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      Effect of adherence to growth hormone treatment on 0–2 year catch-up growth in children with growth hormone deficiency

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      PLoS ONE
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          Abstract

          Background

          Quantifying the association between adherence and the growth response to growth hormone (GH) treatment is hampered by suboptimal methods of measuring adherence, confounders associated with the growth response, and restriction of the outcome parameters to yearly growth velocities.

          Aim

          To investigate the effect of adherence on the two-year growth response to GH treatment in prepubertal children with idiopathic isolated growth hormone deficiency (GHD) participating in the easypod connect observational study (ECOS), a 5-year, Phase IV open-label study to continuously assess real-world adherence via the easypod electronic drug-delivery device.

          Patients and methods

          Outcome measures were change in height standard deviation score (ΔHSDS), index of responsiveness (IoR), and parameters of two catch-up growth (CUG) curve functions (monomolecular growth curve and second degree polynomial) with adj-HSDS (HSDS minus Target height (TH) SDS) as dependent variable. Inclusion criteria were GHD, naïve to GH treatment, known TH, age <10y in girls and <12y in boys, ≥3 measurements, HSDS <-2 at start, complete data on growth and adherence in the first and second year. Linear regression analyses were performed to test the association between adherence (continuous and high vs. low) and the outcome measures, also adjusted for potential clinical confounders (age at start, adj-HSDS at start, birth weight SDS, gestational age (<37 weeks vs ≥37 weeks), GH dose, GH max (n = 58)). The formula of IoR already adjusts for confounders.

          Results

          In total, 95 patients complied with the inclusion criteria. The strongest associations were found between high adherence in the second year (≥91% as cut-off value) and IoR 2y (+0.62), and average adherence and high adherence (≥78%) in the first two years and ΔHSDS 0-2y (+0.11 SD per 1 injection/week, and +0.34 SD for high vs. low adherence).

          Conclusion

          Suboptimal adherence negatively affected the growth response in the first two years of GH treatment.

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          Most cited references27

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          Non-Compliance with Growth Hormone Treatment in Children Is Common and Impairs Linear Growth

          Background GH therapy requires daily injections over many years and compliance can be difficult to sustain. As growth hormone (GH) is expensive, non-compliance is likely to lead to suboptimal growth, at considerable cost. Thus, we aimed to assess the compliance rate of children and adolescents with GH treatment in New Zealand. Methods This was a national survey of GH compliance, in which all children receiving government-funded GH for a four-month interval were included. Compliance was defined as ≥85% adherence (no more than one missed dose a week on average) to prescribed treatment. Compliance was determined based on two parameters: either the number of GH vials requested (GHreq) by the family or the number of empty GH vials returned (GHret). Data are presented as mean ± SEM. Findings 177 patients were receiving GH in the study period, aged 12.1±0.6 years. The rate of returned vials, but not number of vials requested, was positively associated with HVSDS (p<0.05), such that patients with good compliance had significantly greater linear growth over the study period (p<0.05). GHret was therefore used for subsequent analyses. 66% of patients were non-compliant, and this outcome was not affected by sex, age or clinical diagnosis. However, Maori ethnicity was associated with a lower rate of compliance. Interpretation An objective assessment of compliance such as returned vials is much more reliable than compliance based on parental or patient based information. Non-compliance with GH treatment is common, and associated with reduced linear growth. Non-compliance should be considered in all patients with apparently suboptimal response to GH treatment.
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            Understanding the Growth Hormone Therapy Adherence Paradigm: A Systematic Review

            Introduction: Growth hormone (GH) therapy is used to treat a variety of growth disorders in childhood/adolescence. Its efficacy is thought to be dependent on patients' adherence to their treatment regimen. Methods: PubMed was searched using the keywords ‘growth hormone', ‘child'[Mesh], ‘adolescent'[Mesh], and ‘patient compliance'[Mesh]. Results: Most studies of adherence to paediatric GH therapy have used either issued/encashed GH prescriptions or questionnaires. Estimates of prevalence of non-adherence vary from 5-82%, depending on the methods and definitions used. Different studies have variously demonstrated an association (or lack thereof) between adherence and age, socioeconomic status, treatment duration, injection device used and injection-giver. A number of interventions have been proposed to improve adherence, including offering a choice of injection device, but none are supported by trials. Poor adherence is associated with reduced height velocity and likely increased economic costs; evidence for other effects is circumstantial. Conclusion: Adherence to paediatric GH therapy is suboptimal, which may partially explain why the mean final height attained is below that of the general population. Analysis of the causes of non-adherence is complicated by conflicting evidence from different studies. Multifactorial interventions are most likely to be successful in improving adherence. We make recommendations for further research.
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              Monitoring of concordance in growth hormone therapy.

              Concordance with growth hormone (GH) therapy in 75 children was objectively assessed using data on GP prescriptions over 12 months. 23% missed >2 injections/week. Lower concordance was associated with longer duration on GH therapy (p<0.005), lack of choice of delivery device (p<0.005) and short prescription durations (p<0.005), and predicted lower height velocities (p<0.05).
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                24 October 2018
                2018
                : 13
                : 10
                : e0206009
                Affiliations
                [1 ] Department of Child Health, TNO, Leiden, The Netherlands
                [2 ] Global Medical, Safety & CMO, Merck KGaA, Darmstadt, Germany
                [3 ] Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
                McMaster University, CANADA
                Author notes

                Competing Interests: The authors have read the journal's policy and the authors of this manuscript have the following competing interests: PvD and JMW have consultancy agreements with Merck; EK is an employee of Merck KGaA, Darmstadt, Germany.

                Author information
                http://orcid.org/0000-0001-5546-6244
                Article
                PONE-D-18-21145
                10.1371/journal.pone.0206009
                6200242
                30356273
                5a95b437-a342-4729-9c77-c5b6ae73017d
                © 2018 van Dommelen et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 17 July 2018
                : 4 October 2018
                Page count
                Figures: 2, Tables: 2, Pages: 12
                Funding
                This study was sponsored by Merck KGaA, Darmstadt, Germany. Medical writing assistance was provided by David Candlish, inScience Communications, Tattenhall, UK, and sponsored by Merck KGaA, Darmstadt, Germany. The data collection was performed via the easypodTM electronic drug-delivery device, which is a product of Merck KGaA. Also, physician data entry of outcome measures were retrospectively and prospectively collected by Merck KGaA. This data collection was part of the ECOS study, which was conducted in accordance with the principles of the Declaration of Helsinki, Good Clinical Practice (ICH-GCP E6) guidelines and applicable national legal and regulatory requirements. The ECOS study was published in Endocrine Connections (Koledova E, Stoyanov G, Ovbude L, Davies PSW (2018) Adherence and long-term growth outcomes: results from the easypod™ connect observational study (ECOS) in paediatric patients with growth disorders. Endocr Connect. 7: 914-923). Post hoc analysis on the ECOS study was performed by PvD from TNO. TNO is an independent RTO from the Netherlands founded by law. TNO’s professionals put their knowledge and experience to work in creating smart solutions to complex issues. These innovations help to sustainably strengthen social wellbeing and industrial competitiveness. The core values of TNO are integrity, independence, professionalism, and engagement with society. TNO’s Code of Conduct, published on the website of TNO ( https://www.tno.nl/en/about-tno/mission-and-strategy/tno-code), contains a chapter on scientific integrity. Research is conducted without any undue influence from commercial or other interests. Merck KGaA provided support in the form of salaries for author PvD, but did not have any additional role in performing the post hoc analysis. Merck has provided the ECOS data to TNO for this post hoc analysis. Manuscript was reviewed according to Merck publication procedures. The specific roles of all authors are articulated in the ‘author contributions’ section.
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                The analysis was performed from data from ECOS study, which is Merck KgaA sponsored phase IV clinical trial, data sharing should be done in accordance with the European Federation of Pharmaceutical Industries and Associations (EFPIA) and the Pharmaceutical Research and Manufacturers of America’s (PhRMA) Principles for Responsible Clinical Trial Data Sharing. Merck KGaA, Darmstadt, Germany, believes that as a biopharmaceutical company, the sharing of information related to company sponsored clinical trials is central to our mission. The sharing of clinical trial Information enables the medical and scientific community to further develop the medical and scientific knowledge base and permits the public to make informed healthcare decisions. However, because information from company sponsored clinical trials may include confidential personal information and proprietary company information, Merck must ensure that information is provided only in response to legitimate scientific and medical requests and that information disseminated outside of the company properly protects all confidential. All clinical trial information must further be provided only in accordance with applicable laws and codes. Merck will share anonymized patient level, and study level data and redacted clinical study reports from clinical trials in patients with qualified scientific and medical researchers, upon researcher request via the Merck website portal ( https://www.merckgroup.com/en/research/our-approach-to-research-and-development/healthcare/clinical-trials/commitment-responsible-data-sharing.html), as necessary for conducting legitimate research. More information for researchers can be found on this website. Evaluation of the Research Proposal, as well as the qualifications and experience of the Lead Researcher and Research Team, will be conducted by appropriate and qualified person or board. The researcher must enter into a Data Sharing Agreement (“DSA”) with Merck. The standard DSA which must be entered into is posted on Merck’s website. Merck uploads the data to Cloud-Based Data Sharing Analytical Solution where researchers can conduct the approved analysis. A request form is available on the Merck website portal ( https://www.merckgroup.com/en/research/our-approach-to-research-and-development/healthcare/clinical-trials/commitment-responsible-data-sharing.html). A point of contact for information regarding data requests is Sascha-Marc Seidl ( Sascha-Marc.Seidl@ 123456merckgroup.com ).

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