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  • 1.
    Albertsson-Wikland, Kerstin
    et al.
    University of Gothenburg, Sweden.
    Mårtensson, Anton
    University of Gothenburg, Sweden; Stat Konsultgrp, Sweden.
    Savendahl, Lars
    Karolinska University Hospital, Sweden; Karolinska University Hospital, Sweden.
    Niklasson, Aimon
    University of Gothenburg, Sweden.
    Bang, Peter
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Dahlgren, Jovanna
    University of Gothenburg, Sweden.
    Gustafsson, Jan
    Uppsala University, Sweden.
    Kriström, Berit
    Umeå University, Sweden.
    Norgren, Svante
    Karolinska University Hospital, Sweden; Karolinska University Hospital, Sweden.
    Pehrsson, Nils-Gunnar
    Stat Konsultgrp, Sweden.
    Oden, Anders
    Stat Konsultgrp, Sweden; Chalmers, Sweden.
    Mortality Is Not Increased in Recombinant Human Growth Hormone-treated Patients When Adjusting for Birth Characteristics2016In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 101, no 5, 2149-2159 p.Article in journal (Refereed)
    Abstract [en]

    Objective: This study aimed to investigate whether reported high mortality in childhood recombinant human GH (rhGH)-treated patients was related to birth-characteristics and/or rhGH treatment. Design and Setting: We sought to develop a mortality model of the Swedish general population born between 1973 and 2010, using continuous-hazard functions adjusting for birth characteristics, sex, age intervals, and calendar year to estimate standardized mortality ratio (SMR) and to apply this model to assess expected deaths in Swedish rhGH-treated patients with idiopathic isolated GH deficiency (IGHD), idiopathic short stature (155) or born small for gestational age (SGA). Participants:The general population: Swedish Medical Birth Register (1973-2010: 1 880 668 males; 1 781 131 females) and Cause of Death Register (1985-2010). Intervention Population: Three thousand eight hundred forty-seven patients starting rhGH treatment between 1985 and 2010 and followed in the National GH Register and/or in rhGH trials diagnosed with IGHD (n = 1890), ISS (n = 975), or SGA (n=982). Main Outcome Measures: Death. Results: Using conventional models adjusting for age, sex, and calendar-year, the SMR was 1.43 (95% confidence interval, 0.89-2.19), P = .14, observed/expected deaths 21/14.68. The rhGH population differed (P amp;lt; .001) from the general population regarding birth weight, birth length, and congenital malformations. Application of an Advanced Model: When applying the developed mortality model of the general population, the ratio of observed/expected deaths in rhGH-treated patients was 21/21.99; SMR = 0.955 (0.591-1.456)P = .95. Model Comparison: Expected number of deaths were 14.68 (14.35-14.96) using the conventional model, and 21.99 (21.24-22.81) using the advanced model, P amp;lt; .001, which had at all ages a higher gradient of risk per SD of the model, 24% (range, 18-42%; P amp;lt; .001). Conclusions: Compared with the general Swedish population, the ratio of observed/expected deaths (21/21.99) was not increased in childhood rhGH-treated IGHD, ISS, and SGA patients when applying an advanced sex-specific mortality model adjusting for birth characteristics.

  • 2.
    Bang, Peter
    Karolinska Institute and University Hospital.
    Principles of Growth Hormone and Insulin-Like Growth Factor-I Treatment in Children with Idiopathic Short Stature2011In: HORMONE RESEARCH IN PAEDIATRICS, ISSN 1663-2818, Vol. 76, no s3, 24-26 p.Article in journal (Refereed)
    Abstract [en]

    Until recently, growth hormone (GH) was the only treatment available to improve growth rate in short, prepubertal children. Insulinlike growth factor I (IGF-I) is now approved in the United States and the European Union for treatment of short stature in children with severe primary IGF-I deficiency, a condition characterized by unresponsiveness to GH in IGF-I-producing tissues. This has increased the focus on the growth response to GH therapy in short children treated according to current recommendations. In particular, children with idiopathic short stature (ISS) may have some degree of GH insensitivity that decreases their response to GH treatment. This minireview discusses data on the response to GH treatment in patients with ISS and recent studies on the use of IGF-I in subgroups of patients with ISS. The rationale for future combination treatment with GH plus IGF-I is also discussed.

  • 3.
    Bang, Peter
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics.
    Ahmed, S. Faisal
    University of Glasgow, Scotland .
    Argente, Jesus
    Hospital Infantil University of Nino Jesus, Spain University of Autonoma Madrid, Spain Institute Salud Carlos III, Spain .
    Backeljauw, Philippe
    University of Cincinnati, USA .
    Bettendorf, Markus
    University Hospital Children and Adolescents, Germany .
    Bona, Gianni
    University of Piemonte Orientale Amedeo Avogadro, Italy .
    Coutant, Regis
    Angers University Hospital, France .
    Rosenfeld, Ron G.
    Oregon Health and Science University, USA .
    Walenkamp, Marie-Jose
    Vrije University of Amsterdam, Netherlands .
    Savage, Martin O.
    Barts and London Queen Marys School Medical and Dent, England .
    Identification and management of poor response to growth-promoting therapy in children with short stature2012In: Clinical Endocrinology, ISSN 0300-0664, E-ISSN 1365-2265, Vol. 77, no 2, 169-181 p.Article, review/survey (Refereed)
    Abstract [en]

    Growth hormone (GH) is widely prescribed for children with short stature across a range of growth disorders. Recombinant human (rh) insulin-like growth factor-1 (rhIGF-1) therapy is approved for severe primary IGF-I deficiency a state of severe GH resistance. Evidence is increasing for an unacceptably high rate of poor or unsatisfactory response to growth-promoting therapy (i.e. not leading to significant catch up growth) in terms of change in height standard deviation score (SDS) and height velocity (HV) in many approved indications. Consequently, there is a need to define poor response and to prevent or correct it by optimizing treatment regimens within accepted guidelines. Recognition of a poor response is an indication for action by the treating physician, either to modify the therapy or to review the primary diagnosis leading either to discontinuation or change of therapy. This review discusses the optimal investigation of the child who is a candidate for GH or IGF-1 therapy so that a diagnosis-based choice of therapy and dosage can be made. The relevant parameters in the evaluation of growth response are described together with the definitions of poor response. Prevention of poor response is addressed by discussion of strategy for first-year management with GH and IGF-1. Adherence to therapy is reviewed as is the recommended action following the identification of the poorly responding patient. The awareness, recognition and management of poor response to growth-promoting therapy will lead to better patient care, greater cost-effectiveness and increased opportunities for clinical benefit.

  • 4.
    Bang, Peter
    et al.
    Karolinska Institute and University Hospital.
    Bjerknes, R
    University of Bergen.
    Dahlgren, J
    Sahlgrenska Academy, University of Gothenburg.
    Dunkel, L
    Kuopio University Hospital, Finland.
    Gustafsson, J
    University of Uppsala.
    Juul, A
    University of Copenhagen.
    Kriström, B
    Umeå University.
    Tapanainen, P
    University of Oulu, Finland.
    Åberg, V
    Inst Prod Synthe IPSEN AB, Kista, Sweden .
    A Comparison of Different Definitions of Growth Response in Short Prepubertal Children Treated with Growth Hormone2011In: HORMONE RESEARCH IN PAEDIATRICS, ISSN 1663-2818, Vol. 75, no 5, 335-345 p.Article in journal (Refereed)
    Abstract [en]

    Background: How to define poor growth response in the management of short growth hormone (GH)-treated children is controversial. Aim: Assess various criteria of poor response. Subjects and Methods: Short GH-treated prepubertal children [n = 456; height (Ht) SD score (SDS) <=-2] with idiopathic GH deficiency (IGHD, n = 173), idiopathic short stature (ISS, n = 37), small for gestational age (SGA, n = 54), organic GHD (OGHD, n = 40), Turner syndrome (TS, n = 43), skeletal dysplasia (n = 15), other diseases (n = 46) or syndromes (n = 48) were evaluated in this retrospective multicenter study. Median age at GH start was 6.3 years and Ht SDS -3.2. Results: Median [25-75 percentile] first-year gain in Ht SDS was 0.65 (0.40-0.90) and height velocity (HtV) 8.67 (7.51-9.90) cm/year. Almost 50% of IGHD children fulfilled at least one criterion for poor responders. In 28% of IGHD children, Ht SDS gain was <0.5 and they had lower increases in median IGF-I SDS than those with Ht SDS >0.5. Only IGHD patients with peak stimulated growth hormone level <3 mu g/l responded better than those with ISS. A higher proportion of children with TS, skeletal dysplasia or born SGA had Ht SDS gain <0.5. Conclusion: Many children respond poorly to GH therapy. Recommendations defining a criterion may help in managing short stature patients.

  • 5.
    Bang, Peter
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Polak, Michel
    University of Paris 05, France.
    Woelfle, Joachim
    University of Bonn, Germany.
    Houchard, Aude
    Ipsen Pharma, France.
    Effectiveness and Safety of rhIGF-1 Therapy in Children: The European Increlex (R) Growth Forum Database Experience2015In: Hormone Research in Paediatrics, ISSN 1663-2818, E-ISSN 1663-2826, Vol. 83, no 5, 345-357 p.Article in journal (Refereed)
    Abstract [en]

    Background/Aims: We report data from the EU Increlex (R) Growth Forum Database (IGFD) Registry, an ongoing, open-label, observational study monitoring clinical practice use of recombinant human insulin-like growth factor-1 (rhIGF-1) therapy in children. Methods: Safety and effectiveness data on rhIGF-1 treatment of 195 enrolled children with growth failure were collected from December 2008 to September 2013. Results: Mean +/- SD (95% CI) height velocity during first year of rhIGF-1 treatment was 6.9 +/- 2.2 cm/year (6.5; 7.2) (n = 144); in prepubertal patients naive to treatment, this was 7.3 +/- 2.0 cm/year (6.8; 7.7) (n = 81). Female sex, younger age at start of rhIGF-1 therapy, and lower baseline height SDS predicted first-year change in height SDS. The most frequent targeted treatment-emergent adverse events (% patients) were hypoglycemia (17.6%, predictors: young age, diagnosis of Laron syndrome, but not rhIGF-1 dose), lipohypertrophy (10.6%), tonsillar hypertrophy (7.4%), injection site reactions (6.4%), and headache (5.9%). Sixty-one serious adverse events (37 related to rhIGF-1 therapy) were reported in 31 patients (16.5%). Conclusion: Safety and effectiveness data on use of rhIGF-1 in a real-world setting were similar to those from controlled randomized trials. Severe growth phenotype and early start of rhIGF-1 improved height response and predicted risk of hypoglycemia. (C) 2015 S. Karger AG, Basel

  • 6.
    Bang, Peter
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Thorell, Anders
    Karolinska Institute, Sweden; Ersta Hospital, Sweden.
    Carlsson-Skwirut, Christine
    Karolinska Hospital and Institute, Sweden.
    Ljungqvist, Olle
    Örebro University Hospital, Sweden.
    Brismar, Kerstin
    Karolinska Hospital and Institute, Sweden.
    Nygren, Jonas
    Karolinska Institute, Sweden; Ersta Hospital, Sweden.
    Free dissociable IGF-I: Association with changes in IGFBP-3 proteolysis and insulin sensitivity after surgery2016In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, Vol. 35, no 2, 408-413 p.Article in journal (Refereed)
    Abstract [en]

    Background: Patients receiving a carbohydrate drink (CHO) before major abdominal surgery display improved insulin sensitivity postoperatively and increased proteolysis of IGFBP-3 (IGFBP-3-PA) compared to patients undergoing similar surgery after overnight fasting. Aims: We hypothesized that serum IGFBP-3-PA increases bioavailability of circulating IGF-I and preserves insulin sensitivity in patients given CHO. Design: Matched control study. Methods: At Karolinska University Hospital, patients given CHO before major elective abdominal surgery (CHO,n = 8) were compared to patients undergoing similar surgical procedures after overnight fasting (FAST,n = 10). Results from two different techniques for determination of free-dissociable IGF-I (fdIGF-I) were compared with changes in IGFBP-3-PA and insulin sensitivity. Results: Postoperatively, CHO displayed 18% improvement in insulin sensitivity (hyperinsulinemic clamp) and increased IGFBP-3-PA vs. FAST. As determined by IRMA, fdIGF-I increased by 48 +/- 25% in CHO while fdIGF-I decreased by 13 +/- 18% in FAST (p &lt; 0.01 vs. CHO, when corrected for duration of surgery). However, fdIGF-I determined by ultra-filtration decreased similarly in both groups (-22 +/- 8% vs. -25 +/- 8%, p = 0.8) and IGFBP-1 increased similarly in both groups. Patients with less insulin resistance after surgery demonstrated larger increases in fdIGF-I by IRMA (r = 0.58, p &lt; 0.05). Fifty-three % of the variability of the changes in fdIGF-I by IRMA could be explained by changes in IGFBP-3-PA and total IGF-I levels (p &lt; 0.05), while IGFBP-1 did not contribute significantly. Conclusion: During conditions when serum IGF-I bioavailability is regulated by IGFBP-3 proteolysis, measurements of fdIGF-I by IRMA is of physiological relevance as it correlates with the associated changes in insulin sensitivity. (C) 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

  • 7.
    Ekstrom, Klas
    et al.
    Karolinska Hospital and Institute.
    Carlsson-Skwirut, Christine
    Karolinska Hospital and Institute.
    Ritzen, E. Martin
    Karolinska Hospital and Institute.
    Bang, Peter
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics.
    Insulin-Like Growth Factor-I and Insulin-Like Growth Factor Binding Protein-3 Cotreatment versus Insulin-Like Growth Factor-I Alone in Two Brothers with Growth Hormone Insensitivity Syndrome: Effects on Insulin Sensitivity, Body Composition and Linear Growth2011In: HORMONE RESEARCH IN PAEDIATRICS, ISSN 1663-2818, Vol. 76, no 5, 355-366 p.Article in journal (Refereed)
    Abstract [en]

    Background/Aims: Growth hormone insensitivity syndrome (GHIS) is caused by a defective growth hormone receptor (GHR) and is associated with insulin-like growth factor-I (IGF-I) deficiency, severely short stature and, from adolescence, fasting hyperglycemia and obesity. We studied the effects of treatment with IGF-I in either a 1:1 molar complex with IGFBP-3 (IGF-I/BP-3-Tx) or with IGF-I alone (IGF-I-Tx) on metabolism and linear growth. Methods: Two brothers, compound heterozygous for a GHR gene defect, were studied. After 8 months without treatment, we examined the short- and long-term effects of IGF-I/BP-3-Tx and, subsequently, IGF-I-Tx on 12-hour overnight levels of IGF-I, GH, insulin, IGFBP-1, insulin sensitivity by hyperinsulinemic euglycemic clamp, body composition by dual-energy X-ray absorptiometry and linear growth. Results: Mean overnight levels of insulin decreased and IGFBP-1, a measure of hepatic insulin sensitivity, increased on both regimens, but was more pronounced on IGF-I-Tx. Insulin sensitivity by clamp showed no consistent changes. Lean body mass increased and abdominal fat mass decreased in both subjects on IGF-I-Tx. However, the changes were inconsistent during IGF-I/BP-3-Tx. Height velocity was low without treatment, increased slightly on IGF-I/BP-3-Tx and doubled on IGF-I-Tx. Conclusion: Both modalities of IGF-I improved determinants of hepatic insulin sensitivity, body composition and linear growth rate; however, IGF-I alone seemed to be more efficient. 

  • 8.
    Ekstrom, Klas
    et al.
    Karolinska Hospital and Institute, Sweden.
    Pulkkinen, Mari-Anne
    Karolinska Hospital and Institute, Sweden; University of Helsinki, Finland.
    Carlsson-Skwirut, Christine
    Karolinska Hospital and Institute, Sweden.
    Brorsson, Anna-Lena
    Karolinska Hospital and Institute, Sweden.
    Ma, Zhulin
    Aarhus University, Denmark.
    Frystyk, Jan
    Aarhus University, Denmark.
    Bang, Peter
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Tissue IGF-I Measured by Microdialysis Reflects Body Glucose Utilization After rhIGF-I Injection in Type 1 Diabetes2015In: Journal of Clinical Endocrinology and Metabolism, ISSN 0021-972X, E-ISSN 1945-7197, Vol. 100, no 11, 4299-4306 p.Article in journal (Refereed)
    Abstract [en]

    Context: Type 1 diabetes is associated with portal insulin deficiency and disturbances in the GH-IGF axis including low circulating IGF-I and GH hypersecretion. Whether peripheral hyperinsulinemia and GH hypersecretion, which are relevant to the development of vascular complications, result in elevated tissue IGF-I remains unknown. Objective: The purpose of this study was to determine the relationship between whole-body glucose uptake and tissue IGF-I measured by microdialysis. Design: This was a single-blind placebo-controlled crossover study. Setting: The setting was a tertiary pediatric endocrine referral center. Participants: The participants were seven young male adults with type 1 diabetes. Intervention: After an overnight fast, a 6-h lasting euglycemic clamp was performed (constant insulin infusion at 0.5mU/kg x minute and variable glucose infusion rate [GIR]) and a subcutaneous injection of recombinant human (rh) IGF-I (120 mu g/kg) or saline was given after 2 hours. In parallel, tissue IGF-I levels were determined by microdialysis (md-IGF-I). Main Outcome Measures: md-IGF-I levels in muscle and subcutaneous fat, and GIR were determined. Results: md-IGF-I levels were detectable but unchanged after saline. After rhIGF-I, muscle and subcutaneous fat md-IGF-I increased during the second and third hour and then reached a plateau up to 10-fold higher than baseline (P less than .001). GIR was unchanged after saline, whereas it increased 2.5-fold concomitantly with the increase in md-IGF-I (P less than .0001). In contrast, serum IGF-I was increased already at 30 minutes after rhIGF-I and reached a plateau 2-fold above baseline (P less than .0001). Conclusion: We demonstrate that md-IGF-I measurements are valid and physiologically relevant by reflecting rhIGF-I-induced glucose uptake. Future studies should be conducted to elucidate the role of local tissue IGF-I in diabetic vascular complications.

  • 9.
    Salemyr, Jenny
    et al.
    Karolinska Institute and University Hospital, Stockholm.
    Bang, Peter
    Karolinska Institute and University Hospital, Stockholm.
    Örtqvist, Eva
    Karolinska Institute and University Hospital, Stockholm.
    Lower HbA1c after 1 year, in children with type 1 diabetes treated with insulin glargine vs. NPH insulin from diagnosis: a retrospective study2011In: Pediatric Diabetes, ISSN 1399-543X, E-ISSN 1399-5448, Vol. 12, no 5, 501-505 p.Article in journal (Refereed)
    Abstract [en]

    Objective: Insulin glargine offers sustained insulin delivery for 24 h. Change to glargine treatment consistently results in lower fasting glucose and fewer hypoglycemic episodes in children with type 1 diabetes compared to continuation of NPH, although glargine has not been shown to improve HbA1c in randomized trials. Studies comparing glargine and NPH in multiple injection therapy in children treated from diagnosis of type 1 diabetes are lacking. Methods: HbA1c and insulin requirement were compared in a retrospective study of children (7-17 yr of age) with type 1 diabetes treated from diagnosis with basal insulin glargine (n = 49) or NPH (n = 49) in a multiple injection therapy (MIT) regimen with a rapid-acting insulin analogue. Patients were followed every third month for 1 yr. HbA1c, insulin dose, and weight data were retrieved. Results: HbA1c (mean +/- SD) was lower at 3-5 months (5.5 +/- 0.89 vs. 6.2 +/- 0.89%, p < 0.05) and 6-9 months (5.6 +/- 1.14 vs. 6.6 +/- 0.99%; p < 0.001) in glargine treated. After 12 months, HbA1c was significantly lower in glargine treated (6.3 +/- 1.56 vs. 7.1 +/- 1.28; p < 0.01). Reported total insulin doses were similar at nadir (0.5 U/kg BW x 24 h), but significantly lower at 12 months in glargine treated (0.64 +/- 0.23 vs. 0.86 +/- 0.3U/kg BW x 24 h; p < 0.001). Conclusions: HbA1c 1 yr from diagnosis was lower in children treated with glargine from start as compared with those on NPH. This observation should be viewed in the light of a significantly lower dose of total daily insulin in the glargine group.

  • 10.
    Wit, J M.
    et al.
    Leiden University, Netherlands .
    Ranke, M B.
    University of Tubingen, Germany .
    Albertsson-Wikland, K
    University of Gothenburg, Sweden .
    Carrascosa, A
    Autonomous University of Barcelona, Spain .
    Rosenfeld, R G.
    Oregon Health and Science University, OR USA .
    Van Buuren, S
    TNO Qual Life, Netherlands .
    Kristrom, B
    Umeå University, Sweden .
    Schoenau, E
    University of Cologne, Germany .
    Audi, L
    Autonomous University of Barcelona, Spain .
    Hokken-Koelega, A C S
    Erasmus MC, Netherlands .
    Bang, Peter
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics.
    Jung, H
    Lilly Research Labs, Germany .
    Blum, W F.
    Lilly Research Labs, Germany .
    A Silverman, L
    Atlantic Health Syst, NJ USA .
    Cohen, P
    University of So Calif, CA USA .
    Cianfarani, S
    Bambino Gesu Pediat Hospital, Italy .
    Deal, C
    University of Montreal, Canada .
    Clayton, P E.
    University of Manchester, England .
    de Graaff, L
    Erasmus MC, Netherlands .
    Dahlgren, J
    University of Gothenburg, Sweden .
    Kleintjens, J
    Quintiles Consulting, NY USA .
    Roelants, M
    Vrije University of Brussel, Belgium .
    Personalized Approach to Growth Hormone Treatment: Clinical Use of Growth Prediction Models2013In: Hormone Research in Paediatrics, ISSN 1663-2818, E-ISSN 1663-2826, Vol. 79, no 5, 257-270 p.Article, review/survey (Refereed)
    Abstract [en]

    The goal of growth hormone (GH) treatment in a short child is to attain a fast catch-up growth toward the target height (TH) standard deviation score (SDS), followed by a maintenance phase, a proper pubertal height gain, and an adult height close to TH. The short-term response variable of GH treatment, first-year height velocity (HV) (cm/year or change in height SDS), can either be compared with GH response charts for diagnosis, age and gender, or with predicted HV based on prediction models. Three types of prediction models have been described: the Kabi International Growth Hormone Study models, the Gothenburg models and the Cologne model. With these models, 50-80% of the variance could be explained. When used prospectively, individualized dosing reduces the variation in growth response in comparison with a fixed dose per body weight. Insulin-like growth factor-I-based dose titration also led to a decrease in the variation. It is uncertain whether adding biochemical, genetic or proteomic markers may improve the accuracy of the prediction. Prediction models may lead to a more evidence-based approach to determine the GH dose regimen and may reduce the drug costs for GH treatment. There is a need for user-friendly software programs to make prediction models easily available in the clinic.

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