect the central leptin-melanocortin pathways or due to injury of the hypothalamus from pituitary and hypothalamic tumors, such as craniopharyngioma, surgery, trauma, or radiation to the hypothalamus. Traditional treatments of obesity, such as lifestyle intervention and specific diets, are still a therapeutic cornerstone, but often fail to result in meaningful and sustained reduction of body mass index. This review will give an update on pharmacotherapies of HO related to hypothalamic injury. Recent obesity drug developments are promising for successful obesity intervention outcomes.
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Affiliation(s)
- Christian L. Roth
- Seattle Children’s Research Institute, Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, United States
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Anna Zenno
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle, WA, United States
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Shoemaker AH, Tamaroff J. Approach to the Patient With Hypothalamic Obesity. J Clin Endocrinol Metab 2023; 108:1236-1242. [PMID: 36413492 PMCID: PMC10306088 DOI: 10.1210/clinem/dgac678] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
Hypothalamic obesity (HO) is defined as abnormal weight gain due to physical destruction of the hypothalamus. Suprasellar tumors, most commonly craniopharyngiomas, are a classic cause of HO. HO often goes unnoticed initially as patients, families, and medical teams are focused on oncologic treatments and management of panhypopituitarism. HO is characterized by rapid weight gain in the first year after hypothalamic destruction followed by refractory obesity due to an energy imbalance of decreased energy expenditure without decreased food intake. Currently available pharmacotherapies are less effective in HO than in common obesity. While not a cure, dietary interventions, pharmacotherapy, and bariatric surgery can mitigate the effects of HO. Early recognition of HO is necessary to give an opportunity to intervene before substantial weight gain occurs. Our goal for this article is to review the pathophysiology of HO and to discuss available treatment options and future directions for prevention and treatment.
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Affiliation(s)
- Ashley H Shoemaker
- Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Jaclyn Tamaroff
- Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, TN 37212, USA
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Castle-Kirszbaum M, Shi MDY, Goldschlager T. Quality of Life in Craniopharyngioma: A Systematic Review. World Neurosurg 2022; 164:424-435.e2. [PMID: 35580780 DOI: 10.1016/j.wneu.2022.05.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Craniopharyngiomas are morbid tumors that significantly reduce patients' quality of life (QoL). The lifelong burden of endocrine, visual, hypothalamic, and limbic dysfunction can have disastrous consequences for the physical and psychosocial health of patients. Elucidating the factors that influence QoL could guide therapeutic interventions to improve patient well-being. METHODS A systematic review was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement using the PubMed and Medline databases. Studies that had reported patient QoL using validated metrics in both adult and pediatric populations were included. Bias and methodological rigor were assessed using the MINORS (methodological index for nonrandomized studies) criteria. RESULTS A total of 25 studies, including 2025 patients, were available for review. Most studies were small, retrospective, cohort studies with a high risk of bias. The QoL of the patients with craniopharyngioma was lower than that of the general population. Hypothalamic involvement was consistently the strongest predictor of QoL. Endocrinopathy contributed to morbidity but could be ameliorated by hormone replacement therapy. Social and emotional dysregulation and a poor memory are common complaints after surgery, and iatrogenic damage to the infundibulum, hypothalamus, limbic system, and frontal lobes might underlie these concerns. Sleep-wake cycle dysfunction and hypothalamic obesity are serious consequences of hypothalamic damage. CONCLUSIONS An experienced multidisciplinary team is necessary to optimally manage the complex cases of these patients. The poor QoL of patients with craniopharyngioma is multifactorial. However, the contribution of iatrogenesis is not insubstantial. Improved surgical techniques, focusing on hypothalamic preservation, and adjuvant treatment options are required to improve the well-being of these patients.
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Affiliation(s)
- Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia.
| | - Margaret D Y Shi
- Department of Surgery, Northern Hospital, Melbourne, Victoria, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Müller HL, Tauber M, Lawson EA, Özyurt J, Bison B, Martinez-Barbera JP, Puget S, Merchant TE, van Santen HM. Hypothalamic syndrome. Nat Rev Dis Primers 2022; 8:24. [PMID: 35449162 DOI: 10.1038/s41572-022-00351-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/11/2022]
Abstract
Hypothalamic syndrome (HS) is a rare disorder caused by disease-related and/or treatment-related injury to the hypothalamus, most commonly associated with rare, non-cancerous parasellar masses, such as craniopharyngiomas, germ cell tumours, gliomas, cysts of Rathke's pouch and Langerhans cell histiocytosis, as well as with genetic neurodevelopmental syndromes, such as Prader-Willi syndrome and septo-optic dysplasia. HS is characterized by intractable weight gain associated with severe morbid obesity, multiple endocrine abnormalities and memory impairment, attention deficit and reduced impulse control as well as increased risk of cardiovascular and metabolic disorders. Currently, there is no cure for this condition but treatments for general obesity are often used in patients with HS, including surgery, medication and counselling. However, these are mostly ineffective and no medications that are specifically approved for the treatment of HS are available. Specific challenges in HS are because the syndrome represents an adverse effect of different diseases, and that diagnostic criteria, aetiology, pathogenesis and management of HS are not completely defined.
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Affiliation(s)
- Hermann L Müller
- Department of Paediatrics and Paediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Carl von Ossietzky University, Oldenburg, Germany.
| | - Maithé Tauber
- Centre de Référence du Syndrome de Prader-Willi et autres syndromes avec troubles du comportement alimentaire, Hôpital des Enfants, CHU-Toulouse, Toulouse, France
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, Toulouse, France
| | - Elizabeth A Lawson
- Neuroendocrine Unit, Massachusetts General Hospital, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jale Özyurt
- Biological Psychology Laboratory, Department of Psychology, School of Medicine and Health Sciences, Carl von Ossietzky University, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Brigitte Bison
- Department of Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Juan-Pedro Martinez-Barbera
- Developmental Biology and Cancer Programme, Birth Defects Research Centre, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Stephanie Puget
- Service de Neurochirurgie, Hôpital Necker-Enfants Malades, Sorbonne Paris Cité, Paris, France
- Service de Neurochirurgie, Hopital Pierre Zobda Quitman, Martinique, France
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hanneke M van Santen
- Department of Paediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
- Princess Máxima Center for Paediatric Oncology, Utrecht, Netherlands
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Dimitri P. Treatment of Acquired Hypothalamic Obesity: Now and the Future. Front Endocrinol (Lausanne) 2022; 13:846880. [PMID: 35464063 PMCID: PMC9019363 DOI: 10.3389/fendo.2022.846880] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
The hypothalamus is the centre of neuroendocrine regulation of energy homeostasis and appetite. Maldevelopment of, or damage to, the key hypothalamic nuclei disrupts the coordinated balance between energy intake and expenditure leading, to rapid and excessive weight gain. Hypothalamic obesity is compounded by a disruption of the hypothalamic-pituitary axis, sleep disruption, visual compromise, and neurological and vascular sequalae. Amongst suprasellar tumors, craniopharyngioma is the most common cause of acquired hypothalamic obesity, either directly or following surgical or radiotherapeutic intervention. At present, therapy is limited to strategies to manage obesity but with a modest and variable impact. Current approaches include optimizing pituitary hormone replacement, calorie restriction, increased energy expenditure through physical activity, behavioral interventions, pharmacotherapy and bariatric surgery. Current pharmacotherapeutic approaches include stimulants that increase energy consumption, anti-diabetic agents, hypothalamic-pituitary substitution therapy, octreotide, and methionine aminopeptidase 2 (MetAP2) inhibitors. Some pharmacological studies of hypothalamic obesity report weight loss or stabilization but reported intervention periods are short, and others report no effect. The impact of bariatric surgery on weight loss in hypothalamic obesity again is variable. Novel or combined approaches to manage hypothalamic obesity are thus required to achieve credible and sustained weight loss. Identifying etiological factors contributing hypothalamic obesity may lead to multi-faceted interventions targeting hyperphagia, insulin resistance, decreased energy expenditure, sleep disturbance, hypopituitarism and psychosocial morbidity. Placebo-controlled trials using current single, or combination therapies are required to determine the impact of therapeutic agents. A well-defined approach to defining the location of hypothalamic damage may support the use of future targeted therapies. Intranasal oxytocin is currently being investigated as an anorexogenic agent. Novel agents including those targeting pro-opimelanocortin-C and AgRP/NPY expressing neurons and the MC4 receptor may result in better outcomes. This article discusses the current challenges in the management of hypothalamic obesity in children and young people and future therapeutic approaches to increasing weight loss and quality of life in these patients.
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Affiliation(s)
- Paul Dimitri
- The Department of Paediatric Endocrinology, Sheffield Children’s NHS Foundation Trust, Sheffield, United Kingdom
- College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, United Kingdom
- *Correspondence: Paul Dimitri,
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Abstract
Craniopharyngiomas are rare embryonic malformational tumors of the sellar/parasellar region, classified by the World Health Organization (WHO) as tumors with low-grade malignancy (WHO I). The childhood adamantinomatous subtype of craniopharyngioma is usually cystic with calcified areas. At the time of diagnosis, hypothalamic/pituitary deficits, visual disturbances, and increased intracranial pressure are major symptoms. The treatment of choice in case of favorable tumor location (without hypothalamic involvement) is complete resection. It is important to ensure that optical and hypothalamic functionality are preserved. In case of unfavorable tumor location, that is with hypothalamic involvement, a hypothalamus-sparing surgical strategy with subsequent local irradiation of residual tumor is recommended. In the further course of the disease, recurrences and progression often occur. Nevertheless, overall survival rates are high at 92%. Severe impairment of quality of life and comorbidities such as metabolic syndrome, hypothalamic obesity, and neurological consequences can be observed in patients with disease- and/or treatment-related lesions of hypothalamic structures. Childhood-onset craniopharyngioma frequently manifests as a chronic disease so that patients require lifelong, continuous care by experienced multidisciplinary teams to manage clinical and quality of life consequences. For this review, a search for original articles and reviews published between 1986 and 2020 was performed in Pubmed, Science Citation Index Expanded, EMBASE, and Scopus. The search terms used were "craniopharyngioma, hypothalamus, pituitary obesity, irradiation, neurosurgery.
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Affiliation(s)
- Anna Otte
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children´s Hospital, Carl von Ossietzky University Oldenburg, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children´s Hospital, Carl von Ossietzky University Oldenburg, Klinikum Oldenburg AöR, 26133 Oldenburg, Germany
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Perez FA, Elfers C, Yanovski JA, Shoemaker AH, Abuzzahab MJ, Roth CL. MRI measures of hypothalamic injury are associated with glucagon-like peptide-1 receptor agonist treatment response in people with hypothalamic obesity. Diabetes Obes Metab 2021; 23:1532-1541. [PMID: 33651438 PMCID: PMC8353597 DOI: 10.1111/dom.14366] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022]
Abstract
AIM To evaluate whether neuroimaging-delineated regions of hypothalamic injury are associated with a differential treatment response to a glucagon-like peptide-1 receptor agonist (GLP-1RA) in patients with hypothalamic obesity (HO). MATERIALS AND METHODS We performed a prespecified secondary analysis of a randomized, multicentre, double-blind, placebo-controlled trial of people aged 10-25 years with hypothalamic injury and HO randomized to the GLP-1RA exenatide once-weekly (ExQW) or placebo for 36 weeks. Subjects underwent MRI prior to enrolment and the degree of hypothalamic damage was assessed using an integrative hypothalamic lesion score (HLS). Mammillary body (MB) damage was specifically determined. The main clinical endpoints were % change in body mass index (BMI) and change in % body fat. Nested ANCOVA models including a treatment × imaging measure interaction were compared using partial F-tests to assess whether the effect of ExQW treatment differed by severity of hypothalamic damage. RESULTS Complete data were available in 35/42 randomized participants (placebo, n = 15; ExQW, n = 20). ExQW-treated patients with worse HLS or bilateral MB damage had greater reductions in % body fat at 36 weeks (interaction coefficient estimates for HLS: -0.9%, 95% CI -1.6% to -0.2%, p = .02; for MB damage: -7.4%, 95% CI -10.1% to -4.7%, p < .001, respectively) but not for BMI % change. Similarly, patients with more damaged and smaller MB cross-sectional areas had greater reductions in % body fat following ExQW (interaction coefficient estimate 0.3%, 95% CI 0.2%-0.4%, p < .001). CONCLUSIONS In people with HO, greater hypothalamic damage as determined by MRI, in particular MB injury, is associated with greater reductions in adiposity following GLP-1RA treatment.
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Affiliation(s)
- Francisco A. Perez
- Department of Radiology, Seattle Children’s and University of Washington, Seattle, WA 98105
| | - Clinton Elfers
- Seattle Children’s Research Institute, 1900 Ninth Ave, Seattle, WA 98101
| | - Jack A. Yanovski
- Section on Growth and Obesity, Division of Intramural Research, Eunice Kennedy Shriver National, Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892
| | - Ashley H. Shoemaker
- Vanderbilt University Medical Center, Division of Pediatric Endocrinology, Nashville, TN 37212
| | - M. Jennifer Abuzzahab
- McNeely Pediatric Diabetes Center and Endocrinology Clinic, Children’s Minnesota, St. Paul, MN
| | - Christian L. Roth
- Seattle Children’s Research Institute, 1900 Ninth Ave, Seattle, WA 98101
- Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
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Multidisciplinary Approach for Hypothalamic Obesity in Children and Adolescents: A Preliminary Study. CHILDREN-BASEL 2021; 8:children8070531. [PMID: 34206290 PMCID: PMC8304472 DOI: 10.3390/children8070531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 01/07/2023]
Abstract
Hypothalamic obesity (HO) is delineated by an inexorable weight gain in subjects with hypothalamic disorder (congenital or acquired). The aim of the present study was to evaluate the effect of a multidisciplinary approach on weight trend and metabolic outcome in children and adolescents with hypothalamic disease who were overweight or obese. Thirteen patients (aged 8.1–16.1 years) received a personalized diet, accelerometer-based activity monitoring, and psychological assessment. Height, weight, body mass index (BMI), and serum metabolic parameters were assessed at baseline (T0) and after six months (T1). Metformin was introduced at T1 in four subjects who were then re-evaluated after six months (T2). At T1, weight gain was significantly reduced compared with T0 (0.29 ± 0.79 kg/month vs. 0.84 ± 0.55 kg/month, p = 0.03), and weight standard deviation score (SDS) and BMI SDS did not change significantly, as serum metabolic parameters. The four subjects treated with metformin showed a reduction of weight SDS and BMI SDS at T2. In conclusion, patients treated with our multidisciplinary approach showed, after 6 months, favorable results characterized by decreased weight gain and stabilization of weight SDS and BMI SDS in a condition usually characterized by inexorable weight gain. However, further analysis, larger cohorts, and longer follow-up are needed to confirm these preliminary data.
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Roth CL, Perez FA, Whitlock KB, Elfers C, Yanovski JA, Shoemaker AH, Abuzzahab MJ. A phase 3 randomized clinical trial using a once-weekly glucagon-like peptide-1 receptor agonist in adolescents and young adults with hypothalamic obesity. Diabetes Obes Metab 2021; 23:363-373. [PMID: 33026160 PMCID: PMC7821019 DOI: 10.1111/dom.14224] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the efficacy, safety and tolerability of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) in patients with hypothalamic obesity (HO). MATERIALS AND METHODS A two-arm, randomized, multicentre, double-blind, placebo-controlled trial was conducted in 10- to 25-year-olds with hypothalamic injury following intracranial tumour and HO. Participants were randomized to once-weekly subcutaneous injections of a GLP-1 RA exenatide 2 mg (ExQW) or placebo for 36 weeks. The primary efficacy endpoint was 36-week % change in body mass index (BMI). Secondary outcomes included change in body composition (by dual energy x-ray absorptiometry). RESULTS Forty-two participants were randomized to ExQW (n = 23) or placebo (n = 19). Participants were 5 ± 2 years (mean ± SD) postdiagnosis and development of HO (BMI 37.3 ± 7.1 kg/m2 ). In intention-to-treat analysis, the effect of 36-week ExQW vs. placebo on % Δ BMI was not significant (estimated treatment difference -1.7 ± 1.8%, 95% CI -4.1 to 0.6%, P = .40); however, total body fat mass was reduced (estimated treatment difference -3.1 ± 1.4 kg, 95% CI -5.7 to -0.4 kg, P = .02). There was a significant reduction in waist circumference (estimated effect of treatment -3.5 [95% CI -5.5 to -1.6] cm, P = .004). All patients treated with placebo increased % of adipose tissue, while 50% treated with ExQW had reductions (P < .001). Mean HbA1c, glucose tolerance and serum lipids did not change significantly with therapy. ExQW was well tolerated. The most frequent adverse events were transient gastrointestinal disturbances (ExQW vs. placebo: nausea 6/23 vs. 3/18, vomiting 4/23 vs. 4/18 and diarrhoea 7/23 vs. 3/18). CONCLUSIONS GLP-1 RAs are a promising and safe treatment to improve or stabilize HO in children and young adults.
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Affiliation(s)
- Christian L. Roth
- Seattle Children's Research InstituteSeattleWashington
- Department of PediatricsUniversity of WashingtonSeattleWashington
| | - Francisco A. Perez
- Department of RadiologySeattle Children's and University of WashingtonSeattleWashington
| | | | | | - Jack A. Yanovski
- Section on Growth and Obesity, Division of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaMaryland
| | - Ashley H. Shoemaker
- Division of Pediatric EndocrinologyVanderbilt University Medical CenterNashvilleTennessee
| | - M. Jennifer Abuzzahab
- McNeely Pediatric Diabetes Center and Endocrinology ClinicChildren's MinnesotaSt. PaulMinnesota
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Abstract
Energy homeostasis, appetite, and satiety are modulated by a complex neuroendocrine system regulated by the hypothalamus. Dysregulation of this system resulting in hypothalamic obesity (HO) is caused by brain tumors, neurosurgery, and/or cranial irradiation. Craniopharyngioma (CP) is a paradigmatic disease with regard to the development of HO. Initial hypothalamic involvement of CP and/or treatment-related damage to hypothalamic-pituitary axes result in HO. Attempts to control HO with lifestyle interventions have not been satisfactory. No generally accepted pharmacologic or bariatric therapy for HO in CP has been effective in randomized controlled trials. Accordingly, prevention of HO is recommended.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Rahel-Straus-Strasse 10, Oldenburg 26133, Germany.
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14
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Horne VE, Bielamowicz K, Nguyen J, Hilsenbeck S, Lindsay H, Sonabend R, Wood AC, Okcu F, Sisley S. Methylphenidate improves weight control in childhood brain tumor survivors with hypothalamic obesity. Pediatr Blood Cancer 2020; 67:e28379. [PMID: 32383818 DOI: 10.1002/pbc.28379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/24/2020] [Accepted: 04/14/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hypothalamic obesity causes unrelenting weight gain for childhood brain tumor survivors. No single therapy has proven effective for treatment. We aimed to evaluate effectiveness of long-term methylphenidate therapy on body mass index (BMI) change in children with hypothalamic obesity. METHODS A retrospective analysis included children with a history of brain tumor and hypothalamic obesity receiving methylphenidate (10-60 mg/day) for hypothalamic obesity. Subjects were evaluated for BMI trajectory before and after methylphenidate start. Given that z-scores can be skewed in severely obese children, we calculated BMI as a percent of the BMI at the 95th percentile for the child's age and gender (BMI% 95th). RESULTS Twelve patients with hypothalamic obesity completed methylphenidate therapy for at least 6 months (median 3.1 years, range 1.0-5.8 years). All subjects had a suprasellar tumor (nine [75%] with craniopharyngioma) and pituitary dysfunction. Pretreatment median BMI percent of the 95th percentile was 125.6% (interquartile range [IQR] 25-75: 115.3-138.3%) with BMI z-score of 2.4 (IQR 25-75: 2.1-2.6). Following methylphenidate treatment, there was a 69.9% reduction in the median slope of BMI change. Eleven of 12 patients (92%) had a reduction in the slope of their BMI change on methylphenidate treatment. Postmethylphenidate median BMI percent of the 95th percentile decrease to 115.2% (IQR 25-75: 103.6-121.2%) with median BMI z-score of 2.1 (IQR 25-75: 1.8-2.2). Mild side effects were noted in six patients. CONCLUSIONS Methylphenidate use reduced and sustained BMI change in children with hypothalamic obesity. Stimulant therapy is an effective first-line agent for treatment of hypothalamic obesity.
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Affiliation(s)
- Vincent E Horne
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Kevin Bielamowicz
- Division of Hematology/Oncology, Department of Pediatrics, The University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Jessica Nguyen
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Susan Hilsenbeck
- Department of Statistics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Holly Lindsay
- Division of Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rona Sonabend
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alexis C Wood
- Division of Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Fatih Okcu
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Stephanie Sisley
- Division of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.,Division of Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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15
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Müller HL. The Diagnosis and Treatment of Craniopharyngioma. Neuroendocrinology 2020; 110:753-766. [PMID: 31678973 DOI: 10.1159/000504512] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/02/2019] [Indexed: 11/19/2022]
Abstract
Craniopharyngioma (CP) is a rare embryonic malformation of the sellar/parasellar region with a low histological grade. Clinical manifestations are related to hypothalamic/pituitary deficiencies, visual impairment, and increased intracranial pressure. Recent insight into the molecular pathogenesis of CP opens new perspectives on targeted therapy in papillary CP harboring BRAF-V600E mutations. Further research to elucidate pathogenic mechanisms and hopefully prevent hypothalamic involvement of CP is warranted. If the tumor is favorably localized, the therapy of choice is complete resection, with care taken to preserve the optical and hypothalamic functions. In patients with unfavorable tumor localization (i.e., hypothalamic involvement), the recommended therapy is a limited hypothalamus-sparing surgical strategy followed by local irradiation. Surgical treatment strategies should be based on a multidisciplinary approach involving experienced teams. Centralizing the treatment of CP in experienced "centers of excellence" and multicenter-based networks for reference assessments should be considered to assure a high standard of treatment quality. CP recurrence and progression are frequent. Irradiation has proven effective in reducing recurrences and progression. Proton beam therapy, available in a wider range in the near future, will help to avoid radio-oncological side effects. Anatomical involvement and/or surgical lesions of posterior hypothalamic areas can result in serious sequelae that compromise quality of life (QoL), such as hypothalamic obesity and psychopathological symptoms. Novel insights into neuropsychological sequelae after CP occurrence should be the basis for the development of therapeutic neuropsychological interventions. CP should be managed as a frequently chronic disease, providing ongoing care of pediatric and adult patients' clinical and QoL consequences by experienced multidisciplinary teams.
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Affiliation(s)
- Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children's Hospital, Klinikum Oldenburg AöR, Oldenburg, Germany,
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16
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Abuzzahab MJ, Roth CL, Shoemaker AH. Hypothalamic Obesity: Prologue and Promise. Horm Res Paediatr 2019; 91:128-136. [PMID: 30884480 DOI: 10.1159/000496564] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/03/2019] [Indexed: 11/19/2022] Open
Abstract
Hypothalamic obesity (HO) frequently occurs following damage to the medial hypothalamic region, encompassing the arcuate nucleus, the paraventricular nucleus, the ventromedial nucleus, the dorsomedial nucleus, and the dorsal hypothalamic area, which are critically involved in the regulation of satiety and energy balance through neural and humoral connections. HO is most commonly described in the context of craniopharyngioma and its treatment, but it can also occur following other suprasellar tumors, radiation, trauma, or a surgical insult to the hypothalamus. A constellation of loss of satiety and a reduction of the metabolic rate, thermogenesis, and physical activity as well as increased vagal tone and hyperinsulinism with insulin and leptin resistance results in rapid weight gain due to a decreased energy expenditure and increased energy storage in adipose cells. To date, no viable long-term solution for HO has been found, due either to the requirement of intact hypothalamic pathways or to significant side effects. Newer therapeutic modalities focused on the unique pathophysiology of this condition offer potential for successful treatment. In this review, we describe the etiology of HO as well as past/current treatment approaches in the categories of hyperinsulinism, surgical approaches, and targeting energy expenditure/anorectic drugs. We conclude by providing an overview of the clinical trials currently underway.
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Affiliation(s)
| | - Christian L Roth
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Ashley H Shoemaker
- Division of Endocrinology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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17
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van Iersel L, Brokke KE, Adan RAH, Bulthuis LCM, van den Akker ELT, van Santen HM. Pathophysiology and Individualized Treatment of Hypothalamic Obesity Following Craniopharyngioma and Other Suprasellar Tumors: A Systematic Review. Endocr Rev 2019; 40:193-235. [PMID: 30247642 DOI: 10.1210/er.2018-00017] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/25/2018] [Indexed: 12/26/2022]
Abstract
The development of hypothalamic obesity (HO) following craniopharyngioma (CP) and other suprasellar tumors leads to reduced patient quality of life. No treatment algorithms are currently available for management of HO. Depending on which hypothalamic nuclei are destroyed, the pathophysiologic mechanisms and clinical symptoms that contribute to HO differ among patients. Herein, we review the contribution of the hypothalamus to the pathophysiologic mechanisms and symptoms underlying CP-associated HO. Additionally, we performed a systematic search of MEDLINE and Embase to identify all intervention studies for weight management in patients with CP or other suprasellar tumors published until September 2017. The search yielded 1866 publications, of which 40 were included. Of these 40 studies, we identified four modalities for intervention (i.e., lifestyle, dietary, pharmacotherapeutic, or surgical) within six clinical domains (i.e., psychosocial disorders, hyperphagia, sleep disturbances, decreased energy expenditure, hyperinsulinemia, and hypopituitarism). We used the findings from our systematic review, in addition to current knowledge on the pathophysiology of HO, to develop an evidence-based treatment algorithm for patients with HO caused by CP or other suprasellar tumors. Although the individual effects of the HO interventions were modest, beneficial individual effects may be achieved when the pathophysiologic background and correct clinical domain are considered. These two aspects can be combined in an individualized treatment algorithm with a stepwise approach for each clinical domain. Recently elucidated targets for HO intervention were also explored to improve future management of HO for patients with CP and other suprasellar tumors.
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Affiliation(s)
- Laura van Iersel
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Karen E Brokke
- Medical Sciences, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Roger A H Adan
- Department of Translational Neuroscience, University Medical Center Utrecht, Utrecht, Netherlands.,Institute for Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lauren C M Bulthuis
- Medical Sciences, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Erica L T van den Akker
- Department of Pediatric Endocrinology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
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18
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Ashraf S, Nadkarni P, Bansal N, Stred SE. Liraglutide for the Treatment of Hypothalamic Obesity. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2018-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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19
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Ni W, Shi X. Interventions for the Treatment of Craniopharyngioma-Related Hypothalamic Obesity: A Systematic Review. World Neurosurg 2018; 118:e59-e71. [PMID: 29945001 DOI: 10.1016/j.wneu.2018.06.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Craniopharyngiomas (CPs) and their treatment are associated with hypothalamic damage that causes hypothalamic obesity (HO) in 30%-70% of cases. Thus, there is ongoing research regarding tangible solutions for HO, because these patients have unrelenting resistance to basic weight-loss interventions. This review aims to summarize the interventions that are used to treat CP-related HO (CP-HO), including pharmacotherapy and bariatric surgery. METHODS The Cochrane Library, EMBASE, and PubMed databases were searched up to June 2017 for relevant reports. Two reviewers conducted independent evaluations of the studies identified. RESULTS Eighteen articles were included in the systematic review, with 3 reports describing pharmacotherapy in randomized controlled trials and 15 reports describing bariatric surgery. Although several studies described effective interventions for treating CP-HO, the evidence base was limited by its low quality and our inability to perform a meta-analysis, which was related to a lack of adequate or integrated data. CONCLUSIONS Octreotide appears to be a preferred treatment for patients with CP-HO, based on limited data. Gastric bypass surgery may also be suitable for select patients with CP-HO, based on a review of various procedures in this setting. Microsurgical preservation of the hypothalamic structures is mandatory to decrease CP-HO-related morbidity and mortality. Further studies with adequate analytical power and sufficient follow-up are needed to identify effective strategies for CP-HO treatment.
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Affiliation(s)
- Weimin Ni
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Xiang'en Shi
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China.
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20
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Hypothalamic Obesity in Craniopharyngioma Patients: Disturbed Energy Homeostasis Related to Extent of Hypothalamic Damage and Its Implication for Obesity Intervention. J Clin Med 2015; 4:1774-97. [PMID: 26371051 PMCID: PMC4600159 DOI: 10.3390/jcm4091774] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 12/11/2022] Open
Abstract
Hypothalamic obesity (HO) occurs in patients with tumors and lesions in the medial hypothalamic region. Hypothalamic dysfunction can lead to hyperinsulinemia and leptin resistance. This review is focused on HO caused by craniopharyngiomas (CP), which are the most common childhood brain tumors of nonglial origin. Despite excellent overall survival rates, CP patients have substantially reduced quality of life because of significant long-term sequelae, notably severe obesity in about 50% of patients, leading to a high rate of cardiovascular mortality. Recent studies reported that both hyperphagia and decreased energy expenditure can contribute to severe obesity in HO patients. Recognized risk factors for severe obesity include large hypothalamic tumors or lesions affecting several medial and posterior hypothalamic nuclei that impact satiety signaling pathways. Structural damage in these nuclei often lead to hyperphagia, rapid weight gain, central insulin and leptin resistance, decreased sympathetic activity, low energy expenditure, and increased energy storage in adipose tissue. To date, most efforts to treat HO have shown disappointing long-term success rates. However, treatments based on the distinct pathophysiology of disturbed energy homeostasis related to CP may offer options for successful interventions in the future.
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21
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Haliloglu B, Bereket A. Hypothalamic obesity in children: pathophysiology to clinical management. J Pediatr Endocrinol Metab 2015; 28:503-13. [PMID: 25781673 DOI: 10.1515/jpem-2014-0512] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/29/2015] [Indexed: 12/22/2022]
Abstract
Hypothalamic obesity (HyOb) is a complex neuroendocrine disorder caused by damage to the hypothalamus, which results in disruption of energy regulation. The key hypothalamic areas of energy regulation are the ARC (arcuate nucleus), the VMH (ventromedial hypothalamus), the PVN (paraventriculer nuclei) and the LHA (lateral hypothalamic area). These pathways can be disrupted mechanically by hypothalamic tumors, neurosurgery, inflammatory disorders, radiotherapy and trauma or functionally as such seen in genetic diseases. Rapid weight gain and severe obesity are the most striking features of HyOb and caused by hyperphagia, reduced basal metabolic rate (BMR) and decreased physical activity. HyOb is usually unresponsive to diet and exercise. Although, GLP-1 and its anologs seem to be a new agent, there is still no curative treatment. Thus, prevention is of prime importance and the clinicians should be alert and vigilant in patients at risk for development of HyOb.
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22
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Heymsfield SB, Avena NM, Baier L, Brantley P, Bray GA, Burnett LC, Butler MG, Driscoll DJ, Egli D, Elmquist J, Forster JL, Goldstone AP, Gourash LM, Greenway FL, Han JC, Kane JG, Leibel RL, Loos RJ, Scheimann AO, Roth CL, Seeley RJ, Sheffield V, Tauber M, Vaisse C, Wang L, Waterland RA, Wevrick R, Yanovski JA, Zinn AR. Hyperphagia: current concepts and future directions proceedings of the 2nd international conference on hyperphagia. Obesity (Silver Spring) 2014; 22 Suppl 1:S1-S17. [PMID: 24574081 PMCID: PMC4159941 DOI: 10.1002/oby.20646] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 10/11/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Hyperphagia is a central feature of inherited disorders (e.g., Prader-Willi Syndrome) in which obesity is a primary phenotypic component. Hyperphagia may also contribute to obesity as observed in the general population, thus raising the potential importance of common underlying mechanisms and treatments. Substantial gaps in understanding the molecular basis of inherited hyperphagia syndromes are present as are a lack of mechanistic of mechanistic targets that can serve as a basis for pharmacologic and behavioral treatments. DESIGN AND METHODS International conference with 28 experts, including scientists and caregivers, providing presentations, panel discussions, and debates. RESULTS The reviewed collective research and clinical experience provides a critical body of new and novel information on hyperphagia at levels ranging from molecular to population. Gaps in understanding and tools needed for additional research were identified. CONCLUSIONS This report documents the full scope of important topics reviewed at a comprehensive international meeting devoted to the topic of hyperphagia and identifies key areas for future funding and research.
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Affiliation(s)
- Steven B. Heymsfield
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Nicole M. Avena
- Department of Psychiatry, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Leslie Baier
- Diabetes Molecular Genetics Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, NIH, Phoenix, Arizona, USA
| | - Phillip Brantley
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - George A. Bray
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Lisa C. Burnett
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | | | - Daniel J. Driscoll
- Division of Genetics and Metabolism, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dieter Egli
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
- New York Stem Cell Foundation, New York, New York, USA
| | | | | | - Anthony P. Goldstone
- Metabolic & Molecular Imaging Group, MRC Clinical Sciences Centre, Imperial College London, UK
| | | | - Frank L. Greenway
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Joan C. Han
- Section on Growth and Obesity, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - James G. Kane
- Prader-Willi Syndrome Association (USA), Sarasota, Florida, USA
| | - Rudolph L. Leibel
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Ruth J.F. Loos
- The Genetics of Obesity and Related Metabolic Traits Program, The Charles Bronfman Institute for Personalized Medicine, The Mindich Child Health and Development Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ann O. Scheimann
- Division of Pediatric Gastroenterology, Nutrition and Hepatology at Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Christian L. Roth
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Randy J. Seeley
- Center of Excellence in Obesity and Diabetes, University of Cincinnati, Cincinnati, Ohio, USA
| | - Val Sheffield
- Pediatrics and Medical Genetics, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Maïthé Tauber
- Department of Endocrinology, Hôpital des Enfants and Paul Sabatier Université, Toulouse, France
| | - Christian Vaisse
- University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Liheng Wang
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Robert A. Waterland
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics and Molecular & Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Rachel Wevrick
- Department of Medical Genetics, University of Alberta, Edmonton, Canada
| | - Jack A. Yanovski
- Section on Growth and Obesity, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Andrew R. Zinn
- McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, Texas, USA
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Kim JH, Choi JH. Pathophysiology and clinical characteristics of hypothalamic obesity in children and adolescents. Ann Pediatr Endocrinol Metab 2013; 18:161-7. [PMID: 24904871 PMCID: PMC4027083 DOI: 10.6065/apem.2013.18.4.161] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 12/17/2013] [Indexed: 01/30/2023] Open
Abstract
The hypothalamus plays a key role in the regulation of body weight by balancing the intake of food, energy expenditure, and body fat stores, as evidenced by the fact that most monogenic syndromes of morbid obesity result from mutations in genes expressed in the hypothalamus. Hypothalamic obesity is a result of impairment in the hypothalamic regulatory centers of body weight and energy expenditure, and is caused by structural damage to the hypothalamus, radiotherapy, Prader-Willi syndrome, and mutations in the LEP, LEPR, POMC, MC4R and CART genes. The pathophysiology includes loss of sensitivity to afferent peripheral humoral signals, such as leptin, dysregulated insulin secretion, and impaired activity of the sympathetic nervous system. Dysregulation of 11β-hydroxysteroid dehydrogenase 1 activity and melatonin may also have a role in the development of hypothalamic obesity. Intervention of this complex entity requires simultaneous targeting of several mechanisms that are deranged in patients with hypothalamic obesity. Despite a great deal of theoretical understanding, effective treatment for hypothalamic obesity has not yet been developed. Therefore, understanding the mechanisms that control food intake and energy homeostasis and pathophysiology of hypothalamic obesity can be the cornerstone of the development of new treatments options. Early identification of patients at-risk can relieve the severity of weight gain by the provision of dietary and behavioral modification, and antiobesity medication. This review summarizes recent advances of the pathophysiology, endocrine characteristics, and treatment strategies of hypothalamic obesity.
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Affiliation(s)
- Ja Hye Kim
- Division of Pediatric Endocrinology & Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Pediatric Endocrinology & Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Zoicas F, Droste M, Mayr B, Buchfelder M, Schöfl C. GLP-1 analogues as a new treatment option for hypothalamic obesity in adults: report of nine cases. Eur J Endocrinol 2013; 168:699-706. [PMID: 23392214 DOI: 10.1530/eje-12-0997] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with hypothalamic pathology often develop morbid obesity, causing severe metabolic alterations resulting in increased morbidity and mortality. Glucagon-like peptide-1 (GLP-1) analogues improve glycaemic control in type 2 diabetic patients and cause weight loss in obese patients by yet unknown mechanisms. Here we tested whether GLP-1 analogues were also effective in the treatment of obesity and associated metabolic alterations in patients with hypothalamic disease. METHODS Nine patients (eight with type 2 diabetes mellitus) with moderate to severe hypothalamic obesity were treated with GLP-1 analogues for up to 51 months. Body weight, homeostasis model assessment - insulin resistance (HOMA-IR), HbA1c and lipids were assessed. RESULTS Eight patients experienced substantial weight loss (-13.1±5.1 kg (range -9 to -22)). Insulin resistance (HOMA-IR -3.2±3.5 (range -9.1 to 0.8)) and HbA1c values (-1.3±1.4% (range -4.5 to 0.0)) improved under treatment (24.3±18.9 months (range 6 to 51)). Five patients reported increased satiation in response to the treatment. Two of the eight patients complained about nausea and vomiting and one of them abandoned therapy because of sustained gastrointestinal discomfort after 6 months. One patient suffered from intolerable nausea and vomiting and discontinued treatment within 2 weeks. CONCLUSION GLP-1 analogues can cause substantial and sustained weight loss in obese patients with hypothalamic disease. This offers a new approach for medical treatment of moderate to severe hypothalamic obesity and associated metabolic alterations.
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Affiliation(s)
- Flavius Zoicas
- Division of Endocrinology and Diabetes, Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Sherafat-Kazemzadeh R, Yanovski SZ, Yanovski JA. Pharmacotherapy for childhood obesity: present and future prospects. Int J Obes (Lond) 2013; 37:1-15. [PMID: 22929210 PMCID: PMC3522799 DOI: 10.1038/ijo.2012.144] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric obesity is a serious medical condition associated with significant comorbidities during childhood and adulthood. Lifestyle modifications are essential for treating children with obesity, yet many have insufficient response to improve health with behavioral approaches alone. This review summarizes the relatively sparse data on pharmacotherapy for pediatric obesity and presents information on obesity medications in development. Most previously studied medications demonstrated, at best, modest effects on body weight and obesity-related conditions. It is to be hoped that the future will bring new drugs targeting specific obesity phenotypes that will allow clinicians to use etiology-specific, and therefore more effective, anti-obesity therapies.
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Affiliation(s)
- Roya Sherafat-Kazemzadeh
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Susan Z. Yanovski
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
| | - Jack A. Yanovski
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Abstract
The increasing global prevalence of obesity urgently requires an implementation of efficient preventive and therapeutic measures. Weight loss and its maintenance should be considered one of the most important strategies to reduce the incidence of obesity-related co-morbidities such as diabetes and cardiovascular diseases. Lifestyle modification focused on diet and physical activity represents the essential component of any kind of weight management. However, only an intensive lifestyle intervention can be efficient in terms of long-term weight loss. Anti-obesity drugs affect different targets in the central nervous system or peripheral tissues and improve regulatory and metabolic disturbances that contribute to the development of obesity. Anti-obesity medications provide modest additional fat loss to that achieved by lifestyle modification alone, reduce visceral fat stores, improve programme adherence, weight loss maintenance, diminish obesity-related health risks and improve a quality of life. Anti-obesity drugs do play a role in weight management. Their replacement with placebo is followed by weight regain. Due to adverse events, several anti-obesity drugs were withdrawn from the market over the past few years and currently only orlistat remains available for long-term obesity management. Drug withdrawals, failure of clinical trials with several new anti-obesity compounds as well as inappropriate demands of drug regulating agencies concerning the study protocol led to scepticism about the perspectives in the pharmacotherapy of obesity. However, recently developed anti-obesity medications such as gut hormone analogues and drug combinations provided encouraging results in terms of weight loss, safety and improvement of cardio-metabolic health risks.
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Bereket A, Kiess W, Lustig RH, Muller HL, Goldstone AP, Weiss R, Yavuz Y, Hochberg Z. Hypothalamic obesity in children. Obes Rev 2012; 13:780-98. [PMID: 22577758 DOI: 10.1111/j.1467-789x.2012.01004.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypothalamic obesity is an intractable form of obesity syndrome that was initially described in patients with hypothalamic tumours and surgical damage. However, this definition is now expanded to include obesity developing after a variety of insults, including intracranial infections, infiltrations, trauma, vascular problems and hydrocephalus, in addition to acquired or congenital functional defects in central energy homeostasis in children with the so-called common obesity. The pathogenetic mechanisms underlying hypothalamic obesity are complex and multifactorial. Weight gain results from damage to the ventromedial hypothalamus, which leads, variously, to hyperphagia, a low-resting metabolic rate; autonomic imbalance; growth hormone-, gonadotropins and thyroid-stimulating hormone deficiency; hypomobility; and insomnia. Hypothalamic obesity did not receive enough attention, as evidenced by rarity of studies in this group of patients. A satellite symposium was held during the European Congress of Obesity in May 2011, in Istanbul, Turkey, to discuss recent developments and concepts regarding pathophysiology and management of hypothalamic obesity in children. An international group of leading researchers presented certain aspects of the problem. This paper summarizes the highlights of this symposium. Understanding the central role of the hypothalamus in the regulation of feeding and energy metabolism will help us gain insights into the pathogenesis and management of common obesity.
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Affiliation(s)
- A Bereket
- Department of Pediatrics, Marmara University, Istanbul, Turkey.
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Page-Wilson G, Wardlaw SL, Khandji AG, Korner J. Hypothalamic obesity in patients with craniopharyngioma: treatment approaches and the emerging role of gastric bypass surgery. Pituitary 2012; 15:84-92. [PMID: 21935755 PMCID: PMC3641571 DOI: 10.1007/s11102-011-0349-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hypothalamic obesity is a potential sequela of craniopharyngioma, arising from hypothalamic damage inflicted by either the tumor and/or its treatment. The marked weight gain that characterizes this disorder appears to result from impaired sympathoadrenal activation, parasympathetic dysregulation, and other hormonal and hypothalamic disturbances that upset the balance between energy intake and expenditure. Given hypopituitarism is commonly present, careful management of hormonal deficits is important for weight control in these patients. In addition, diet, exercise, and pharmacotherapy aimed at augmenting sympathetic output, controlling hyperinsulinism, and promoting weight loss have been used to treat this disease, but these measures rarely lead to sustained weight loss. While surgical interventions have not routinely been pursued, emerging data suggests that surgical weight loss interventions including Roux-en-Y gastric bypass can be safely and effectively used for the management of hypothalamic obesity in patients with craniopharyngioma.
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Affiliation(s)
- Gabrielle Page-Wilson
- Department of Medicine, Columbia University College of Physicians and Surgeons, William Black Medical Research Building, 650 West 168th Street, Room 905, New York, NY 10032, USA
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Hypothalamic Obesity following Craniopharyngioma Surgery: Results of a Pilot Trial of Combined Diazoxide and Metformin Therapy. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2011; 2011:417949. [PMID: 21603206 DOI: 10.1155/2011/417949] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/07/2011] [Indexed: 01/08/2023]
Abstract
Objective. To assess the effect of combined diazoxide-metformin therapy in obese adolescents treated for craniopharyngioma. Design. A prospective open-label 6-month pilot treatment trial in 9 obese subjects with craniopharyngioma. Diazoxide (2 mg/kg divided b.i.d., maximum 200 mg/day) and metformin (1000 mg b.i.d.). Whole body insulin sensitivity index (WBISI) and area-under-the-curve insulin (AUC(ins)) were calculated. Results. Seven subjects completed: 4M/3F, mean ± SD age 15.4 ± 2.9 years, weight 99.7 ± 26.3 kg, BMI 35.5 ± 5.6 kg/m(2), and BMI SDS 2.3 ± 0.3. Two were withdrawn due to vomiting and peripheral edema. Of participants completing the study, the mean ± SD weight gain, BMI, and BMI SDS during the 6 months were reduced compared to the 6 months prestudy (+1.2 ± 5.9 versus +9.5 ± 2.7 kg, P = .004; -0.3 ± 2.3 versus +2.2 ± 1.5 kg/m(2), P = .04; -0.04 ± 0.15 versus +0.11 ± 0.08, P = .021, resp.). AUC(ins) correlated with weight loss (r = 0.82, P = .02) and BMI decrease (r = 0.96, P = .009). Conclusion. Combined diazoxide-metformin therapy was associated with reduced weight gain in patients with hypothalamic obesity. AUC(ins) at study commencement predicted effectiveness of the treatment.
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Park CH, Jeong SJ, Lee HJ, Lee EO, Bae H, Lee MH, Kim SH, Jung HJ, Ahn KS, Kim SH. Traditional medicine Taeeumjowitangkagambang exerts antiobesity and hypolipidemic effects via antioxidant enzyme enhancement. Phytother Res 2011; 24:1700-9. [PMID: 21031632 DOI: 10.1002/ptr.3179] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Taeeumjowitangkagambang (ETJKB) is a traditional Korean medicine that has been clinically used for obesity with little mechanistic understanding. The present study investigated antiobesity and hypolipidemic effects of ETJKB in high fat diet fed rats as well as a 3T3-L1 pre-adipocyte differentiation model. ETJKB significantly inhibited the lipidogenesis in 3T3-L1 adipocytes in a concentration-dependent manner as well as reduced the cellular adipokine leptin level. Daily oral gavage of ETJKB to rats fed a high fat diet significantly attenuated body weight gain and abdominal and epididymal fat weights. ETJKB treatment also reduced the levels of total cholesterol, low density lipoprotein (LDL) and triglyceride as well as increased high density lipoprotein (HDL) in serum compared with the untreated control. Similarly, the ETJKB treatment decreased the levels of total lipid, triglyceride and cholesterol in liver tissue in high fat diet fed rats. Interestingly, ETJKB significantly increased the activities of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase in liver tissue, while decreasing the hydroxyl radical, thiobarbituric acid reactive substances (TBARS), carbonyl concentration. An improvement of antioxidant enzymes was associated with improved body weight control and healthier lipid profiles and therefore may play an important role in the antiobesity and hypolipidemic effects of ETJKB.
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Affiliation(s)
- Cheol-Hwan Park
- College of Oriental Medicine, Kyung Hee University, 1 Hoegidong, Dongdaemungu, Seoul 130-701, South Korea
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Myslobodsky M, Eldan A. Winning a won game: caffeine panacea for obesity syndemic. Curr Neuropharmacol 2010; 8:149-60. [PMID: 21119886 PMCID: PMC2923369 DOI: 10.2174/157015910791233213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 02/20/2010] [Accepted: 02/23/2010] [Indexed: 02/08/2023] Open
Abstract
Over the past decades, chronic sleep reduction and a concurrent development of obesity have been recognized as a common problem in the industrialized world. Among its numerous untoward effects, there is a possibility that insomnia is also a major contributor to obesity. This attribution poses a problem for caffeine, an inexpensive, “natural” agent that is purported to improve a number of conditions and is often indicated in a long-term pharmacotherapy in the context of weight management. The present study used the “common target” approach by exploring the tentative shared molecular networks of insomnia and adiposity. It discusses caffeine targets beyond those associated with adenosine signaling machinery, phosphodiesterases, and calcium release channels. Here, we provide a view suggesting that caffeine could exert some of its effects by acting on several signaling complexes composed of HIF-1α/VEGF/IL-8 along with NO, TNF-α, IL1, and GHRH, among others. Although the relevance of these targets to the reported therapeutic effects of caffeine has remained difficult to assess, the utilization of caffeine efficacies and potencies recommend its repurposing for development of novel therapeutic approaches. Among indications mentioned, are neuroprotective, nootropic, antioxidant, proliferative, anti-fibrotic, and anti-angiogenic that appear under a variety of dissimilar diagnostic labels comorbid with obesity. In the absence of safe and efficacious antiobesity agents, caffeine remains an attractive adjuvant.
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Abstract
Hypothalamic obesity (HyOb) was first defined as the significant polyphagia and weight gain that occurs after extensive suprasellar operations for excision of hypothalamic tumours. However, polyphagia and weight gain complicate other disorders related to the hypothalamus, including those that cause structural damage to the hypothalamus like tumours, trauma, radiotherapy; genetic disorders such as Prader-Willi syndrome; side effects of psychotropic drugs; and mutations in several genes involved in hypothalamic satiety signalling. Moreover, 'simple' obesity is associated with polymorphisms in several genes involved in hypothalamic weight-regulating pathways. Thus, understanding HyOb may enhance our understanding of 'simple' obesity. This review will claim that HyOb is a far wider phenomenon than hitherto understood by the narrow definition of post-surgical weight gain. It will emphasize the similarity in clinical characteristics and therapeutic approaches for HyOb, as well as its mechanisms. HyOb, regardless of its aetiology, is a result of impairment in hypothalamic regulatory centres of body weight and energy expenditure. The pathophysiology includes loss of sensitivity to afferent peripheral humoral signals, such as, leptin on the one hand and dysfunctional afferent signals, on the other hand. The most important afferent signals deranged are energy regulation by the sympathetic nervous system and regulation of insulin secretion. Dys-regulation of 11β-hydroxysteroid dehydrogenase 1 (11β-HSD1) activity and melatonin may also have a role in the development of HyOb. The complexity of the syndrome requires simultaneous targeting of several mechanisms that are deranged in the HyOb patient. We review the studies evaluating possible treatment strategies, including sympathomimetics, somatostatin analogues, triiodothyronine, sibutramine, and surgery.
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Affiliation(s)
- I Hochberg
- Rambam Medical Center and Rappaport Family Faculty of Medicine and Research Institute, Technion - Israel Institute of Technology, Haifa, Israel.
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Abstract
Although obesity is a chronic disease like hypertension and diabetes, obesity is not treated with drug combinations as are other chronic diseases. This is because orlistat and sibutramine, the two drugs approved for long-term treatment of obesity, do not result in additive weight loss when combined. This article discusses the history of combination drug therapy for treating obesity, the lessons learned from that experience, and describes the drug combinations now in development. One combination of two standardized dietary herbal supplements that result in clinically significant weight loss is also described. Obesity is poised to enter the era of combination drug therapy, as is now the routine in the treatment of other chronic diseases like hypertension and diabetes. The advent of combination drug therapy for obesity treatment offers hope for increasing the efficacy of obesity pharmacotherapy.
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Affiliation(s)
- Frank L Greenway
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, 70808, USA.
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Chen S, Xiao N, Zhang X. Effect of combined therapy with ephedrine and hyperbaric oxygen on neonatal hypoxic-ischemic brain injury. Neurosci Lett 2009; 465:171-6. [PMID: 19765636 DOI: 10.1016/j.neulet.2009.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 09/04/2009] [Accepted: 09/08/2009] [Indexed: 01/30/2023]
Abstract
Perinatal hypoxic-ischemic (HI) is a major cause of brain injury in the newborn, and there is a lack of effective therapies to reduce injury-related disorders. The aim of the present study was to evaluate the effect of a combination of ephedrine and hyperbaric oxygen (HBO) on neonatal hypoxic-ischemic brain injury. 7-day-old Sprague-Dawley rat pups were randomly divided into sham operation, HI, ephedrine, HBO, and combined group. The ephedrine group was intraperitoneally injected with ephedrine, HBO group was treated for 2h at 2.5 absolute atmosphere (ATA) per day, the combined group received both ephedrine and HBO treatments, the sham operation and HI groups were intraperitoneally injected with normal saline. Rat brains at 7 days after HI, were collected to determine histopathological damage and the expression levels of Caspase-3 and Nogo-A. Four weeks after insult, animals were challenged with Morris water maze test. The expressions of Caspase-3 and Nogo-A were reduced in treating groups compared to those in HI group (P<0.01). Compared with the single treatment groups, the expression levels of Caspase-3 and Nogo-A were significantly reduced in the combined group (P<0.01). Compared with the single treatment groups, the average time of escape latency was significantly shorter (P<0.01) and the number of platform location crossing was more (P<0.05) in combined group. These findings indicate that the combination of ephedrine and HBO can enhance the neuroprotective effect in the neonatal rat HI model partially mediated by inhibiting Caspase-3 and Nogo-A pathways.
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Affiliation(s)
- Siyuan Chen
- Department of Rehabilitation Center, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
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Stimulation of sympathetic innervation in the upper gastrointestinal tract as a treatment for obesity. Med Hypotheses 2009; 72:706-10. [PMID: 19246162 DOI: 10.1016/j.mehy.2008.12.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 12/17/2008] [Accepted: 12/20/2008] [Indexed: 11/22/2022]
Abstract
Sympathetic activity and obesity have a reciprocal relationship. Firstly, hypothalamic obesity is associated with decreased sympathetic activity. Caffeine and ephedrine increase sympathetic activity and induce weight loss, of which 25% is due to increased metabolic rate and 75% is due to a reciprocally decreased food intake. Secondly, hormones and drugs that affect body weight have an inverse relationship between food intake and metabolic rate. Neuropeptide Y decreases sympathetic activity and increases food intake and body weight. Thirdly, a gastric pacemaker Transcend and vagotomy increase the ratio of sympathetic to parasympathetic activation, decrease food intake, and block gut satiety hormones. Weight loss with the pacemaker or vagotomy is variable. Significant weight reduction is seen only in a small group of those treated. This suggests that activation of the sympathetic arm of the autonomic nervous system may be most important for weight loss. Systemic sympathetic activation causes weight loss in obese patients, but side effects limited its use. We hypothesize that selective local electrical sympathetic stimulation of the upper gastrointestinal tract may induce weight loss and offer a safer, yet effective, obesity treatment. Celiac ganglia delivers sympathetic innervation to the upper gastrointestinal tract. Voltage regulated electrical simulation of the rat celiac ganglia increased metabolic rate in a dose-dependent manner. Stimulation of 6, 3, or 1.5 V increased metabolic rate 15.6%, 6.2%, and 5%, respectively in a single rat. These responses support our hypothesis that selective sympathetic stimulation of the upper GI tract may treat obesity while avoiding side effects of systemic sympathetic activation.
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