cetrorelix and Puberty--Precocious

The pharmacodynamics of gonadotropin-releasing hormone (GnRH) agonists includes an initial 'flare-up' of the pituitary-gonadal axis, followed by reduced luteinizing hormone (LH) secretion. The question is if combining a short-acting antagonist with a long-acting agonist can diminish gonadotropin flare-up.. To achieve quick downregulation in patients with recently diagnosed central precocious puberty (CPP, 7 patients) or short stature with short predicted final height (3 patients), we combined the GnRH antagonist cetrorelix (3 subcutaneous injections every 72 h) at the beginning of GnRH agonist treatment (leuprorelin or triptorelin) in 6 patients and compared the effect to 4 patients treated solely with GnRH agonist. To monitor effects, we measured LH and FSH concentrations in urine collected from initial morning urination during the first month of treatment.. In both treatment groups, gonadotropin flare-up could be detected in urine levels increased due to the flare-up phenomenon which was of short duration (<5 days) in the majority (5 of 6) of combined-treated patients and in the minority (1 of 4) of patients treated by agonist alone. During the first 10 days of treatment, mean LH concentration measured in urine was significantly lower in 4 CPP patients treated by the combined therapy compared to 3 CPP patients treated by the agonist only (mean LH combined therapy: 10.4 +/- 2.8 vs. 20.1 +/- 11.0 mU/ml in the agonist-only group, mean +/- SEM, p < 0.05). Significant correlations between stimulated serum LH in GnRH test prior to treatment and maximum urine LH after initiating GnRH analogue treatment (r = 0.547, p = 0.043), as well as basal serum LH and basal urine LH (r = 0.685, p = 0.014) were found.. Combined GnRH agonist and antagonist treatment led to rapid gonadotropin suppression. Also, urine measurements of LH and FSH seemed suitable for monitoring gonadotropin-inhibiting or -stimulating properties of GnRH analogues in individual patients. However, a controlled trial of a larger patient cohort is required to decide which treatment is the most effective.

Topics: Adolescent; Child; Drug Therapy, Combination; Female; Follicle Stimulating Hormone; Gonadotropin-Releasing Hormone; Humans; Luteinizing Hormone; Male; Puberty, Precocious; Statistics, Nonparametric; Triptorelin Pamoate

This report presents the case of a 7-year-old girl with gonadotrophin-independent precocious puberty treated with cetrorelix [gonadotrophin-releasing hormone (GnRH) antagonist] after poor response to GnRH agonist therapy was observed in the endocrinology outpatient clinic. Uterine and ovarian morphology returned to within the normal prepubertal range after GnRH antagonist was injected subcutaneously. Vaginal bleeding stopped completely. The effects of GnRH antagonist treatment were comparable to those of GnRH agonist. The potential advantage of GnRH antagonists would be a clinically significant direct effect on the ovary, if it exists, and GnRH antagonists should be available for use in such children.

Topics: Child; Child, Preschool; Female; Gonadotropin-Releasing Hormone; Gonadotropins; Hormone Antagonists; Humans; Injections; Ovary; Ovulation; Pregnancy; Puberty, Precocious; Treatment Failure; Ultrasonography; Uterus

Little is known about the effects of antagonistic GnRH analogues vs. agonists on bone strength, specifically in context of treating precocious puberty. Peripubertal female rats were treated from postnatal day 25 - 36 with either the GnRH agonist triptorelin (TRIP) or the antagonist cetrorelix (CET). Using peripherial quantitative computerized tomography (pQCT) we investigated effects on bone parameters. Onset of puberty was retarded by both analogues as measured by prevention of vaginal opening at 36 d of age and reduced uterine weights. In the tibia, cortical content, cortical area related to body weight, and periosteal circumference related to weight were significantly reduced in CET-treated rats - indicating reduced bone modeling and reduced bone strength (cortical circumference related to body weight: CET 0.066 +/- 0.001 vs. TRIP 0.068 +/- 0.001 vs. controls 0.071 +/- 0.001 mm/g, mean +/- SEM, p < 0.05 CET vs. controls; cortical area related to body weight: CET 3.87 +/- 0.46 vs. TRIP 6.80 +/- 0.63 vs. controls 8.07 +/- 1.13, x 10 (-3) mm (2)/g, p < 0.001 CET vs. controls; cortical content: CET 0.316 +/- 0.038 vs. TRIP 0.546 +/- 0.051 vs. controls 0.624 +/- 0.089 mg/mm, p < 0.01 CET vs. controls). In conclusion, although both CET and TRIP inhibit puberty in rats, cortical thinning was only seen in CET-treated rats. This indicates that GnRH antagonist treatment might cause reduced bone strength which is partly comparable to postmenopausal bone loss. When using new GnRH antagonists for treating precocious puberty in humans, parameters for bone strength and mineralization should be monitored.

Topics: Animals; Bone Remodeling; Female; Gonadotropin-Releasing Hormone; Hormone Antagonists; Humans; Luteolytic Agents; Puberty, Precocious; Rats; Rats, Sprague-Dawley; Receptors, Gonadotropin; Sexual Maturation; Triptorelin Pamoate

Central precocious puberty is commonly treated by gonadotropin releasing hormone (GnRH) agonists. To compare modes of action and effectiveness of GnRH analogues and assess treatment combinations of agonistic (triptorelin) and antagonistic (cetrorelix acetate) GnRH analogues with established treatment, we used prepubertal 31-d-old ovariectomized female rats. Strongest inhibition of LH and FSH occurred after 2-d treatment with antagonist alone (LH 0.08 +/- 0.02 versus 3.2 +/- 0.56 ng/mL in controls; FSH 10.8 +/- 2.8 versus 44.2 +/- 5.0 ng/mL in controls, p < 0.001). Combined agonist/antagonist was second most effective of the treatments (after 5 d treatment, LH 0.52 +/- 0.15 versus 4.9 +/- 1.1 ng/mL in controls; p < 0.01). Pituitary gonadotropin subunit LHbeta mRNA levels were inhibited in all groups except controls, but pituitary GnRH receptor mRNA was stimulated by agonist yet unaffected by combined analogues. Explanted ovaries were incubated with either analogue, both 10-6 M. After 4 h, GnRH receptor mRNA levels were significantly reduced by antagonist but not agonist. To verify puberty-inhibiting effects of GnRH analogues, we used 26-d-old female rats with androgen-induced precocious puberty after injecting subcutaneously single 300 microg danazol on postnatal d 5. Single application of cetrorelix depot (cetrorelix embonate) reduced serum estradiol levels and pituitary LHbeta expression; GnRH receptor mRNA levels were down-regulated in the pituitary and ovary (p < 0.05). In androgen-induced precocious puberty model, single injection of antagonist effectively arrests premature hormonal activation and down-regulates pituitary and ovarian GnRH receptors. We conclude that GnRH analogue combination and especially antagonist alone treatment most directly suppress gonadotropin levels. This implies that early treatment gonadotropin flare-up associated with agonist treatment is avoidable.

Topics: Androgens; Animals; Danazol; Disease Models, Animal; Estrogen Antagonists; Female; Gonadotropin-Releasing Hormone; Hormone Antagonists; Hypothalamus; Luteolytic Agents; Ovariectomy; Ovary; Pituitary Gland; Puberty, Precocious; Rats; Rats, Sprague-Dawley; Receptors, Estrogen; Receptors, LHRH; Triptorelin Pamoate; Uterus

To address whether gonadotropin-releasing hormone (GnRH) regulates its own expression and the expression of its receptor in the hypothalamus and ovary, we treated five groups of prepubertal/peripubertal female rats from postnatal days 25-36 with either the GnRH agonist triptorelin (TRIP) or the GnRH antagonist cetrorelix (CET), each 10 or 100 microgram/day, or a placebo. We compared their effects regarding pubertal development, serum gonadotropins and the expression of GnRH and GnRH-receptor in the hypothalamus, pituitary, ovary and uterus. Onset of puberty was determined by vaginal opening, and expression levels of GnRH and GnRH-receptor were determined using either quantitative real-time PCR or competitive RT-PCR. Onset of puberty was retarded by both analogs but CET (100 microgram/day) inhibited while TRIP (10 and 100 microgram/day) stimulated serum gonadotropins (P<0.05). The expression of GnRH in the preoptic area did not show significant differences among the treatment groups but ovarian GnRH mRNA levels were significantly stimulated by CET (100 microgram/day). GnRH mRNA could not be detected in the uterus by either real-time PCR or competetive RT-PCR. The GnRH-receptor expression in the hypothalamus (preoptic area and mediobasal hypothalamus) did not vary among any of the groups, whereas in the pituitary GnRH-receptor mRNA levels were stimulated by TRIP (10 microgram/day) but inhibited by CET (100 microgram/day). In contrast, in the ovary GnRH-receptor mRNA levels were inhibited by both TRIP (100 microgram/day) and CET (100 microgram/day). Interestingly, the GnRH-receptor was even expressed in the uterus where it was strongly stimulated by both CET and TRIP in a dose-related manner. This shows that in addition to their different pituitary effects, the GnRH analogs cetrorelix and triptorelin exert different actions at the hypothalamic, ovarian and uterine level. This study also demonstrates an organ-specific regulation of GnRH and GnRH-receptor gene expression which is likely part of a local autoregulatory system. We conclude that the ovarian and uterine effects of GnRH analogs must be considered in addition to their known pituitary effects when deciding which GnRH analog is most suitable for treating precocious puberty.

Topics: Analysis of Variance; Animals; Autocrine Communication; Dose-Response Relationship, Drug; Estradiol; Female; Follicle Stimulating Hormone; Gene Expression; Gonadotropin-Releasing Hormone; Homeostasis; Humans; Hypothalamus; Luteinizing Hormone; Models, Animal; Ovary; Pituitary Gland; Puberty, Precocious; Rats; Rats, Sprague-Dawley; Receptors, LHRH; Reverse Transcriptase Polymerase Chain Reaction; RNA, Messenger; Sexual Maturation; Stimulation, Chemical; Triptorelin Pamoate; Uterus