Oral octreotide capsules for the treatment of acromegaly: comparison of 2 phase 3 trial results.

PURPOSE: Results are presented from 2 to 3 trials investigating oral octreotide capsules (OOC) as an alternative to injectable somatostatin receptor ligands (iSRLs) in the treatment of acromegaly. METHODS: CH-ACM-01 was an open-label trial (N = 155) and CHIASMA OPTIMAL was a double-blind placebo-controlled (DPC) trial (N = 56), both investigating OOC as maintenance therapy for patients with acromegaly who were biochemical responders receiving iSRLs. RESULTS: Baseline characteristics in both trials reflected those expected of patients with acromegaly responding to treatment and were similar between trials, despite differences in inclusion criteria. OOC demonstrated a consistent degree of biochemical response across trials, with 65% of patients in CH-ACM-01 maintaining response during the core period and 64% of patients in CHIASMA OPTIMAL at the end of the DPC. Mean insulin-like growth factor I (IGF-I) levels remained within inclusion criteria at the end of treatment in both trials. Of 110 patients entering the fixed-dose phase in CH-ACM-01, 80% maintained or improved acromegaly symptoms from baseline to the end of treatment. Over 85% of patients in both trials elected to continue into the extension phases. OOC were found to be well tolerated across both trials, and no dose-related adverse events were observed. CONCLUSIONS: OOC demonstrated remarkably consistent results for biochemical response, durability of response, and preference to continue with oral treatment across these 2 complementary landmark phase 3 trials, despite differences in the design of each. Trial registration NCT03252353 (August 2017), NCT01412424 (August 2011).

Long-term medical treatment of cushing's disease with pasireotide: a review of current evidence and clinical experience.

Cushing's disease is a rare condition of chronic hypercortisolism caused by an adrenocorticotropic hormone-secreting pituitary adenoma and associated with debilitating complications and excess mortality. Transsphenoidal adenomectomy is generally first-line treatment but is contraindicated in some patients and associated with significant post-surgical recurrence. While there are few data to support long-term use of most pharmacologic treatments, pasireotide (a multireceptor-targeted somatostatin analog) recently demonstrated sustained benefit in a 12-month, multicenter, Phase III trial and in 2 long-term extension studies. The Phase III trial (N=162) demonstrated reductions in urinary free cortisol in most patients, with durable treatment effect over 12 months. Biochemical improvement was generally paralleled by reductions in Cushing's-related signs and symptoms and enhanced health-related quality of life. Long-term treatment was evaluated in 58 patients who entered a planned 12-month extension phase. Reductions in urinary free cortisol remained stable throughout the extension, with further improvements noted in clinical signs and symptoms. Similar results were reported in the smaller Phase II extension (N=18; median treatment duration, 9.7 months; range, 2 months-4.8 years). Case reports have recently emerged demonstrating sustained disease control for upto 7 years in some patients. Safety considerations for long-term medical treatment with pasireotide are generally similar to those for other somatostatin analogs, except for the incidence and severity of hyperglycemia. Most patients experience new or worsening hyperglycemia with pasireotide treatment. Expert recommendations for treatment of pasireotide-associated hyperglycemia have recently been published and new studies are planned to elucidate the optimal treatment approach for pasireotide-associated hyperglycemia.

Exenatide decreases hepatic fibroblast growth factor 21 resistance in non-alcoholic fatty liver disease in a mouse model of obesity and in a randomised controlled trial.

AIMS/HYPOTHESIS: Systemic fibroblast growth factor (FGF)21 levels and hepatic FGF21 production are increased in non-alcoholic fatty liver disease patients, suggesting FGF21 resistance. We examined the effects of exenatide on FGF21 in patients with type 2 diabetes and in a diet-induced mouse model of obesity (DIO). METHODS: Type 2 diabetes mellitus patients (n = 24) on diet and/or metformin were randomised (using a table of random numbers) to receive additional treatment consisting of pioglitazone 45 mg/day or combined therapy with pioglitazone (45 mg/day) and exenatide (10 µg twice daily) for 12 months in an open label parallel study at the Baylor Clinic. RESULTS: Twenty-one patients completed the entire study and were included in the analysis. Pioglitazone treatment (n = 10) reduced hepatic fat as assessed by magnetic resonance spectroscopy, despite a significant increase in body weight (Δ = 3.7 kg); plasma FGF21 levels did not change (1.9 ± 0.6 to 2.2 ± 0.6 ng/ml [mean ± SEM]). However, combined pioglitazone and exenatide therapy (n = 11) was associated with a significant reduction of FGF21 levels (2.3 ± 0.5 to 1.1 ± 0.3 ng/ml) and a greater decrease in hepatic fat. Besides weight gain observed in the pioglitazone-treated patients, lower extremity oedema was observed as a side effect in two of the ten patients. Three patients who received pioglitazone and exenatide combination therapy complained of significant nausea that was self-limiting and did not require them to leave the study. In DIO mice, exendin-4 for 4 weeks significantly reduced hepatic triacylglycerol content, decreased hepatic FGF21 protein and mRNA, and enhanced phosphorylation of hepatic AMP-activated protein kinase (AMPK) and acetyl-CoA carboxylase, although no significant difference in weight and body fat was observed. Hepatic FGF21 correlated inversely with hepatic AMPK phosphorylation CONCLUSIONS/INTERPRETATION: In type 2 diabetes mellitus, combined pioglitazone and exenatide therapy is associated with a reduction in plasma FGF21 levels, as well as a greater decrease in hepatic fat than that achieved with pioglitazone therapy. In DIO mice, exendin-4 treatment reduces hepatic triacylglycerol and FGF21 protein, and enhances hepatic AMPK phosphorylation, suggesting an improvement of hepatic FGF21 resistance. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT 01432405.

Role of Sp1 in insulin regulation of gene expression.

Sp1 is a ubiquitous nuclear factor that plays a key role in maintaining basal transcription of 'house-keeping' genes. However, recent evidence points to a more important function for Sp1 in mediating 'cross-talk' between selected signaling cascades to regulate the target genes that respond to these pathways. The role of Sp1 in mediating the actions of the peptide hormone insulin is of specific interest and serves as a model for detailing effects of intracellular signaling on Sp1 activity. This review summarizes studies suggesting that changes in Sp1 phosphorylation provide one potential mechanism for manipulating activity of this protein. A growing body of evidence reveals that the DNA binding and transcription activity of Sp1 may increase or decrease in response to changes in phosphorylation. This enables 'fine-tuning' of Sp1 activity for regulation of gene transcription. Several mechanisms exist by which Sp1 alters gene activity in response to insulin. These include independent Sp1 activity as well as collaboration or competition with others factors. This review points to an ever-increasing role for Sp1 in regulating the transcription of genes in response to extracellular signals such as insulin.

The rainbow trout metallothionein-B gene promoter: contributions of distal promoter elements to metal and oxidant regulation.

In this report, the contributions of the distal 5'-regulatory sequences of the rainbow trout (Oncorhynchus mykiss) metallothionein (tMT)-B gene promoter (-738 to +5) were studied. Transfection of the -738 promoter fragment in a rainbow trout hepatoma cell line (RTH-149) resulted in 4- to 5-fold greater activity compared to the proximal -137 promoter region. Mutation of the proximal MREa abolishes the basal activity of the -738 fragment indicating that the distal regulatory elements require a cooperative interaction with MREa. However, the fragments containing both distal MREs, c and d (positioning -570 and -680, respectively), or MREc alone could confer basal and metal-induced activity when fused to the TATA box. This suggests that these distal elements are functional and therefore may play a role as basal elements in their natural state. The trout MT genes are also induced by oxidants including H2O2, tBHP and tBHQ. The larger promoter fragment -738 responds to H2O2, while the -137 fragment does not. However, fusion of the isolated MREc fragment (-648 to -533) in its native orientation, upstream of the -137 promoter elicits a response to H2O2, although no response is seen with MREc in reverse. These data suggest that this distal fragment contains functional oxidant responsive elements which have resemblance to the mammalian antioxidant responsive element (AREs).

The DNA binding activity of metal response element-binding transcription factor-1 is activated in vivo and in vitro by zinc, but not by other transition metals.

We examined the DNA binding activity of mouse and human MTF-1 in whole cell extracts from cells cultured in medium containing zinc or cadmium and from untreated cells after the in vitro addition of zinc or cadmium, as well as using recombinant MTF-1 transcribed and translated in vitro and treated with various transition metals. Incubation of human (HeLa) or mouse (Hepa) cells in medium containing cadmium (5-15 microM) did not lead to a significant increase (<2-fold) in the amount of MTF-1 DNA binding activity, whereas zinc (100 microM) led to a 6-15-fold increase within 1 h. MTF-1 binding activity was low, but detectable, in control whole cell extracts and was increased (>10-fold) after the in vitro addition of zinc (30 microM) and incubation at 37 degrees C for 15 min. In contrast, addition of cadmium (6 or 60 microM) did not activate MTF-1 binding activity. Recombinant mouse and human MTF-1 were also dependent on exogenous zinc for DNA binding activity. Cadmium did not facilitate activation of recombinant MTF-1, but instead inhibited the activation of the recombinant protein by zinc. Interestingly, glutathione (1 mM) protected recombinant MTF-1 from inactivation by cadmium, and allowed for activation by zinc. It was also noted that zinc-activated recombinant MTF-1 was protected from cadmium only when bound to DNA. These results suggest that cadmium interacts with the zinc fingers of MTF-1 and forms an inactive complex. Of the several transition metals (zinc, cadmium, nickel, silver, copper, and cobalt) examined, only zinc facilitated activation of the DNA binding activity of recombinant MTF-1. These data suggest that transition metals, other than zinc, that activate MT gene expression may do so by mechanisms independent of an increase in the DNA binding activity of MTF-1.

Molecular analyses of metallothionein gene regulation.

Metallothionein (MT) genes encode small proteins that chelate metal ions through metal-thiolate bonds with cysteine residues. MTs may have a role in cellular zinc homeostasis and metal detoxification. Congruent with these putative functions, MT gene transcription is induced by metals via multiple metal-responsive elements (MREs) present in the MT gene 5'-regulatory regions. This chapter mainly is focused on studies of the functional and physical interactions of MRE binding proteins with MT promoters from human and rainbow trout. In addition to mediating zinc induction, MREs may make important contributions to nonmetal induced promoter activity. In part, differential basal activity of MREs appears to be determined by sequence and position in the promoter. During zinc induction, increased functional MRE activity correlates with increased activity of mammalian MRE binding proteins by zinc treatment in vivo or in vitro, as detected by electrophoretic mobility shift assays. Interestingly, the addition of cadmium in vitro or in vivo has no detectable effect even though it strongly induces MT gene expression in the same time course. This raises questions about how the effects of cadmium are mediated by MREs. The molecular masses and MRE complex migration of the zinc-responsive factors we detect are consistent with mouse and human metal-responsive transcription factor (MTF) and expression of the MTF cDNAs increases co-transfected MT promoter activity in both mammalian and trout cell lines underlining the conservation of MRE binding factor function among diverse species.

Functional analyses of the human metallothionein-IG gene. In vitro and in vivo studies.

We have analyzed the human (h) metallothionein (MT)-IG proximal promoter region (-174 to +5) using a TATA box mutation (TATCA) and four trinucleotide mutants of the proximal MREa. Transient transfection of HepG2 cells was complemented by in vitro transcription with rat liver nuclear extracts. In both systems, mutations of the TATA box and conserved core of metal responsive element (MRE)a were detrimental to hMT-IG promoter activity suggesting that both elements make significant contributions to hMT-IG transcription. Although MRE binding factors were active in vitro, further metal activation of MT promoter activity was accomplished only by in vivo metal treatment rather than addition of zinc in vitro. Southwestern blotting identified nuclear proteins in rat liver and HepG2 cells which physically interact with MREa in a zinc-dependent manner and could be responsible for MREa function in each system. In addition, the functional effects of the TATCA mutation correlate with altered physical interaction with TATA box-binding protein as observed using DNase I protection.

Metal-responsive elements of the rainbow trout metallothionein-B gene function for basal and metal-induced activity.

In this study, the contributions of the two metal-responsive elements (MREs) of the rainbow trout (Salmo gairdnerii) metallothionein (tMT)-B gene promoter (-137 to +5) were analyzed. The effect of MRE mutations on the basal and zinc-induced activities of tMT-B promoter-reporter gene fusions were determined by transfection of a rainbow trout hepatoma (RTH-149) cell line. Together, MREa and MREb cooperate to elicit a significant response to zinc but exhibit differential basal and metal-induced activity. The MREa sequence (-62 to -51) is important for basal promoter activity and can function independently, whereas the more distal MREb (-89 to -100) mainly contributes to metal induction through cooperative interactions with MREa. The degree of basal character of the MREs is partially determined by nucleotide differences at the flexible position N of the MRE consensus TGC(G/A)CNC. In mouse L and HepG2 cells, MREa activity is conserved, but the contributions of the MREb region differ, including reduced cooperativity with MREa. There are also differences in the apparent molecular masses of the rainbow trout and mammalian nuclear factors that bind to the tMT-B promoter and MREa sequence.

Confirmation of the Carolina slate belt as an exotic terrane.

An assemblage of Middle Cambrian Atlantic faunal province trilobites has been found in the rocks of the Carolina slate belt near Batesburg, South Carolina. Geologic and paleomagnetic data suggest that the Carolina slate belt and the adjacent Charlotte belt constitute an exotic terrane that was accreted to North America in early to middle Paleozoic time.