Treatment of acromegaly with octreotide: effectiveness and tolerability of its pulsatile administration by portable pump.

This study was undertaken to evaluate effectiveness and tolerability of octreotide administered in active acromegaly by pulsatile means and compare these data with intermittent three-times-a-day therapy. We studied 13 acromegalics with active disease. All patients received octreotide subcutaneously administered in a pulsatile way using a portable pump delivering 25 micrograms every 120 minutes and in an intermittent way (100 micrograms three times daily) (TID). From pretreatment values (56.5 +/- 13.4 micrograms/L) the 24-h integrated mean GH levels (IC-GH) were significantly reduced both during pulsatile and TID octreotide administration (P < 0.01). IC-GH was significantly lower during pulsatile therapy (17.0 +/- 5.2 micrograms/L) than during TID (22.0 +/- 11.5 micrograms/L; P < 0.05). Before octreotide, IGF-I levels were 669.8 +/- 85.7 micrograms/L; during octreotide therapy they were reduced in 12/13 patients (TID 340.2 +/- 41.5 micrograms/L, pulsatile 338.1 +/- 55.3 micrograms/L; P < 0.01). A correlation between IC-GH and IGF-I levels was observed only during TID administration of octreotide (R = 0.652; P < 0.05). The 24-hour GH pattern fluctuated widely before the start of octreotide therapy. During TID administration, GH levels tended to rise again before the following octreotide injection; this did not occur during pulsatile therapy. Side effects were fewer during pulsatile (15%) than TID (31%) octreotide administration (NS). Asymptomatic gallstones appeared in 1 patient. In conclusion subcutaneous pulsatile octreotide administration in acromegalic patients by means of a small portable pump seems able to produce, a steadier control of GH-IGF-I hypersecretion and fewer side effects than TID administration at same dosage.

Effect of octreotide on circulating IGF-I chromatographic profile: evidence for an inhibitory action on the formation of the 150-kDa ternary complex.

OBJECTIVE: The increasing use in clinical practice of octreotide (a somatostatin analogue which inhibits the secretion of GH and other peptide hormones) led us to study the effects of this treatment on GH, insulin-like growth factors (IGF)-I and II and IGF-binding protein (IGFBP)-3, as well as on circulating IGFBP complexes in acromegalic patients. DESIGN: The circulating concentrations of GH, IGF-I, IGF-II and IGFBP-3 were measured in acromegalic patients before and after 3, 6, 9, and 12 months of treatment with octreotide (group I: n = 5), and compared with those found in a group of patients (group II) treated with bromocriptine (n = 3), cabergoline (n = 7) radiotherapy (n = 3) or surgical therapy (n = 2). In pools of serum obtained from patients treated with octreotide, dopaminergic drugs, surgery and radiation, before and after therapy, immunoreactive IGF-I and IGFBP-3 were also evaluated after Superdex 200 gel filtration in neutral conditions. RESULTS: Before treatment, the concentration of IGF-I and IGFBP-3 were above the normal range in all patients, while IGF-II levels were slightly reduced. After treatment with octreotide, IGF-I (P = 0.004), IGF-II (P = 0.02) and IGFBP-3 (P < 0.001) were significantly reduced as compared to basal levels. In subjects of group II, only IGF-I concentration was significantly reduced by the treatment (P = 0.02), and a negative correlation between IGF-I and IGF-II concentrations was found (r = -0.58, P < 0.0001). After gel filtration immunoreactive IGF-I and IGFBP-3 were found in the 150-kDa mol.wt. region in serum obtained from untreated patients and from treated patients of group II, while in the serum of octreotide-treated patients the IGF-I and IGFBP-3 peaks were shifted to the 60-kDa mol.wt. region, thus suggesting that the acid-labile subunit of the 150-kDa complex was drastically reduced. Since the GH concentrations in groups I and II were similar (M +/- SEM; 13.8 +/- 7.4 and 21.2 +/- 10.6 mU/l respectively), the marked reduction in acid-labile subunit in the octreotide treated patients can be explained by a direct inhibitory effect of somatostatin on the subunit. CONCLUSIONS: Octreotide exerts an inhibitory effect not only on IGF-I but also on IGF-II. The reduced formation of the 150-kDa complex probably causes an increased metabolic clearance rate of IGF peptides which can account for the reduced concentration of both IGFs after treatment with octreotide.

[Behavior of the pituitary-thyroid axis in acromegalic subjects during prolonged intermittent and pulsatile treatment with octreotide]. / Comportamento dell'asse ipofiso-tiroideo in soggetti acromegalici durante prolungato trattamento intermittente e pulsatile con octreotide.

Octreotide, as well as endogenous somatostatin, inhibits GH and TSH secretion. The drug is employed in the medical therapy of acromegaly. We studied the effects of a long-term (1-120 months; median 12 months) therapy with octreotide (300 micrograms/day) given in 3-times intermittent s.c. administration or in pulsatile s.c. (25 micrograms/120 min) way, upon the pituitary-thyroid axis. Thirteen patients (11 with normal thyroid function, 1 with secondary hypothyroidism, 1 with toxic goiter) with active acromegaly were studied. In the euthyroid patients no significative variations in both TSH levels and thyroid hormones were found during octreotide therapy. In the non-euthyroid patients octreotide did not induce changes in the dosages of drugs acting to thyroid function. The 24-hour IC-TSH levels did not show any variation during octreotide. TSH response to TRH was reduced (P < 0.05) during octreotide therapy. No correlation among TSH, IGF-I and GH levels was observed. Long-term treatment of acromegaly with octreotide reduces TSH response to TRH but do not interfere with both 24-hour IC-TSH levels and thyroid function.

In vivo and in vitro effect of growth hormone on estradiol secretion by human granulosa cells.

GH therapy increases the ovarian response to gonadotropin stimulation in women presenting with ovaries that are relatively resistant to conventional gonadotropin therapy. As it is not completely certain whether GH modulates the actions of FSH on granulosa cells directly or via insulin-like growth factor-I (IGF-I) production, we studied its effect on steroid release by human granulosa cells obtained from subjects affected by unexplained or male factor infertility. In all subjects, superovulation for in vitro fertilization/embryo transfer was induced by treatment with gonadotropins or GH plus gonadotropins combined. The effects of the different in vivo treatments were evaluated in the conditioned medium obtained after the first 24 h of incubation; granulosa cells from patients treated with GH released higher amounts of estradiol and progesterone into the medium than did granulosa cells from patients treated with gonadotropins alone. When the release of steroid due to the in vivo treatment was exhausted, cells were subjected to increasing concentrations of GH in the presence or absence of 200 nmol anti-IGF Sm 1.2 monoclonal antibody (MoAb) or the antitype I receptor alpha IR3 MoAb. The results revealed that GH stimulates estradiol production in a dose-dependent fashion, and the presence of the MoAbs drastically reduces the GH effect. These data demonstrate that the established stimulatory effect of GH on ovarian function is dependent not only on the increased levels of circulating IGF-I, but also on a direct effect of GH on granulosa cells, which seems to be mediated at least in part by the autocrine action of IGF, particularly IGF-II. In fact, chromatographic analysis of medium conditioned by human granulosa cells revealed that these cells clearly produce IGF-II and IGF-binding proteins and only small amounts of IGF-I. Since GH appears to be able to increase the in vitro effect of both IGF-I and IGF-II, we can hypothesize a sensitization of the granulosa cells to the IGF-II produced by the cells themselves, which acts through the IGF-I receptor.

In vitro paracrine regulation of human keratinocyte growth by fibroblast-derived insulin-like growth factors.

Human keratinocytes isolated from a skin biopsy and cultured in vitro on a feeder-layer of irradiated fibroblasts reconstitute a stratified squamous epithelium suitable for grafting onto patients suffering from large burn wounds. Since conditioned medium from 3T3-J2 cells can partially substitute for the intact feeder-layer, we studied the possible involvement of insulin-like growth factors acting in a paracrine fashion. IGFs were measured (after Sephadex G-50 gel-chromatography in acid conditions) in media conditioned by a feeder-layer of lethally irradiated 3T3-J2 fibroblasts on which keratinocytes were grown. Immunoreactive (IR) IGF-I, IGF-II, and IGF binding activity were present in the medium conditioned by the feeder-layer. The medium conditioned by keratinocytes showed nearly undetectable amounts of IR IGF-I and IGF-II, suggesting that keratinocytes are unable to synthesize IGFs peptides. Recombinant IGF-I and IGF-II, and conditioned medium from 3T3-J2 cells, caused a dose-dependent increase of 3H-thymydine incorporation in cultured keratinocytes. The stimulatory effect of IGF and of 3T3-J2 conditioned medium was inhibited by the MoAb Sm 1.2, which recognizes both IGF-I and IGF-II but not insulin, and by the MoAb alpha IR-3, which is a specific antagonist of type-I IGF receptor. Fetal mouse-derived 3T3-J2 cells and adult human skin fibroblasts were equally able to sustain keratinocyte growth and in both cases addition of Sm 1.2 MoAb causes a 50% decrease in the keratinocyte number. When the non-IGF-producing BALB/c 3T3 cells were used as a feeder-layer, the keratinocytes number was similar to that observed with 3T3-J2 and with human fibroblasts plus the Sm 1.2 MoAb. IGF-I and IGF-II restored the BALB/c 3T3 growth promoting activity to the level of 3T3-J2 and of normal human fibroblasts. Our results suggest that fetal mouse 3T3-J2 and human fibroblasts synthesize IGF peptides, while keratinocytes do not. Fibroblast-derived IGFs stimulate keratinocyte growth in a paracrine fashion, suggesting their role in the regulation of keratinocyte proliferation in skin growth and in wound healing.

Immunoreactive insulin-like growth factor I (IGF-I) and IGF-I-binding protein content in human thyroid tissue.

We measured immunoreactive insulin-like growth factor I (IGF-I) in extracts of normal and nodular thyroid tissue obtained at surgery from patients with nontoxic goiter. The nodular tissues contained a higher concentration [mean, 279.0 +/- 69.7 (+/- SE) mU/g] than paired normal tissues (115.5 +/- 17.9 mU/g; P = 0.024; n = 12); a difference was evident in all but one patient. Sephadex G-50 gel filtration of tissue extracts revealed two immunoreactive peaks, the first in the void volume of the column, and the second in the elution volume of authentic IGF-I. The first peak was identified as IGF-I-binding protein by sodium dodecyl sulfate-polyacrylamide gel electrophoresis after cross-linking with iodinated IGF-I. Isolated thyroid cell membranes contained high affinity IGF-I-binding sites of similar affinity and numbers in both normal and nodular thyroid tissue. The IGF-I content of six thyroid cancer extracts was higher than that of normal thyroid tissue, but the IGF-I content of thyroid tissue from six patients with Graves' disease and five patients with Hashimoto's thyroiditis was similar to that in normal thyroid tissue. These data suggest that the stimulatory effect of TSH on thyroid cell proliferation could be mediated through IGF-I action and suggest that an increase in IGF-I production could sustain the goitrogenic process.

Evidence for autocrine mitogenic stimulation by somatomedin-C/insulin-like growth factor I on an established human lung cancer cell line.

The production of immunoreactive somatomedin-C/insulin-like growth factor I (Sm-C/IGF-I) by the established cell line derived from a human lung carcinoma CALU-6 has been evidenced in the serum-free medium in increasing concentrations as a function of the incubation time. Gel filtration in acid conditions of cell-conditioned medium collected after 72 h showed peaks of immunoreactive Sm-C/IGF-I in the elution volume corresponding to the molecular weight of the synthetic Sm-C/IGF-I, and in the high molecular weight region, where specific binding sites for Sm-C/IGF-I could be also demonstrated. These results indicate that this established cell line produces high amounts of immunoreactive Sm-C/IGF-I and of Sm-C/IGF-I carrier protein. The pooled fractions corresponding to the molecular weight of synthetic Sm-C/IGF-I showed a competitive binding curve parallel to the standard in the Sm-C/IGF-I RIA system, and a mitogenic activity on cells from the same line similar to the one observed using two different pure Sm-C/IGF-I preparations, obtained by chemical synthesis or by DNA recombinant technology. When a monoclonal antibody (sm-1.2) raised against Sm-C/IGF-I was added into the medium, the mitogenic effect observed by both synthetic and cell-derived Sm-C/IGF-I peptide was completely abolished; the monoclonal antibody also partially inhibited the effect of 10% fetal calf serum and the thymidine incorporation observed in serum-free medium without growth factors. In serum-free medium the monoclonal antibody produced a 45% reduction of cells in S phase by thymidine labeling index without modification of the growth fraction as determined by primer-dependent alpha-DNA polymerase labeling index. In conclusion it seems that Sm-C/IGF-I has a critical role in the autocrine stimulation of the replication of this cell line.

Evidence for an increased somatomedin-C/insulin-like growth factor I content in primary human lung tumors.

Immunoreactive somatomedin-C/insulin-like growth factor I (SM-C/IGF I) content was measured in human neoplastic lung tissue obtained from surgery on 10 patients (seven epidermoid carcinoma, three adenocarcinoma), and in normal lung tissue obtained from the same excised portion. SM-C/IGF I content in lung tumors was 615 +/- 123 (SE) milliunits/g of tissue (range, 214-1531), significantly higher (P less than 0.01) than normal tissue (234 +/- 51 milliunits/g of tissue; range, 37-537); in particular, every subject showed a clear-cut difference of SM-C/IGF I content between neoplastic and normal tissue (ratio, 3.41 +/- 0.69; range, 1.4-7.2). The results were essentially unchanged when data were expressed relative to hemoglobin or DNA tissue content. By contrast, in peripheral plasma SM-C/IGF I concentration was 0.51 +/- 0.17 units/ml, significantly lower (P less than 0.01) than in 59- to 70-yr-old control subjects (1.10 +/- 0.13 units/ml). In conclusion, the lung tumors studied, irrespective of their histological structure, contain more SM-C/IGF I than does normal tissue. Whether this is due to a primary in situ production of SM-C/IGF I or is secondary to overproduction of other inducers such as platelet derived growth factor-like peptides is yet to be clarified. The reduced circulating SM-C/IGF I concentration seems to be related more to the nutritional status of the patients.