Ashraf T Soliman MD PhD FRCP Professor of Pediatrics and Endocrinology Linear Growth and PUBERTAL ABNORMALITIES IN CHILDREN AND ADOLESCENTS WITH Beta Thalassemia Ashraf T Soliman MD PhD FRCP Professor of Pediatrics and Endocrinology

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Musallam K M et al. Haematologica 2013;98:833-844

Clinical complications profile of regularly transfused β-thalassemia major patients. Growth failure Differences in common clinical complications profile between non-transfusion-dependent thalassemias compared to regularly transfused β-thalassemia major patients. The figure illustrates those complications that are often observed at a higher prevalence in one group over the other in available studies and clinical settings, although all mentioned complications can exist in both entities at varying rates. ©2013 by Ferrata Storti Foundation Musallam K M et al. Haematologica 2013;98:833-844

What is the Magnitude of these problems? Do Patients with Thalassemia have significant Growth and Pubertal Disorder? What is the Magnitude of these problems?

Nutrition Genes T4 GH – IGF-I Nutrition Genes T4 Sex Steroids Nutrition GH-IGF-I Genes T4

How to Assess Growth Axis GHRH test GH Stimulation test History Nutrition Physical exam Anthropometry Measure IGF-I Measure Growth and bone age

How to Assess Gonadal Axis GnRH test FSH- LH Basal + Pulsatile properties Basal Testosterone and T after HCG Basal Estradiol & Progesterone History Tanner stage Growth Physical Exam Growth- Tanner Staging Testicle size, US ovary -uterus Bone age

How to Investigate Short Patient

What is the Magnitude of these problems? Do Patients with Thalassemia have significant Growth and Pubertal Disorder? What is the Magnitude of these problems?

Prevalence of Growth & Pubertal Abnormalities SURVEYS Prevalence of Growth & Pubertal Abnormalities in Patients with Thalassaemia Major

I. Growth and Pubertal Survey Qatar Egypt Iran Italy Cyprus Romania

Growth and Pubertal Surveys Country survey Growth Delay Hypogonadism Cyprus 35% 32% Greece 42% Italy --- 49% Egypt 62% 73% males, 42% females Qatar 46% Romania 54% 77% males 41% females N. America ---- TIF 30.8% 40.5% Pediatr Endocrinol Rev. 2007 Dec;5(2):642-8. ,& Clin Endocrinol (Oxf). 1995 Jun;42(6):581-6. Acta Endocrinologica (Buc), vol. I, no. 2, p. 201-212, 2005

QATAR SURVEY

Alexandria Survey ( n = 120) HtSDS 49% < -2 83% < -1 17 % > -1

GVSDS < -1 in patients and controls

Thalassaemia (males) 73 % had test. vol < 3 ml n = 45 , all > 14 yr Age = 16.9 +/- 3.5 yr 73 % had test. vol < 3 ml

Age of Thelarche

Thal: Breast Development All >14 y Age = 17.2 +/- 3.2 yr 42 % --No breast development

Age of Menarche (years)

Qatar- Growth and Endocrine Complications in Thalassemic Children and Adolescents (6-18 years)

CONCLUSIONS Thalassaemia 49% had HtSDS <-2 and 83% <-1 73% of boys (>14 y) lack pubescent changes 42% of girls ( >14) lack pubescent changes

What is the Growth Pattern of these Patients ? Which Stage of Growth is more affected ?

Anita Saxena, Int J Hum Genet, 3(4): 237-246 (2003)

Disturbed Upper /Lower segement because of short trunk due to vertebral pathology Anita Saxena, Int J Hum Genet, 3(4): 237-246 (2003)

Thalassemics Vs Normal Weight Curves for Thalassemics Vs Normal Anita Saxena, Int J Hum Genet, 3(4): 237-246 (2003)

Time of Growth Abnormalities 1. Late Childhood (Nutrition, GH-IGF-I, T4) 2. Pubertal Growth Spurt (attenuated) (Sex steroids, GH-IGF-I, Nutrition, T4, Insulin)

Summary Thalassemic patients are short Slow rate of linear growth +/- low body weight and BMI Delayed or absent pubertal spurt Growth faltering sets in earlier but becomes obvious after the age of 8 years

High Prevalence of short stature (Soliman et al., 1999; Low et al., 1998; Theodoridis et al., 1998; Caruso-Nicoletti, 1998; Roth et al., 1997; Kwan et al., 1995; Grundy et al., 1994). Truncal shortening: Rodda et al., 1995; Hamidah et al., 2001).

Why patients with TM do not grow well ???

What is the effect of Intensive Chelation Therapy on Growth ? Started early-Positive effect on linear growth. 80% attained normal adult height ( Garcia-Mayor et al, Horm Res 1993; 40, 5.)

??? Effectiveness of Different Transfusion Treatment Regimes Growth impairment and pubertal abnormalities in thalassemia major, has persisted despite major treatment advances. Chelation therapy may not always prevent or ameliorate late growth failure and/or delayed or absent puberty. (Chan et al. 2000; De Sanctis et al. 2000).

POSSIBLE FACTORS AFFECTING GROWTH AND PUBERTY IN THALASSAEMIA

Reported Endocrine abnormalities: Thalassaemia: GH/IGF-I abnormalities Hypogonadism(1ry, 2ry) Thyroid dysfunction IGT, IDDM PTH deficiency

GH-IGF-I Growth Axis In Thalassemia Major

Studies / questions on GH /IGF-I in TM GH response to provocation ? Spontaneous GH secretion ? IGF-I / BP3 secretion ? IGF-I/BP3 generation in response to exogenous GH in these patients ? GH-IGF-I response to blood transfusion Effect of GH treatment on linear growth ?

Studies on GH-IGF-I axis Effect of associated hypogonadism, hypothyroidism, DM ? Nutrition effect on IGF-I secretion ? Anatomy (MRI) of the hypothalamic/pituitary area in these patients ?

1. Do patients with Thalassemia have GH deficiency ?

Prevalence of GH deficincy in thalassemia Country Prevalence % Qatar –Doha ( n =81) 45% Egypt – Alexandria ( n = 120) 40% Egypt – Cairo ( n = 30) 33% Greece- Athens 38% Turkey-Izmir Iran-Shiraz (n= 138) (53.5% ) boys, (46.5%) girls Italy - Ferrara ( adults) 8% males, 9% females Italy – Rome (adults) 32 % Italy- Milan (adults) 22% (severe) 19% (partial) J Endocrinol Invest. 2010 Sep;33(8):534-8. Epub 2010 Feb 15. Clin Endocrinol (Oxf). 2007 Nov;67(5):790-5. Epub 2007 Jul 3. IJMS . Vol 27, No. 2, June 2002 Arch Med Sci 2010; 6, 1: 90-95 J Trop Pediatr (1999) 45 (1): 23-30. J Trop Pediatr. 2002 Feb;48(1):50-4.

Thal : GH after stimulation 40% of patients had peak GH < 7 Ug/L

Short Thalassemic With Normal GH response to provocation 2. Do they secrete normal GH spontaneously at night ??

Thal : Nocturnal GH (patient-1) and age-matched control 30 Patient 1 Control 25 20 15 GH 10 5 8 9 10 11 12 13 14 15 16 17 18 19 20 73 73

Thal: Nocturnal GH secretion (patient -2) vs control 74 74

Tha: Nocturnal GH secretion (patient-4) vs control 75

Thal: Nocturnal GH secretion (patient -5) vs control 76 76

Thal: Nocturnal GH secretion (patient-6) vs control 77 77

Thal: Nocturnal GH secretion (patient -7) vs control 78 78

Thal: Nocturnal GH secretion (patient -8) vs control 79 79

Thal: Nocturnal GH secretion (patient -9) vs control 80 80

Thal: Nocturnal GH secretion (patient-10) vs control 81 81

GH Neuro-secretory Dysfunction High incidence of GH Neuro-secretory Dysfunction (40% of short patients)

3. Do They Secrete Normal IGF-I ??

IGF-I in TM vs GHD vs CDGP 85 85

Low IGF-I High Prevalence (50-85%) with Defective GH secretion Normal GH response Neurosecretory dysfunction Soliman et al., 1999) (Shamshirsaz A A et al) 2003) Vannasaeng.S et al , 1980 Roth C et al., 1997 Soliman et al., 1999 Spoliotis BE; 1996 Pasqualetti et al 1992

What is the pattern of IGF-I throughout childhood ? The age-related levels in serum total IGF-I in thalassemic males were significantly decreased from early childhood to 18 years of age compared to normal subjects.

IGF-I Generation in GHD vs GHS Thalassemic males with GHD did not show any significant peak of IGF-I levels until 18 years of age. Thalassemic males with normal GH response to provocation (GHS) achieved a significant peak level of IGF-I that was attenuated and late compared to normal males.

IGF-I Secretion The basal serum IGF-I concentrations at different ages did not differ between the GHD and GHS groups until the age of 12 years. After 12 years of age, IGF-I levels were significantly higher in thalassemic children with GHS.

Comparison between Growth and IGF-I secretion throughout childhood and puberty Soliman AT, PER, 2010 Anita Saxena, Int J Hum Genet, 3(4): 237-246 (2003)

Short Patients with Thalassemia 4. Do They Generate Enough IGF-I in Response To GH ?? Partial GH Resistance ?

Thal: IGF-I generation

IGF-BP3 in Thalassemia

IGFBP3 after GH injection

Thal: GH/IGF-I/BP3 axis Children with thalassemia: High incidence of GHD and GH-NSD Low IGF-I Lower IGFBP3 Decreased IGF-I synthesis after GH vs CDGD and GHD

Does correction of anemia increase secretion of IGF-I in T children with low IGF-I ? and /or Does it improve the response of IGF-I to exogenous stimulation by GH?

5. What is the effect of anemia on IGF-I Secretion ?

Correction of anemia significantly increased IGF-I Secretion

IGF-I levels increased significantly with correction of anemia. GH injections increased IGF-I significantly in TM. The peak IGF-I response to GH injections did not differ before vs after blood transfusion.

7. What is the Effect of Pubertal Delay /Failure on Growth and IGF-I ? 8. What is the effect of defective GH-IGF-I axis on puberty ?

Thalassaemic Boys Have high incidence pubertal delay/failure and short stature 1. Gonadotropin deficiency (pituitary) 2. Defective sex-steroid secretion (testes) have been described 3. Defective growth spurt

Deprivation of GH and IGF-I: 1) Delays the timely onset of puberty 2) Slows the pace of pubertal maturation (all species); 3) Attenuates phallic growth (human); 4) Reduces adult testicular size (rodent); but does not affect fertility in the mature individual (all species) Zachmann M, 1970 . J Clin Endocrinol Metab 30:85–92 Young IR1989 J Endocrinol 121:563–570 Ernst M, 1991 Mol Endocrinol 5:1081–1089 Slootweg MC, 1997, J Endocrinol 155:159–164

PUBERTAL ASSESSMENT IN THALASSEMIA MAJOR

Pubertal Surveys In BTM Country survey Hypogonadism Cyprus 32% Greece 42% Italy 49% Egypt 73% males, 42% females Qatar 46% Romania 77% males 41% females N. America 35% TIF 40.5% Pediatr Endocrinol Rev. 2007 Dec;5(2):642-8. ,& Clin Endocrinol (Oxf). 1995 Jun;42(6):581-6. Acta Endocrinologica (Buc), vol. I, no. 2, p. 201-212, 2005 6-9-2012

Thalassaemia (males) 73 % had test. vol < 3 ml n = 45 , all > 14 yr Age = 16.9 +/- 3.5 yr 73 % had test. vol < 3 ml Ashraf T Soliman 6-9-2012 12/22/2017 112 112

Testicular Volume Ashraf T Soliman 6-9-2012 12/22/2017 113 113

Age of Thelarche Ashraf T Soliman 6-9-2012 12/22/2017 114 114

Thal: Breast Development All >14 y Age = 17.2 +/- 3.2 yr 42 % --No breast development Ashraf T Soliman 6-9-2012 12/22/2017 115 115

Age of Menarche (years) Ashraf T Soliman 6-9-2012 12/22/2017 116 116

CONCLUSIONS Thalassaemia 40-70% of boys (>14 y) lack pubescent changes 40-60% of girls ( >14y) lack pubescent changes 117 6-9-2012 117

Hypogonadism Effect on Growth in TM Deprivation of sex-steroids at or after the time of expected puberty : Loss or attenuation of pubertal growth spurt predisposes to reduced peak bone mass (osteopenia, osteoporosis) Testosterone, GH, IGF-I concentrations correlate with bone mass in some analyses Ongphiphadhanakul B, Clin Endocrinol (Oxf) 1998; 49:803–809 van den Beld AW, J Clin Endocrinol Metab 2000; 85:3276–3282 Seeman E, Am J Physiol 1996; 270:E320–E327

Puberty : Thalassemic Patients 1. Delayed puberty 2. Hypo gonadotropic hypogonadism 3. Defective testosterone secretion 4. Defective spermatogenesis 5. Delayed onset of menstruation 6. Primary Amenorrhea 7. Secondary Amenorrhea

Basal Investigations 1. Low Sex steroid (testosterone- Estradiol) 2. low Gonadotropin (LH and FSH) (Hypogonadotrophic hypogonadism)

LH Secretion patient vs controls

Pubertal Induction And Growth

Testosterone replacement in HH males The anabolic effects of testosterone are associated with : 1) Increased pulsatile GH secretion 2) Increased IGF-I synthesis in liver and bone cells 3) Increased GI absorption and skeletal retention of calcium and magnesium 4) Increased mass, mechanical loading and energy expendature. Cicognani A, Acta Endocrinol (Copenh) 1989; 121:777–783 Hansen TB, J Clin Endocrinol Metab 1996; 81:3352–3359

What is the effect of Nutrition on Growth and IGF-I in TM ?

Nutrition is an important factor in growth and development Protein/Calorie Defect due to hyper-catabolism (BM, Cardiac and Resp ) Zinc deficiency exists as a growth-limiting factor in thalassemia major : Short stature, low weight, anorexia, and hypogonadism found in the zinc deficiency, has been found in most of the patients (Arcasoy and Cavadar 1981; Arcasoy et al. 1983). Vitamin D Deficiency

Wt, BMI and IGF-I Before vs after Nutritional Supplementation

Vitamin D Deficiency Vitamin D deficiency was detected in 50-100% of thalassemic adolescents. An IM injection of a mega dose of cholecalciferol is an effective therapy for treatment for 3 months. Correction of VDD --- Increased Linear Growth and IGF-I level Pediatric Endocrinology Reviews (PER), 6 Supp 1, 2008 NAPOLI N. Bone ISSN, 2006; 8756-328 Br J Haematol. 2008 Jun;141(6):891-4

Zinc Deficiency and Treatment Biochemical evidence of Zn deficiency in 40% of Thalassemic patients Those who received Zn for 1-7 years had higher growth velocity and HTSDS. Arcasoy A et al. Am J Hematol 1987, 24:127

PATHOLOGY Pituitary Liver Pancreas

MRI studies in patients with defective GH secretion (n = 9) Evidence of iron deposition in the pituitary gland and midbrain (n = 7) Marked diminution of the pituitary size (n = 4) Thinning of the pituitary stalk (n = 3) with its posterior displacement (n = 2),

T1 T2 A T Soliman J Trop Pediatr. 1999 Dec;45(6):327-37.

A T Soliman J Trop Pediatr. 1999 Dec;45(6):327-37.

Pituitary Siderosis Pediatr Radiol. 2007 December; 37(12): 1191–1200. patient Control A 12-year-old β-thalassaemia major. Midsagittal T1-weighted (TR/TE 500/20 ms) scan shows low-signal intensity of the anterior pituitary lobe (arrow) and the bone marrow (asterisks) suggesting iron overload. The pituitary gland is small measuring 3.5 mm. This patient developed hypogonadotropic hypogonadism. b An 11-year-old male with β-thalassaemia major. Mid-sagittal T1-weighted (TR/TE 500/20 ms) shows normal signal intensity of the anterior pituitary lobe (arrow) along with normal pituitary gland height (6 mm). The bone marrow (asterisk) shows low-signal intensity suggesting iron overload

Siderosis of Liver and Pancreas Pediatr Radiol Siderosis of Liver and Pancreas Pediatr Radiol. 2007 December; 37(12): 1191–1200 A 17-year-old male with β-thalassaemia major. Axial scan, fourth echo of a multiecho spin-echo sequence (TR/TE: 2000/20, 40, 60, 80, 100, 120, 140, 160 ms), shows low-signal intensity in the liver, bone marrow of the spinal body and the pancreas suggesting iron overload.

The photomicrograph (iron stain; magnification, 500) of undecalcified bone section illustrates the thick linear deposition of iron (blue line) along the mineralization front (thick arrows). The unmineralized zone is also stained blue, but with lighter intensity (areas between thin arrows). Active osteoblasts (arrowheads) are also present along the osteoid surface.

Iron deposition in Kupffer cells and spilling into parenchymal cells in late stages of hemosiderosis

What is the Effect of GH therapy on Growth and IGF-I in TM ??

Thal: Growth on GH therapy

Thal: IGF-I & GV after GH therapy

Short term (one year) GH Therapy Studies Demonstrated that treatment for one year resulted in significant increase in the growth velocity without increase in rate of skeletal maturation. The growth rate on GH therapy was significantly slower in TM and their IGF-I were lower vs non-thalassemic children with GHD or ISS on same GH doses.

Short term (> 2 years) GH Therapy Studies A positive growth response to GH was demonstrated in the second year of treatment in the report by( Wu et al ) And for 3 to 4 years with improvement in the height SDS for both bone age and chronological age in other studies (Kwan EYW, J Pediatr Endocrinol Metab 2000; 13 : 545-552

(Final adult height) after GH Therapy for 2-9 years Before Treatment Final adult Ht Boys -3.7 -1.75 Girls -2.8 -1.58 Theodoridis et al. J Pediatr Endocrinol Metab 1998; 11 (Suppl 3) : 835-844. HtSDS Before Treatment Final Adult Height SDS Improvement compared to mid-parental Ht N= 10 Started -age 11 y -2.63 -0.6 1.6 Low LC, Ind J Ped 2005, 159, 64

What is the effect of Bone Marrow Transplantation on Growth ?

BMD after bone marrow transplantation in TM (n = 32) F/U > 2 yr The HtSDS increased by 0.6 SD ( from -1.6 to 1) 5 years after BMT. Before BMT 40% had HtSDS < -2 40 % were < -2 5 Years after BMT only 15% had HtSDS < -2. Pediatr Hematol Oncol. ;21 (5):411-9

TM – Effect of bone marrow transplantation (BMT) ( n= 47) A strict correlation between age at time of transplant and final adult height. T M who were <7 years had a less impaired growth rate than did patients who were >7 years. The greatest loss in height was observed with High Ferritin and ALT. Subjects who received BMT before 7 years had normal adult Ht in relation to the genetic target height . Subjects who received BMT after 7 years of age, failed to achieve their full genetic potential. A close effect of the age at time of transplant on subsequent growth rate. Bone Marrow Transplantation (2001) 28, 201-205.

Bone Marrow Transplant. 1997 Oct;20(7):567-73. GH therapy (2y): effect On TM patients after BMT (IGF-I secretion & growth) Responders Increased GV Increased IGF-I secetion Decreased Ferritin Decreased ALT and AST Non-responders Decreased GV No change in IGF-I Increased Ferritin Higher ALT and AST There was a significant correlation between IGF-I, ALT, AST & ferritin in all patients before and after therapy. Bone Marrow Transplant. 1997 Oct;20(7):567-73.

Thalassaemia (Summary) Slow linear growth (HtSDS, GV) High prevalence of impaired spontaneous and provoked GH secretion Low IGF-I and BP3 secretion Low of IGF-I after GH injection and therapy. GV improved on GH therapy but < those for ISS and GHD Partial improvement of final adult ht with GH therapy.

RECOMMENDATIONS

Increasing IGF-I : Proper transfusion and Chelation Improving nutritional status ( Protein-Calorie, Vitamin D, Zn, Carnitine) Correcting GHD (GH / IGF-I therapy) Inducing puberty at proper time, Prevention of hepatitis Bone marrow transplantation (before 7 y) Might improve growth and BMD

IGF-I therapy with or without GH is on small trials now ???? TM patients with and without GHD have low IGF-I secretion. Their Growth and IGF-I response to GH is suboptimal (GH resistance) They need bigger GH doses for accelerating growth. Final adult height after GH treatment is still short IGF-I has growth promoting as well as insulin-like activities while GH is lipolytic. IGF-I therapy with or without GH is on small trials now ????

Algorithm If the patient is GH deficient ---Start GH therapy early If he responds to normal dose (0.02-0.03 mg/kg/day) with proper increase of IGF-I--- continue If GV is slow and/or IGF-I low - Increase GH dose At or after (13 (F) and 14 (M) years slowly induce puberty simulating the normal physiology At all stages supplement nutrition +/- Zinc +/- vit D therapy to increase IGF-I --- growth. Correct any Thyroid hormone deficiency

Puberty Guidelines (6-months Intervals) Tanner staging should be recorded every six months. Girls without evidence of an advancing pubertal stage by 12-13 years and boys by 14 years require screening with LH/ FSH, and se steroid. If LH and FSH levels are low for the patient’s age, suspect hypogonadism. GnRH stimulation may help to dx HH. (This should to be done prior to a blood transfusion on a different day than the oral glucose tolerance test.) 6-9-2012

BTM: Male Hypogonadism Testosterone level should be checked annually in boys, starting in the early adolescent years (at approximately 13 years old). If testosterone level is low--- endocrine consultation --- start monthly Testosterone vs HCG treatment. The starting dose is usually 50 mg, given monthly as an intramuscular shot. The dose needs to be adjusted periodically for the patient’s age and pubertal status, as well as for a sexually active man. 6-9-2012

BTM: Female Hypogonadism Estrogen replacement is recommended for amenorrheic adolescent girls and adult women: 2.5-5ug Ethinyl Estradiol with increasing doses q 6mon Afterward, an oral contraceptive pill may replace Premarin. A gynecological consultation and fertility evaluation is recommended for women on estrogen therapy. 6-9-2012

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