LBMON197 Predictors Of Response To Growth Hormone Treatment In Pediatric Growth Disorders: Analysis From The Answer Program And Nordinet® IOS

Background

The American Norditropin® Studies: Web-Enabled Research (ANSWER) Program and the NordiNet® International Outcome Study (NordiNet® IOS) were large-scale, non-interventional studies intended to gather long-term data on the effectiveness and safety of Norditropin® (somatropin) treatment in the real-world setting. Data were collected in the US and Europe from 2006 to 2016.

Objective

To determine predictors of response to daily growth hormone (GH) for height outcomes using a longitudinal analysis across 5 years of real-world data from pediatric patients with growth hormone deficiency (GHD), Turner syndrome (TS), Noonan syndrome (NS), and Prader-Willi syndrome (PWS).

Methods

Data were combined for ANSWER and NordiNet® IOS studies for GH-treatment-naïve pediatric patients on daily somatropin. Descriptive statistics for baseline demographics, outcomes, and GH (mg/kg/d) data were analyzed for each indication; statistics for outcome and GH data were analyzed over time for absolute values and change from baseline values at year 1 through year 5. A longitudinal statistical approach was used to identify factors, including age at treatment start and HSDS at baseline, significantly associated with change in height SDS from baseline (ΔHSDS) in a regression model. Repeated-measures regression analyses were performed on ΔHSDS, adjusting for covariates. Longitudinal growth responses over the follow-up years were evaluated.

Results

Overall, 14,295 patients were included in the analyses: 3766 females and 8917 males with GHD, 1307 patients with TS, 55 females and 148 males with NS, and 52 females and 50 males with PWS. Mean (SD) GH dose for patients with GHD was 0. 037 (0. 012) mg/kg/d (females) and 0. 038 (0. 012) mg/kg/d (males), for those with TS was 0. 045 (0. 011) mg/kg/d, those with NS was 0. 042 (0. 012) mg/kg/d, and those with PWS was 0. 031 (0. 013) mg/kg/d. HSDS improved over time across all indications. Greater improvement in HSDS was observed for years 1 and 2 of follow-up, with a plateau in years 4 and 5; this plateau was most apparent in patients with TS. Age at start of GH therapy had a significant effect on ΔHSDS for all indications (P<0. 001 for all). Lower baseline HSDS on average resulted in lower HSDS improvement over time. In a regression model, the GH dose (mg/kg/d) from the previous year was positively associated with ΔHSDS, with a significant positive slope for GHD and TS (P<0. 0001 for both). A 0. 01 increase in GH mg/kg/d increased the average HSDS improvement by 0. 02 to 0. 03 units in GHD and 0. 03 units in TS. Slopes for NS (P=0.3534) and PWS (P=0.1485) were not significant.

Conclusions

On average, GH treatment resulted in HSDS improvements over baseline across all indications; patients with GHD had the highest improvement, while patients with TS had the lowest improvement. Earlier treatment with GH led to better outcomes in HSDS. Increasing the dose of GH also led to better outcomes in HSDS.

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

Therapy for 6.5-7.5 years with recombinant insulin-like growth factor I in children with growth hormone insensitivity syndrome: a clinical research center study

Eight children with GH insensitivity syndrome were treated with recombinant human insulin-like growth factor I (IGF-I) (80--120 microg/kg sc twice daily) for 6.5--7.5 yr. We previously reported that height velocity (HV) improved with treatment (from mean pretreatment HV of 4.0 cm/yr), to 9.3 cm/yr for the first year and 6.2 cm/yr for the second year. HV remained slightly below this during the subsequent years (mean HV: 5.4, 5.5, 5.2, and 4.8 cm/yr during years 3--6). Mean height SD score before therapy was -5.6; and it improved to -4.5, -4.4, and -4.2 after 2, 4, and 6 yr of therapy, respectively. Treatment was accompanied by gain in body weight and fat. Bone age advanced normally in the prepubertal patients, but it advanced more rapidly during the latter years of treatment in those patients undergoing pubertal changes. The growth of spleen and kidneys (determined by ultrasound) was rapid in the first 2--3 yr of therapy. More age- appropriate growth ensued, but six patients had a renal length for height more than 2 SD above the mean at 6--7 yr of treatment. No major adverse changes in biochemical profile were observed. IGF-I-related hypoglycemia occurred early in treatment with the younger patients, but this problem abated as treatment was continued. IGF-I therapy is effective in promoting statural growth in GH insensitivity syndrome patients, but the growth response is neither as intense nor as well-sustained as the growth response to GH among children with GH deficiency.

Novel ring chromosome composed of X- and Y-derived material in a girl with manifestations of Ullrich-Turner syndrome

We present a female infant who has a novel genetic variant of Ullrich-Turner syndrome. Chromosome analysis on amniotic fluid cells obtained because of ultrasound observation of nuchal thickening showed 45,X in all cells. The infant was born with a low posterior hairline and moderate edema over hands and feet. Postnatal chromosome analysis demonstrated two cell lines-47% of the metaphases were 45,X, but 53% had a ring chromosome in addition to the normal X. FISH studies using alpha satellite probes, an X-whole-chromosome-paint (WCP) probe, and a Y-cocktail probe determined that the ring was composed of both X and Y sequences. FISH studies also determined that the KAL locus was present on the ring, but that XIST was absent. PCR-based analysis of lymphocyte DNA documented that the ring contained sequences from both the short and the long arm of the Y chromosome. X-chromosome analysis using a panel of highly polymorphic markers indicated that the ring contained material derived only from Xp22.1 to Xp21.3. No Xq material was identified on the ring, and androgen receptor-based X-inactivation studies suggested that the intact X chromosome was not subject to random X inactivation.

Phosphaturic mesenchymal tumor-induced rickets

We describe two prepubertal girls with oncogenic rickets. The first patient, 9 years of age, presented with recent-onset lower-extremity pain. The second girl, presented at 4 years of age following a 9-month period of muscle weakness, bone pain, and poor linear growth. Laboratory analyses in both patients revealed hypophosphatemia and hyperphosphaturia; elevated circulating alkaline phosphatase activity was present in one of them. Radiographic evidence of a generalized rachitic process was evident in both cases. Computerized tomography of the paranasal sinuses and facial bones in patient 1 revealed a small lesion eroding through the inner table of the left mandibular ramus. Microscopic examination of this mass revealed a spindle cell neoplasm with chondroid material, dystrophic calcification, and both osteoclast-like and fibroblast-like cells. Prominent vascularity and marked atypia were present. These features are consistent with a phosphaturic mesenchymal tumor of the mixed connective tissue variant. In the second patient, computerized tomography revealed a lytic lesion located in the right proximal tibia, with histologic features consistent with a phosphaturic mesenchymal tumor of the nonossifying fibroma-like variant. Resection of each tumor resulted in rapid correction of the phosphaturia and healing of the rachitic abnormalities. A careful search for small or occult tumors should be carried out in cases of acquired phosphaturic rickets.

Prolonged treatment with recombinant insulin-like growth factor-I in children with growth hormone insensitivity syndrome--a clinical research center study. GHIS Collaborative Group

Eight children with GH insensitivity syndrome, five with GH receptor deficiency (Laron syndrome) and three with growth-attenuating antibodies to GH, were treated with recombinant human insulin-like growth factor I (IGF-I) for 24 months (one was treated for 36 months). Their ages at the beginning of therapy ranged from 2-11 yr. The dose of IGF-I ranged between 80-120 micrograms/kg, given sc twice daily. During the first year of treatment, height velocity (HV) improved in each patient (mean pretreatment HV, 4.0 cm/yr; mean of first year, 9.3 cm/yr). HV declined by 33% during the second year (mean HV, 6.2 cm/yr). The third year HV of the one patient so treated was approximately the same as that in the second year. The mean SD score HV before therapy was -2.4 and improved to +3.8 and +0.5 after 1 and 2 yr of therapy, respectively. Increased HV was accompanied by weight gain. IGF-I-related hypoglycemia occurred infrequently and only early in treatment. No adverse changes in biochemical profile were observed. Bone age did not advance more rapidly than chronological age (mean change in bone age, 2.1 yr; mean change in chronological age, 2.2 yr). The growth of the spleen and kidneys (determined by ultrasound) was rapid in the first year of therapy. In the second year, spleen growth slowed to a normal rate in most patients. Kidney growth, however, remained relatively rapid. These results indicate that IGF-I stimulates statural growth for at least 2 yr and confirms that this peptide has the capacity to act through endocrine mechanisms. Prolonged treatment of GH insensitivity syndrome patients shows promise. The stimulation of growth by IGF-I treatment over years needs to be documented, and patients need to be monitored for side-effects.

Effect of intravenous insulin-like growth factor I in two patients with leprechaunism

Leprechaunism (Donohue syndrome) is an autosomal recessive disorder characterized by hyperglycemia, extreme insulin resistance, dysmorphic features, failure to thrive, and early death. In this study, recombinant IGF-I, which has both insulin-like and anabolic effects, was administered to two infants with leprechaunism in an attempt to reduce hyperglycemia and improve nutritional status. IGF-I was infused for 66 h in patient FL-1 and 62 h in patient NC-2, with maximal infusion rates of 110 and 40 micrograms/kg/h, respectively. Although supraphysiologic concentrations of IGF-I were achieved (459 and 1583 micrograms/L in FL-1 and NC-2, respectively), there were no apparent glucose-lowering or nitrogen-sparing effects. Insulin concentrations decreased from extremely high values (16804 and 10224 pmol/L) but remained elevated (611 pmol/L in FL-1 and 5869 pmol/L in NC-2). No changes in serum and urinary urea nitrogen or electrolytes occurred. IGF binding protein-2, which was the predominant IGF binding protein in serum by ligand blot and immunoblot, did not change with IGF-I infusion. IGF binding protein-3 levels were low at baseline and increased slightly during the infusion. We hypothesize that the lack of significant glucose-lowering and anabolic responses to IGF-I could be secondary to a postreceptor defect in IGF-I signaling resulting from the absence of functional insulin receptors.

Homozygous deletion of the human insulin receptor gene results in leprechaunism

Homozygous inactivation of a gene, as is frequently performed to generate mouse models, provides an opportunity to elucidate the role that the gene plays in normal physiology. However, studies of human disease provide direct insight into the effect of inactivating mutations in man. In this investigation, we have identified a one year-old boy from a consanguineous pedigree who is homozygous for deletion of the insulin receptor gene resulting in leprechaunism. Contrary to previous predictions, the complete deletion of the insulin receptor gene is compatible with life.

Synthesis and regulation of insulin-like growth factor binding protein-5 in FRTL-5 cells

FRTL-5 cells, a diploid nontransformed line of rat thyroid follicular cells, exhibit a marked mitogenic response to insulin-like growth factors (IGFs) when they are exposed to TSH. Because IGF binding proteins (IGFBPs) are important modulators of IGF actions, we investigated the capacity of FRTL-5 cells to synthesize IGFBPs. We found that FRTL-5 cell conditioned media contained a single band of approximately 31 kilodaltons on ligand blot analysis. This band represents IGFBP-5 because: 1) it can be immunostained with a specific antibody raised against human IGFBP-5; 2) by Northern analysis, total RNA from FRTL-5 cells contains a major 6-kilobase transcript when hybridized with a cDNA for rat IGFBP-5; and 3) no transcripts were observed when Northern blots of FRTL-5 cells were hybridized with complementary DNAs for rat IGFBP-1, -2, -3, -4 or -6. Conditioned media IGFBP-5 increased in response to IGF-I, IGF-II, and insulin in a dose-dependent fashion, compared with unstimulated FRTL-5 cells. At maximally effective concentrations IGF-I was 3.5- and 6-fold more potent than IGF-II and insulin, respectively. The addition of a monoclonal antibody (Sm 1.2) to IGF-I completely inhibited IGF-I stimulation of the IGFBP-5 6-kilobase transcript and the appearance of IGFBP-5 in FRTL-5 conditioned media. Stimulation of IGFBP-5 synthesis by the IGFs and insulin appeared to be regulated at the messenger RNA (mRNA) level, because each stimulated similar increases in both IGFBP-5 mRNA and media protein at maximally effective concentrations. TSH, on the other hand, inhibited basal levels of IGFBP-5 mRNA and attenuated the increase in IGFBP-5 mRNA stimulated by IGF-I. FRTL-5 cells provide a relatively uncomplicated model to study the regulation and action of IGFBP-5 and the mechanisms by which IGFs interact with this binding protein.