ODP426 SPIOMET4HEALTH: a 4-Arm Trial to Test the Effects of Lifestyle Intervention plus either Placebo, or Pioglitazone (PIO), or Spironolactone-Pioglitazone (SPIO), or Spironolactone-Pioglitazone-Metformin (SPIOMET) in Adolescent Girls and Young Women with PCOS

Introduction

PCOS in adolescent girls and young women is nowadays thought to be, in essence, an epiphenomenon of ectopic fat accumulation. By definition, "adolescent PCOS" is characterized by androgen excess (as well clinical as biochemical) and oligo-anovulation (often judged by oligo-amenorrhea) (1) presenting between 2 and 8 years after menarche. There is no FDA-approved treatment for "adolescent PCOS". In SPIOMET4HEALTH (a project funded by the European Commission under Grant Agreement 899671), we aim at reducing ectopic fat in an early phase of PCOS, with a standardized lifestyle intervention plus a pharmacological addendum consisting of either placebo, or PIO, or SPIO, or SPIOMET. In "adolescent PCOS", low-dose pioglitazone (7.5 mg/d) may exert insulin-sensitizing and gonadotropin-normalizing effects, in part by raising the circulating concentrations of high-molecular-weight adiponectin; low-dose spironolactone (50 mg/d) may not only act as an anti-androgen but also exert anti-mineralocorticoid effects that raise energy expenditure by activating brown adipose tissue; low-dose metformin (850 mg/d) is known to act through multiple mechanisms and was recently shown to be capable of changing the relative deficit of GDF15 into an abundance that is thought to contribute to reduce liver fat.

Subjects & Methods

In the SPIOMET4HEALTH trial, patients with "adolescent PCOS" (age range 12. 0–23.9 years; BMI <35 kg/m 2) will be recruited in seven centers across Europe. A total of 364 patients are expected to engage into a lifestyle intervention, and to receive either placebo, or PIO, or SPIO, or SPIOMET once daily (1: 1: 1: 1 randomization; single tablets; double blinding) for 12 months. Post-treatment follow-up will span 6 months. The primary endpoint is ovulation rate, as judged by a combination of menstrual data and progesterone concentrations in saliva; the analysis will start by testing for superiority between placebo and SPIOMET. Secondary endpoints include pre-treatment, on-treatment and post-treatment measures of androgen excess, body composition and insulin sensitivity, as well as measures of quality of life, and of adherence to treatment. The design of this trial has been endorsed by the European Medicines Agency, as part of a "Paediatric Investigation Plan".

Expected Results/Discussion

The SPIOMET4HEALTH project is expected to deliver the first results of an international, randomized, double-blind, active-controlled/placebo-controlled trial evaluating the safety, efficacy, and tolerability of the fixed dose combination SPIOMET in adolescent girls and young women with PCOS. Favorable results of this Phase 2 trial may advance SPIOMET into Phase 3. Reference: Ibáñez L, et al. An International Consortium Update: pathophysiology, diagnosis, and treatment of polycystic ovarian syndrome in adolescence. Horm Res Paediatr 2017;88: 371-395.

Presentation: No date and time listed

PMON336 Pfizer Registry of Outcomes in Growth hormone RESearch (PROGRES): A multi-country, non-interventional, prospective, cohort study of patients receiving human growth hormone treatments under routine clinical care

Background

Children with growth hormone deficiency (GHD) are treated with recombinant human growth hormone (rhGH), usually administered as a daily subcutaneous injection. Long-acting hGH (LAGH) treatments (approved and in development) have the potential to improve adherence and treatment outcomes. Somatrogon is a LAGH currently being developed as a once-weekly injectable treatment for GHD. The Pfizer Registry of Outcomes in Growth hormone RESearch (PROGRES) study was initiated to assess the long-term safety and effectiveness of Genotropin and other hGH formulations to treat GHD under routine clinical care.

Goals & aims: The overall goal of the registry is to increase our understanding of hGH treatments as used in a real-world setting. Enrolling children treated with different daily hGH brands as well as somatrogon (if approved in a given geography) will enable comparison between daily and LAGH, and across daily hGH brands. The primary objectives of the study are to describe and compare the safety and effectiveness of daily and LAGH treatments in children. Secondary objectives include evaluating adherence to hGH treatments and the health-related quality of life (HRQoL) and treatment experience of patients receiving hGH treatments.

Methods

For this non-interventional, prospective, phase 4 cohort study, eligible patients (male or female at any age) from &gt;20 countries are planned for inclusion, with the aim of targeting 667 patients across the daily hGH brands in each of the three geographic regions. Patients will be enrolled from September 2021 to October 2029, with data collection planned until October 2030. Study inclusion criteria include prescription of daily Genotropin or other approved hGH treatments for GHD and the provision of informed consent/assent. If somatrogon is approved by regulatory agencies, somatrogon-treated patients will also be eligible for inclusion. Patients participating in any interventional clinical trials at the time of enrollment will be excluded from the study. Patients will be followed until the end of the study, withdrawal of consent, death, switch to an excluded hGH, or loss to follow-up, whichever occurs first. In addition to demographic and clinical characteristics, information on hGH treatment brand, dose and start/end dates will be collected, along with reasons for switching or discontinuing treatment. Primary safety outcomes include adverse events (AEs), serious AEs, and AEs of special interest. Primary effectiveness outcomes include annual height velocity (HV) and change in HV standard deviation scores. Treatment adherence, compliance outcomes, HRQoL, and patient treatment experience will be assessed.

Conclusions

The findings from the PROGRES study will provide valuable insights into the use of somatrogon, Genotropin and other approved hGH treatments in real-world clinical practice, specifically with regard to the long-term safety and effectiveness of these treatments as well as treatment compliance and patient HRQoL.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

MON-029 Polycystic Ovary Syndrome (PCOS) in Adolescent Girls:Toward a Simple On-Treatment Predictor of Post-Treatment Ovulation Rate

There is no approved treatment for adolescent girls with PCOS. The vast majority of these patients are guided into a trajectory that starts with oral contraceptive (OC) treatment, leads into oligo-anovulatory subfertility, then into the use of assisted reproductive techniques, and ultimately into pregnancies with a double-to-triple risk for complications (such as gestational diabetes, preeclampsia and preterm birth) potentially with lifelong sequelae in the offspring.

Evidence is converging into the insight that adolescent PCOS is frequently driven by hepato-visceral fat excess (“central obesity”) ensuing from a mismatch between (rather restrictive) prenatal and (rather abundant) postnatal nutrition, on a background of genetic susceptibility (Trends Endocrinol Metab 2018;29:815). This insight has prompted the exploration of an alternative PCOS treatment that aims at reducing the central-fat excess (without causing weight loss in non-obese girls) in order to normalize the entire phenotype, including ovulation rate.

So far, this alternative approach has been tested in two randomized controlled pilot studies that were performed in non-obese girls with PCOS and with no need for contraception (total N=62; age 16 yr; BMI 24 Kg/m2; treatment for 1 year; ovulation assessment during the post-treatment year). In these studies, the effects of an OC were compared to those of SPIOMET, which is a low-dose combination of spironolactone (= a mixed anti-androgen and -mineralocorticoid, also activating brown adipose tissue; Diab Ob Metab 2019;21:509), pioglitazone and metformin (= two insulin sensitizers acting through different mechanisms).

Pooled results of the pilot studies confirm the first report (J Adolesc Health 2017;61:446) that SPIOMET has more normalizing effects than OC; there were approximately 3-fold more ovulations post-SPIOMET than post-OC; normovulation occurred only post-SPIOMET; anovulation was &gt;10-fold more frequent post-OC.

Pooled results also disclosed two new features of adolescent PCOS: low concentrations of circulating CXCL14 (= a brown adipokine, signaling activity in brown adipose tissue; Cell Metab 2018;28:750) and miR-451a (= an inhibitor of THRSP-mediated hepatic lipogenesis; Mol Cell Endocrinol 2018;474:260), both of which remain abnormally low on OC, but normalize on SPIOMET treatment. The on-treatment Z-scores of fasting insulin and miR-451a explained together approximately 50% of the variation in post-treatment ovulation rates. This simple duo, if validated in larger and more diverse PCOS populations, may become a first on-treatment predictor of post-treatment ovulation rate.

OR25-3 Toward a Circulating Marker of Hepato-Visceral Fat Excess: S100A4 in Adolescent Girls with Polycystic Ovary Syndrome

S100A4 has recently been identified as an adipokine that can serve as a marker of "pernicious" subcutaneous adipose tissue (Arner et al, Int J Ob 2018). However, S100A4 can also be released by an inflammatory subset of macrophages in the liver (Osterreicher et al, Proc Natl Acad Sci USA 2011). Development of polycystic ovary syndrome (PCOS) in adolescent girls is often driven by an early excess of fat in subcutaneous adipose tissue, accompanied by an excess of fat in ectopic locations, notably in viscera and liver (Cree-Green et al, Obesity 2016; de Zegher et al, Trends Endocrinol Metab 2018). Adolescent PCOS phenotypes are normalized more by preferential reduction of hepato-visceral adiposity with a low-dose combination of spironolactone, pioglitazone and metformin (SPIOMET) than by treatment with an oral contraceptive (OC) (Ibanez et al, J Adolesc Health 2017). Nowadays, the assessment of hepato-visceral adiposity (by magnetic resonance imaging) is rather cumbersome. In an attempt to identify a circulating marker of hepato-visceral fat excess, we studied whether S100A4 concentrations are elevated in adolescent girls with PCOS and, if so, whether they tend to normalize with OC or SPIOMET treatment. In 12 healthy controls and in 51 adolescent girls with PCOS (by International Consortium Update criteria; Ibanez et al, Horm Res Pediatr 2017), we assessed circulating S100A4 along with endocrine markers (including fasting insulin, SHBG, testosterone [by LC-MS/MS], high-molecular-weight adiponectin), body composition (by dual X-ray absorptiometry), and abdominal fat partitioning (by magnetic resonance imaging). Girls with PCOS were randomized for treatment with an OC (n=27) or SPIOMET (n=24) for 1 year, and the changes in their study endpoints were analysed. S100A4 concentrations were on average 71% (or 2.1 Z-score) higher in girls with PCOS than in controls (P<0.001), and they associated with hepato-visceral adiposity (r=0.47; p=0.001). Treatment with OC failed to lower the elevated S100A4 concentrations, whereas treatment with SPIOMET lowered circulating S100A4 toward normal (P<0.001 for within-group changes, and P<0.01 for between-group changes); on-treatment reduction of circulating S100A4 associated closely with reduction of hepato-visceral adiposity (r=0.50; p<0.0001). If the present findings are corroborated in other study cohorts with PCOS, then S100A4 is a first candidate-member of a future set of circulating markers that may simplify the diagnosis and follow-up of patients with PCOS, and perhaps also of patients with other phenotypes of central obesity.

Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery

BACKGROUND

The duodenal-jejunal bypass sleeve (DJBS) has been shown to achieve a completely endoscopic duodenal exclusion without the need for stapling. This report is the first randomized controlled trial for weight loss.

METHODS

In a 12-week, prospective, randomized study, subjects received either a low fat diet and the DJBS or a low fat diet control (no device). Twenty-five patients were implanted with the device and 14 received the control. The groups were demographically similar. Both groups received counseling at baseline only, which consisted of a low calorie diet, and exercise/behavior modification advice. No additional counseling occurred in either group. Measurements included starting and monthly body weight and serum blood tests. The device group also had a plain abdominal film post implant, a monthly KUB and a 4-week post explant EGD.

RESULTS

Twenty device (80%) subjects maintained the DJBS without a significant adverse event for the 12-week duration. At 12 weeks, the mean excess weight loss was 22% and 5% for the device and control groups, respectively (p < 0.001). Five subjects (20%) were endoscopically explanted early secondary to upper GI (UGI) bleeding (n = 3), anchor migration (n = 1) and sleeve obstruction (n = 1). The UGI bleeding occurred at a mean of 13.8 days post implant. EGD was performed in each of these cases with no distinct bleeding source identified. No blood transfusion was required. The migration occurred on day 47 and manifested as abdominal pain. The subject with the sleeve obstruction presented with abdominal pain and vomiting on day 30. Eight subjects (40%) underwent the 4 week post explant EGD at which time mild degrees of residual duodenal inflammation was noted.

CONCLUSION

The DJBS achieves noninvasive duodenal exclusion and short term weight loss efficacy. Longer term randomized controlled sham trials for weight loss and treatment of T2DM are underway.

Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline

OBJECTIVE

Our objective was to develop clinical practice guidelines for the evaluation and treatment of hirsutism in premenopausal women.

PARTICIPANTS

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, six additional experts, two methodologists, and a medical writer. The Task Force received no corporate funding or remuneration.

EVIDENCE

Systematic reviews of available evidence were used to formulate the key treatment and prevention recommendations. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group criteria to describe both the quality of evidence and the strength of recommendations. We used "recommend" for strong recommendations, and "suggest" for weak recommendations.

CONSENSUS PROCESS

Consensus was guided by systematic reviews of evidence and discussions during one group meeting, several conference calls, and e-mail communications. The drafts prepared by the Task Force with the help of a medical writer were reviewed successively by The Endocrine Society's CGS, Clinical Affairs Core Committee (CACC), and Council. The version approved by the CGS and CACC was placed on The Endocrine Society's Web site for comments by members. At each stage of review, the Task Force received written comments and incorporated needed changes.

CONCLUSIONS

We suggest testing for elevated androgen levels in women with moderate or severe hirsutism or hirsutism of any degree when it is sudden in onset, rapidly progressive, or associated with other abnormalities such as menstrual dysfunction, obesity, or clitoromegaly. For women with patient-important hirsutism despite cosmetic measures, we suggest either pharmacological therapy or direct hair removal methods. For pharmacological therapy, we suggest oral contraceptives for the majority of women, adding an antiandrogen after 6 months if the response is suboptimal. We recommend against antiandrogen monotherapy unless adequate contraception is used. We suggest against using insulin-lowering drugs. For women who choose hair removal therapy, we suggest laser/photoepilation.

Ovarian 17 alpha-hydroxyprogesterone responses to GnRH analog testing in oligomenorrheic insulin-dependent diabetic adolescents

OBJECTIVE

To investigate the pituitary-ovarian function in adolescent girls with insulin-dependent diabetes mellitus (IDDM).

DESIGN

Clinical case-control study.

METHODS

The GnRH analog leuprolide acetate was administered subcutaneously to 16 adolescents with IDDM (seven eumenorrheic and nine oligomenorrheic) and 13 controls between 0800 and 0900 h. Blood samples were collected at baseline and 0.5, 3, 6 and 24 h after leuprolide to measure levels of gonadotropins, 17 alpha-hydroxyprogesterone (17-OHP), androgens and estradiol.

RESULTS

Mean baseline serum LH levels were significantly higher in eumenorrheic compared with oligomenorrheic IDDM patients, while peak LH responses to GnRH analog testing were similar in all subjects. Oligomenorrheic IDDM girls showed, as a group, a distinct 17-OHP response to GnRH analog stimulation, which in five out of nine girls was in the range of functional ovarian hyperandrogenism (> or = 8.6 nmol/l). Androgen and estradiol levels were not significantly altered in any group. No correlation was found between steroid levels and HbA1c levels, although the latter were significantly higher in oligomenorrheic than in eumenorrheic patients.

CONCLUSION

About 50% of the oligomenorrheic IDDM adolescents had an increased ovarian 17-OHP response to GnRH analog stimulation in the range of functional ovarian hyperandrogenism. Factors other than metabolic control, such as stress, may play an etiologic role in IDDM ovarian dysfunction.

A retrospective study of the effects of pelvic irradiation for gynecological cancer on anorectal function

PURPOSE

To evaluate the prevalence of anorectal dysfunction following therapeutic pelvic irradiation.

METHODS AND MATERIALS

Anorectal function was evaluated in 15 randomly selected patients (aged 47-84 years) who had received pelvic irradiation for treatment of carcinoma of the uterine body and cervix 5 and 10 years earlier. The following parameters were assessed in each patient: (a) anorectal symptoms (questionnaire), (b) anorectal pressures at rest and in response to rectal distension, voluntary squeeze, and increases in intraabdominal pressure (multiport anorectal manometry with concurrent electromyography of the anal sphincters), (c) rectal sensation (rectal balloon distension) and, (d) anal sphincteric morphology (ultrasound). Results were compared with those obtained in nine female control subjects.

RESULTS

Ten of the 15 patients had urgency of defecation and 4 also suffered fecal incontinence. Basal anorectal pressures measured just proximal to the anal canal (p = 0.05) and anorectal pressures generated in response to voluntary squeeze measured at the anal canal were less (p < 0.01) in the patients. The fall in anal pressures in response to rectal distension was greater in the patients (p < 0.05) and the desire to defecate occurred at lower rectal volumes (p < 0.05). The slope of the pressure/volume relationship in response to rectal distension was greater (p < 0.05) in the patients, suggestive of a reduction in rectal compliance. In 14 of the 15 patients at least one parameter of anorectal motor function was outside the control range. There was no difference in the thickness of the anal sphincters between the two groups.

CONCLUSION

Abnormal anorectal function occurs frequently following pelvic irradiation for gynecological malignant diseases and is characterized by multiple dysfunctions including weakness of the external anal sphincter, stiffness of the rectal wall, and a consequent increase in rectal sensitivity.

Hyperinsulinemia in postpubertal girls with a history of premature pubarche and functional ovarian hyperandrogenism

Previous studies have documented the association of insulin resistance and hyperandrogenism in adult women with functional ovarian hyperandrogenism (FOH) or polycystic ovary syndrome (a form of FOH). However, the possible impact of adrenal hyperandrogenism development during childhood in premature pubarche (PP) patients on postpubertal insulin secretion patterns remains unclear. The fasting insulin to glucose ratio, C peptide, early insulin response to glucose (IRG), mean blood glucose, mean serum insulin (MSI), glucose uptake rate in peripheral tissues (M), and insulin sensitivity indexes (SI) in response to a standard oral glucose tolerance test were evaluated in 13 PP girls with FOH (group A; age, 17.2 +/- 0.5 yr), 11 eumenorrheic nonhirsute PP girls (group B; age, 16.6 +/- 0.5 yr), and 21 age-matched controls (group C). Body mass indexes (BMI) were similar in the 3 groups (group A, 23.3 +/- 0.8; group B, 22.5 +/- 0.6; group C, 20.6 +/- 0.5 kg/m2). MSI values were significantly higher in FOH patients than in controls (74.7 +/- 17.6 vs. 45.7 +/- 4.1 mU/L; P < 0.01), but were not different from those in group B (63.3 +/- 11.1 mU/L). Thirty-eight percent of FOH patients (group A) and 27% of non-FOH patients (group B), all of whom had normal BMI, showed MSI levels well above the upper normal limit for controls (> 83.3 mU/L). MSI correlated with the degree of ovarian hyperandrogenism [defined by an abnormal 17-hydroxyprogesterone response to challenge with the GnRH analog leuprolide acetate; group A] and with the free androgen index [testosterone (nanomoles per L)/sex hormone-binding globulin (nanomoles per L) x 100; groups A and B)]. Although IRG, glucose uptake rate in peripheral tissues, mean blood glucose, and SI values were not significantly different in the 3 groups, 3 patients in group A and 1 patient in group B showed decreased insulin sensitivity and/or an enhanced early IRG. Among others, significant correlations between MSI and free androgen index values (r = 0.6; P < 0.002; groups A and B) and between BMI and SI (r = -0.53; P < 0.05; groups A and B) were found. Peak 17-hydroxyprogesterone responses to ACTH at PP diagnosis correlated positively with SI in both groups of patients (r = 0.53; P < 0.007). Hyperinsulinemia is a common feature in adolescent PP patients with FOH and appears to be directly related to the degree of androgen excess. Long term follow-up of PP patients into adulthood is warranted to ascertain whether hyperinsulinemia actually precedes FOH development and whether overt insulin resistance ensues.

Insulin treatment in adolescence

Treatment of the adolescent diabetic continues to be a challenge for the physician. Ninety-five diabetic patients aged from 12-18 years were treated according to several therapeutic regimens. Principally the Spanish school time-table and, in some cases, life-style or brittle diabetes, determined the adoption of one of five proposed routines. The degree of control achieved assessed by the mean levels of HbA1 (10.6-10.3%), and the frequency and severity of hypoglycaemic accidents ("mild" variety in 25-30% of patients) were similar in all groups with total pancreatic insufficiency. The switch to a four-daily injection regimen (routine 5) with a pen-injector failed to improve metabolic control but patients had more flexibility in meal size and timing. These results suggest that even in teenagers diabetes can be acceptably treated.

[Palliative treatment of carcinoma of the hepatic duct junction. Intra-hepatic derivation or trans-tumoral intubation? (author's transl)]

Intra-hepatic cholangiojejunostomy (group I patients) and simple trans-tumoral intubation (group II patients) were retrospectively compared in a series of 44 patients with primary carcinoma of the hepatic duct junction. Hospital mortality was 30% in the 13 group I patients and 9.5% in the 21 group II patients. Jaundice and pruritus were equally relieved in both groups. The mean survival time (hospital deaths excluded) was 16 months in group I and 12 months in group II patients. It is concluded that the decision as to which of these two palliative surgical procedures should be performed must rest on the degree of biliary duct distension as well as on the patient's age and general condition.