United States

Levothyroxine (LT4) is the treatment of choice for hypothyroidism and the second most prescribed medication in the United States. Despite its established efficacy and widespread availability, approximately 40% of patients treated with LT4 fail to achieve thyroid stimulating hormone (TSH) levels within the normal range. Current LT4 product guidelines recommend administration in the fasting state 30-60 minutes before breakfast to avoid a food interaction leading to reduced intestinal absorption of LT4. This recommendation may impact compliance, as over 50% of adult Americans drink coffee every day, 65% of which is consumed during breakfast.While the majority of patients receive LT4 tablets, there is evidence that liquid formulations that bypass the gastric dissolution phase may mitigate the interference with coffee. ThyquidityTM (levothyroxine sodium) oral solution has demonstrated bioequivalence to Synthroid® under fasting conditions and allows individualized dosing flexibility in a variety of clinical scenarios. A bioavailability study was conducted to assess the rate and extent of absorption of the oral LT4 solution (100 mcg /5 mL) administered with coffee compared to administration under fasting conditions in an open label, randomized, two-period, two-treatment, two-sequence, crossover, single dose bioavailability study in 40 healthy adults. A single 600 μg oral dose of LT4 solution (ThyquidityTM, 30 mL) was administered 5 minutes before drinking 8 ounces of American coffee (without milk or sweeteners) or under fasting conditions in each study period. Blood samples were collected for total (bound and free) T4 for 48 hours after drug administration. Treatment periods were separated by a 40-day wash-out period.The ratios of geometric LS means with corresponding 90% confidence intervals (CI) were calculated from the exponential of the difference between the LT4 solution administration 5 minutes prior to coffee and administration under fasting condition for AUC0-48 and Cmax. An absence of a food effect would be concluded if the baseline corrected 90% CIs of this ratio fell within 80.00% to 125.00% for Ln-transformed AUC0-48 and Cmax.Forty healthy adults participated in the trial. There were no serious adverse events (AE) or discontinuations due to AEs. The geometric LS mean ratio of AUC0-48 and Cmax for baseline-adjusted LT4 were 93.98% (90.06-98.07%) and 95.99% (92.64- 99.45%) respectively. The corresponding 90% CIs were included within the acceptance range for bioequivalence.This study demonstrated comparable bioavailability of a single oral 600 μg dose of Thyquidity oral solution administered, 5 minutes prior to coffee or under fasting conditions. These results are consistent with earlier evidence that liquid LT4 overcomes the interference from coffee seen with LT4 tablets and may offer additional flexibility for patients.

ENDO 2022

Comparable Bioavailability of a Novel Levothyroxine Solution when Administered with Coffee

**Program**
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over 20 Meet the Professor sessions presented both in-person and live-streamed virtually and another 20+ presented live in Atlanta;
four Basic Science Pathways, including Diabetes and Metabolism; Neuroendocrinology; Nuclear Receptors and Signaling; and Reproductive Endocrinology; and
more than 30 oral sessions and a robust virtual poster hall for accepted scientific abstracts.

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Spanning the spectrum of science, clinical care, and social implications, an outstanding slate of world-renowned speakers will showcase the most cutting-edge advances on research and medicine.

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**Basic Science Pathways**

These special “meeting-within-a-meeting” tracks integrate focused discussions, poster sessions, and networking opportunities to provide you with the latest research in:
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**Meet the Professor & Meet the Scientist**
Discover insights from experts on treating a variety of endocrine conditions and emerging science in the field of endocrinology, and learn the latest in patient care and scientific research.

ENDO’s comprehensive program provides attendees the opportunity to learn about the latest developments in hormone science and medicine from renowned investigators, expert clinicians, and educators from all over the world. 

technical paper

Background: Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis mostly reported in Eastern Asian countries with relatively few known cases among non-Asian diaspora in the West.Case: A 28-year-old African American male with no documented medical history reported to the ED with concern for mechanical fall secondary to progressively worsening muscle weakness. Symptoms began the prior evening with proximal lower extremity and bilateral shoulder weakness which then became severe generalized weakness in all four extremities by morning prompting a fall due to unstable gait and inability to maintain stable seated position. A 60 lb weight loss over the prior year was also noted. Vital signs were notable for blood pressure 154/67 mmHg, tachycardia 109 beats per minute, and tachypnea 20 breaths per minute. Initial labs were significant for hypokalemia 2.2 mEq/L (3.5 – 5.5 mEq/L), hs-troponin 59 ng/L (n < 20 ng/L), CK 444 U/L (38 – 174 U/L), ALP 186 U/L (35 – 110 U/L), TSH < 0.01 uIU/mL (0.35 – 5.5 uIu/mL), free T4 4.13 ng/dL (0.61 – 1.12 ng/dL), free T3 15.10 pg/mL (2.5 – 3.9 pg/mL) and total T3 404 ng/dL (87 – 178 ng/dL). EKG revealed sinus tachycardia with prolonged PR-interval to 236 ms and prominent precordial U-waves. The patient was given potassium chloride 40 meq IV and PO supplementation, started on propranolol 10mg PO QID and methimazole 30mg PO daily, and admitted to telemetry. Endocrinology recommended increasing the methimazole dose to 20mg PO TID. Thyroid ultrasound revealed a heterogeneous hyper-vascular gland. Follow up labs included: thyroid stimulating immunoglobulin 4.97 IU/L (n < 0.10 IU/L), thyroid peroxidase antibody 19 IU/L (n < 9 IU/mL), gamma glutamyl transpeptidase 22 (9 – 65 U/L). Findings were consistent with Graves' disease. Repeat metabolic panel showed appropriate potassium response to supplementation trending between 3.9 meq/L to 4.2 meq/L at six-hour intervals. Hs-troponin peaked at 108 ng/L likely due to demand ischemia in the setting of persistent tachycardia. Follow-up 2D echocardiogram was remarkable for borderline LVH with 60% EF. Patient displayed rapid improvement in muscle strength as potassium normalized; creatine kinase trended down to 49 U/L with resolving myopathy. Patient was discharged on methimazole 20mg PO TID and propranolol 10mg PO QID and told to increase PO intake of potassium rich foods. He was advised to avoid strenuous activity for at least 2 weeks.His potassium was 4.5 meq/L on follow-up endocrinology appointment one week after discharge. He did not endorse residual symptoms and remained compliant with medications.Conclusion: This is a case of TPP amidst undiagnosed Graves' disease that resolved with timely potassium repletion. Documented TPP cases in non-Asians, especially African Americans, are rare and should be investigated further.

Thyrotoxic Periodic Paralysis: An Uncommon Complication Presenting From an Unsuspected Demographic

Background: SH2B adaptor protein 1 (SH2B1) binds to Janus kinase 2 and enhances leptin signaling through the central melanocortin-4 receptor (MC4R) pathway, a key regulator of energy balance. Variants in SH2B1 or a 220–kilobase pair distal deletion of chromosome 16p11.2, including SH2B1, are associated with hyperphagia (pathologic insatiable hunger), severe early-onset obesity, reduced final height, and insulin resistance. Setmelanotide, an MC4R agonist, produced significant weight and hunger reduction after 3 months in patients with SH2B1 heterozygous variants or 16p11.2 deletion in a Phase 2 study. This analysis is the first to assess the continued efficacy of ~1 year of setmelanotide treatment in patients with SH2B1 genetic obesity.
Methods: Patients aged ≥6 years with SH2B1 heterozygous variants or 16p11.2 deletion encompassing SH2B1 were eligible for this long-term extension (LTE) trial (NCT03651765) if they completed a prior (index) trial in which they received setmelanotide and demonstrated clinical benefit based on weight and hunger results, and acceptable safety as determined by the investigator. Patients received a minimum of 4 months of setmelanotide treatment as part of the index trial and began the LTE immediately following the completion of the index trial. Study visits occurred approximately every 3 months. Study objectives included evaluating changes in body weight measures and assessing tolerability. The current analysis reports outcomes after ~1 year of setmelanotide treatment across the index and LTE trials relative to index trial baseline.
Results: As of October 29, 2021, 35 patients with obesity and SH2B1 heterozygous variants or 16p11.2 deletion had enrolled in the index trial. Of patients entering the LTE, 19, 15, and 14 had received at least 6, 9, and 12 months of treatment, respectively. At index trial baseline, mean (standard deviation [SD]) body mass index (BMI) for all patients was 47.2 (12.8) kg/m2, body weight in patients aged ≥18 years (n=22) was 139.7 (35.4) kg, and BMI Z-score in patients aged <18 years (n=13) was 3.56 (0.60). Mean (SD) percent change in BMI was −3.4% (8.1%; n=19), −5.9% (10.0%; n=15), and −9.7% (8.0%; n=14) after 6, 9, and 12 months of treatment. Mean (SD) percent change in body weight in patients aged ≥18 years was −4.4% (5.0%; n=9), −6.8% (5.0%; n=7), and −7.7% (10.0%; n=8) after 6, 9, and 12 months, respectively. Mean (SD) change in BMI Z-score was −0.55 (0.17; n=6) after 12 months. No patients discontinued due to adverse events during the LTE . No new safety concerns emerged during long-term treatment.
Conclusions: Setmelanotide treatment provided clinically meaningful reductions in weight-related measures in patients with SH2B1 heterozygous variants or 16p11.2 deletion up to ~1 year. These data support the continued investigation of setmelanotide in this population, which is underway in the planned Phase 3 EMANATE trial (NCT05093634).

Body Mass Index and Weight Reduction in Patients With SH2B1 Genetic Variant Obesity After One Year of Setmelanotide

Background: Lipodystrophy syndromes are associated with inadequate adipocyte capacity that results in an earlier threshold for ectopic deposition and metabolic dysfunction. We have previously reported that patients with familial partial lipodystrophy (FPLD) present with metabolic severity equivalent to what is observed at 8-12 BMI points higher in a population with common obesity. Currently, there is no strong evidence that any specific diet is the preferred treatment, but bariatric surgery has been reported to improve metabolic outcomes in a few patients. Here, we report the effect of an aggressive calorie-restricted diet in a patient with FPLD who showed remarkable benefit after 16 weeks of the intervention. Clinical Case: This is a 38-year-old female diagnosed with FPLD type 2, with LMNA p. R482Q mutation who had a history of recurrent pancreatitis, NAFLD, impaired ovulation, and diabetes mellitus. She had a short-term goal of improving her metabolic state rapidly to achieve pregnancy by IVF. Upon presentation, body weight was 81.6kg, BMI 23.2kg/m2, HbA1c 7.7% and triglycerides 215mg/dL. She was started on very-low calorie diet (VLCD) (800 kcal/day) employing a formula total liquid diet meal replacement:  160 kcal per shake (18g total carbohydrates, 15g net carbohydrates, 3.5g fat, and 16g protein) with the goal to reduce body weight by 15% as has been described for patients in the University of Michigan Weight Management Program. After 1 week on diet, she discontinued glucose and lipid lowering therapies. After 12-weeks of VLCD followed by 4 weeks of transition to low-calorie diet (incorporating 3 meal replacements, one meal, and ad libitum non-starchy vegetables), we observed 12.3kg of body weight and a 1.4% decrease in HbA1c. Insulin resistance was reduced by 66.7 and 61.5% (HOMA-IR and ADIPO-IR, respectively). Fasting insulinemia was reduced by 64.2%. We also performed an OGTT with 75g of glucose for 180 min and observed a decrease in the area under the curve of insulin (-33.2%), triglycerides (-40.7%), and free fatty acids (-34%). DEXA scan showed a reduction in total body fat of 16%. Liver fat via the chemical shift MRI method was reduced from 10±2% to 2±1%. She did not experience any adverse events during the intervention. More importantly, her egg retrieval rate and egg quality during IVF were far superior to past attempts. Conclusion: This case illustrates the strong effect and safety of a VLCD intervention in a patient with lipodystrophy. We observed rapid reduction in body weight, and in insulin resistance leading to the remission of diabetes mellitus, hypertriglyceridemia and fatty liver disease. Moreover, there was improved response to ovulation induction. Our data encourage the use of this medical approach for other patients with similar metabolic and reproductive abnormalities due to adipose tissue distribution abnormalities.

A Very-Low Calorie Diet Can Reduce Insulin Resistance and Cause Remission of Diabetes Mellitus and Hypertriglyceridemia in a Patient With Familial Partial Lipodystrophy Type 2

Background: The prevalence of sarcopenic obesity (SO) is increasing worldwide, posing important challenges to public health and national health care system, especially during the COVID pandemic. In subjects with SO, it is essential to reduce body weight preserving lean mass, in order to avoid a worsening of muscle function. Lifestyle modification with adequate nutrition and proper physical activity is essential to counteract SO progression. In accordance with the Position Statement of the Italian Society of Endocrinology, Very Low Calorie Ketogenic Diet (VLCKD), a well established nutritional intervention in the context of obesity, has been promoted also for the treatment of SO (1). To date, the effects of physical training during VLCKD have not been studied. Aim: This pilot study aims to determine the efficacy of VLCKD combined with interval training, compared to a VLCKD alone, on weight-loss, body composition and physical performance in patient with SO. Materials and methods: Twenty-six patients with SO, aged between 50 and 70 years, who met the inclusion criteria, accepted to adhere to a VLCKD nutritional program (< 800 Kcal/die) and gave informed consent, were enrolled in the study. Thirteen patients followed a structured VLCKD protocol (VLCKD group) and thirteen patients followed a structured VLCKD protocol combined with interval training (IT), two times a week (VLCKD+IT group). Data were collected at baseline (T0) and after 45 days (T45). Anthropometric indexes, body composition analysis by Bioelectrical Impedance Analysis (BIA), muscle strength measurement by Chair Stand Test and physical performance analysis by Short Physical Performance Battery were assessed at baseline and at the end of treatment. Results: At the end of the study, Body Mass Index, body weight and waist circumference were significantly reduced both in the VLCKD group and in the VLCKD+IT group. Moreover, significant improvement of muscle strength and physical performance was found in all groups. A significant reduction in hip circumference was observed only in the VLCKD+IT group. A multiple comparison of delta variations in the measured parameters between groups was performed. No differences were observed for the majority of parameters, with the exception of FFM and FM: interestingly, the individuals fed with VLCKD combined with IT preserved their FFM (p <0.0001) and reduced their FM (p = 0.0006) to a greater extent than in the VLCKD group. Conclusions: Our pilot study showed that VLCKD was effective in terms of body weight reduction, particularly of FM; moreover, we conclude that the combination of VLCKD and interval training determines a better preservation of FFM. References: 1. Caprio, M. et al. Very-low-calorie ketogenic diet (VLCKD) in the management of metabolic diseases: systematic review and consensus statement from the Italian Society of Endocrinology (SIE). J Endocrinol Invest 2019, 42, 1365-1386, doi: 10.1007/s40618-019-01061-2.

Very Low Calorie Ketogenic Diet combined with interval training for preserving muscle mass during weight loss in sarcopenic obesity: a pilot study

Background: Prader-Willi syndrome (PWS), a rare genetic neurobehavioral-metabolic condition, is characterized by hyperphagia, accumulation of excess fat, hypotonia, and behavioral/psychological complications.  There are no currently approved medications to treat hyperphagia in patients with PWS; DCCR is under development as a treatment for PWS.
Objectives and methods: The objective was to evaluate long-term safety of DCCR in individuals with PWS. 125 participants with genetically-confirmed PWS ≥4 years old with hyperphagia were treated with oral daily DCCR in multi-center studies conducted at 29 sites in the US and the UK: a 13-week, Phase 3, double-blind, placebo-controlled study (DESTINY PWS) and its long-term, open-label extension study (to 52 weeks and beyond). Enrolled participants had hyperphagia assessed by the Hyperphagia Questionnaire for Clinical Trials (HQ-CT). The target DCCR dose was ≥3.3 mg/kg (optimal dose 4.2 - 5.8 mg/kg). 103 patients received DCCR for 52 weeks and 54 patients received DCCR for at least 78 weeks.
Results: Overall, DCCR was well tolerated with the majority of adverse events (AEs), (77.6%) having grade 1 or 2 severity. Treatment-emergent adverse events (TEAEs) occurred in 98.4% of participants.  Drug related TEAEs occurred in 80.0% of participants. Twenty participants experienced serious adverse events (SAEs), for which only two participants were considered drug related (one patient with peripheral/pulmonary edema and another with fluid retention). There were no Suspected Unexpected Serious Adverse Reactions (SUSARs) or SAEs leading to death.  The most common TEAEs were hypertrichosis (61.6%), peripheral edema (34.4%), and hyperglycemia (22.4%).  TEAEs infrequently resulted in discontinuation of study drug (7.2% of participants).  These results are consistent with the observed safety profile of DCCR from prior studies.
Consistent with the expected AE of hyperglycemia, fasting glucose rose through Week 26 (mean change from baseline ± SD mmol/L = 0.35±0.81) and returned nearly to baseline by 15 months of treatment (0.11±0.61).  HbA1c followed a similar pattern, increasing at 26 weeks (mean change from baseline ± SD % = 0.19±0.50) and returning nearly to baseline by 15 months (0.03±0.38).  In participants experiencing hyperglycemia, the AE resolved with continued treatment in about half of cases.  Four participants experienced recurrent hyperglycemia.  About 90% of cases of peripheral edema resolved while treatment continued, requiring infrequent dose adjustment (7%) or the need for diuretic treatment (3%). Most cases of hypertrichosis (>80%) were mild and only in one instance led to discontinuation.  About 35% of cases of hypertrichosis were resolved/resolving at Week 52.
Conclusions: DCCR was well tolerated beyond 52 weeks of administration. The most common treatment-emergent adverse events were expected based on prior studies of DCCR. These included hypertrichosis, peripheral edema and hyperglycemia, which were typically mild and resolved without treatment in most cases.

Long-Term Safety of Diazoxide Choline Extended-Release (DCCR) Tablets in Patients with Prader-Willi Syndrome

The need for personalized medicine in obesity is pressing, but we are currently unable to predict individual responses to weight loss (WL) medications. The melanocortin (MC) system consisting of proopiomelanocortin (POMC) and agouti related protein (AgRP) neurons and brain MC-Rs plays a critical role in regulating energy homeostasis and is targeted by lorcaserin (LOR), a 5HT2cR agonist previously FDA approved for WL. We therefore investigated the short and long-term effects of LOR on the MC system as assessed by cerebrospinal fluid (CSF) neuropeptide measurements and other parameters in order to identify potential biomarkers to predict WL response.
Methods: In phase-1 of our two-phase study, thirty subjects with obesity were randomized to receive placebo or LOR for 7-days and were then crossed over to 7-days of LOR or placebo after a 3-week washout period. Subjects then continued to phase-2 and were treated with LOR for 6-months. The study was terminated early as LOR was withdrawn from the market and only 19 subjects completed 6M. Anthropometrics, plasma and CSF were collected and test meals were administered after both placebo and LOR during phase-1 and at the end of phase-2. POMC prohormone and the POMC-derived peptide, β-endorphin (β-EP), were measured in CSF by in house ELISA and RIA. The MC-R antagonist, AgRP, was measured by ELISA in CSF and plasma as both may reflect brain AgRP.
Results: During phase-1 there was a decline in CSF POMC (p=0.001) and an increase in CSF β-EP (p=0.0017) resulting in an increase in the ratio of β-EP /POMC (processed peptide/prohormone) (p<0.0001) after 7-days of LOR vs placebo. Serum insulin and HOMA-IR also decreased despite no WL during phase-1 (p<0.005).
After 6M of LOR, average WL was 6.9 %, with 11/19 subjects achieving >5% and 7/19 >10% WL. Leptin, insulin and HOMA-IR declined. CSF POMC remained lower and β-EP and β-EP/POMC remained higher after 6M vs 7-day placebo (baseline), whereas AgRP increased only at 6M. Anthropometrics and caloric intake during test meals were not significantly different between LOR and placebo in phase-1 and did not predict WL at 6M. Phase-1 changes in POMC or β-EP did not predict WL. However, baseline CSF POMC and POMC/AgRP ratio correlated negatively with WL and were significantly lower in subjects with >10% WL. A CSF POMC cutoff of < 220 fmol/ml at baseline was found to predict 10% WL at 6M (p=0.045 Fisher).
Conclusion: In this study we show that the melanocortin system is impacted after 1 week of LOR. Furthermore lower melanocortin activity at baseline predicted a better weight loss response to drug treatment. Assessment of melanocortin activity could thus provide a way to personalize the pharmacotherapy of obesity with possible future alternative selective 5HT2cR agonists.

Defining Predictors of Weight Loss Response to Lorcaserin

BACKGROUND:
Combined estrogen and progestin hormonal contraceptives (CHCs, including combined oral contraceptives, hormonal patches, or vaginal rings) expose women to supraphysiologic levels of reproductive hormones, which in turn suppress endogenous estrogen and progesterone. Sustained elevations of synthetic estrogen/progestin or suppression of endogenous hormones in CHC users may lead to altered dietary intake and/or patterns of physical activity (PA). Previously, we reported that CHC use was associated with higher energy intake (EI) and weight regain over 1 year after weight loss in women with overweight and obesity enrolled in a behavioral weight loss program, suggesting a potential impact of CHCs on energy balance in the weight reduced state. The aim of this secondary data analysis was to compare dietary intake and PA in weight-stable women with overweight or obesity using CHCs to non-CHC users.
METHODS:
Pre-menopausal women with overweight or obesity (n=269, age 18-55 years, BMI 27-45kg/m2) enrolled in 3 different interventional weight loss trials were categorized as CHC users (CHC, n=48) or non-CHC controls (CON, n=221). Fat mass (FM) and lean mass (LM) were measured with DXA. Self-reported dietary energy and macronutrient intake was obtained from either 3-day (n=178) or 7-day (n=91) written diet diaries and analyzed using Nutrition Data System for Research (NDSR) software. Healthy eating index (HEI) scores for diet quality were calculated in a subset (CHC=17, CON=84) of participants using variables available in NDSR output files. Additionally, average daily step counts were measured over 1 week in a subset (CHC=27, CON=143) of participants using the activPAL device.
RESULTS:
Age was lower in CHC users (mean±SD; CHC 35.39.0 vs. CON 39.47.6 years, p<0.01), but race and ethnicity did not differ between the two groups. After controlling for age, there were no significant differences between groups in baseline BMI (mean±SEM; CHC 34.30.7 vs. CON 34.80.3 kg/m2), weight (93.62.4 vs. 94.21.1 kg), %FM (43.30.6 vs. 42.70.3 %), or %LM (54.30.6 vs. 54.70.3 %). There were no significant differences between groups in EI (mean±SEM; CHC 1763.778.1 vs. CON 1768.836.7 kcal); proportions of fat (36.70.9 vs. 36.90.4 %), carbohydrate (43.91.1 vs. 44.30.5 %), and protein intake (17.70.6 vs. 17.30.3 %); or HEI scores (58.32.9 vs. 56.81.3). There was a trend for lower daily step count in CHC users (mean±SEM; CHC 5978460 vs. CON 6913197 steps/day, p=0.07).
CONCLUSION:
Daily steps tended to be lower in CHC users compared to controls, while differences in self-reported dietary intake were not observed. Future studies that are done in larger samples over a greater range of BMI and with more detailed measures of PA timed to the menstrual cycle are needed to explore the extent to which CHC use may impact energy balance in women.

A Cross-Sectional Study Evaluating the Impact of Combined Hormonal Contraceptives on Components of Energy Balance in Pre-Menopausal Women with Overweight or Obesity

Background: The central hypothalamic melanocortin-4 receptor (MC4R) pathway is a key regulator of energy balance. Certain variants in genes upstream of MC4R, including those encoding the leptin receptor (LEPR), proopiomelanocortin (POMC), steroid receptor coactivator 1 (SRC1; also known as NCOA1), prohormone convertase (PC)1/3 (encoded by the gene PCSK1), and SH2B adaptor protein 1 (SH2B1) genes, lead to impaired MC4R pathway signaling and rare genetic diseases of obesity. While the deficiencies resulting from these genetic variants differ in some clinical features, they are all characterized by hyperphagia (pathologic insatiable hunger) and early-onset obesity during childhood. Setmelanotide, an MC4R agonist, reduced body weight and hyperphagia (assessed by hunger scores) after 3 months in patients with heterozygous POMC, including patients with the N221D variant in PCSK1; LEPR; SRC1; and SH2B1 (including a 220–kilobase pair distal deletion of chromosome 16p11.2) variants in an earlier Phase 2 trial. In the Phase 2 trial, 12 of 35 (34%) patients with heterozygous POMC, PCSK1, or LEPR variants; 9 of 30 patients (30%) with heterozygous SRC1 variants; and 13 of 35 (37%) patients with heterozygous SH2B1 variants achieved ≥5% weight loss after 3 months of setmelanotide treatment.Methods: EMANATE is a randomized, double-blind, placebo-controlled Phase 3 trial (NCT05093634) comprising 5 similar independent sub-studies based on genetic variants. For eligibility, patients must be 6-65 years old, have history of hyperphagia and childhood obesity, current obesity defined as BMI ≥30 kg/m² (in those ≥18 years old), and BMI ≥95th percentile (in those 6-17 years old). Patients must also have a heterozygous genetic variant in POMC or PCSK1; heterozygous genetic variant in LEPR; a homozygous, heterozygous, or compound heterozygous variant in SRC1 or SH2B1 (including a chromosomal deletion of 16p11.2 including SH2B1); or a heterozygous N221D variant in PCSK1. Patients with ≥2% weight loss in the prior 3 months, HbA1C >10%, clinically significant pulmonary, cardiac, or oncological disease, or history of significant liver or serious kidney disease are not eligible. Within each sub-study, patients will be randomized 1: 1 to receive daily subcutaneous injections of setmelanotide or placebo for 52 weeks. The primary outcome is the mean change in body weight in patients who receive setmelanotide compared with placebo. Safety will be assessed by frequency and severity of adverse events.
Current Status: EMANATE is currently underway and began enrolling patients in early 2022. The planned enrollment is 560 patients. If successful, this placebo-controlled Phase 3 trial will support setmelanotide treatment for improvements in body weight–related measures and hunger in an expanded population of patients living with rare genetic diseases of obesity.

Setmelanotide in Patients With Heterozygous POMC, LEPR, SRC1, or SH2B1 Obesity: Design of EMANATE – A Placebo-Controlled Phase 3 Trial

Background: Congenital leptin deficiency (CLD) is a rare autosomal recessive form of monogenic obesity caused by loss-of-function mutations in the leptin gene. Monogenic obesity disorders, including CLD, have been reported to be prevalent among children with severe obesity in a consanguineous Pakistani population. Targeted therapy is available in the form of recombinant human leptin (metreleptin). We previously reported baseline characteristics of the first cases of CLD identified in the United States, sisters of Pakistani origin with a family history of consanguinity. This report provides follow-up after 18 months of metreleptin therapy in an observational research protocol.

Clinical Case: Two sisters ages 18 yrs (A; BMI 45.2 kg/m2) and 20 yrs (B; 45.0 kg/m2) were referred for evaluation of obesity. Both had hyperphagia and excessive weight gain by age 3 months. They had been treated with combination OCPs in adolescence due to primary amenorrhea and hypogonadotropic hypogonadism. Sister A was diagnosed with type 2 diabetes at age 15 years and was treated with metformin and liraglutide with suboptimal glycemic control (HbA1C 9.3%). At the time of their initial evaluation, serum leptin levels were undetectable. After discontinuing OCPs, testing confirmed hypogonadotropic hypogonadism. Both patients were homozygous for the pathogenic variant c398delG in exon 3 of the leptin gene (LEP), which causes a frameshift/premature stop codon. Treatment was initiated with metreleptin 5 mg daily SC in Sister A and 3.75 mg SC daily, increasing to 5 mg daily at Week 8 in Sister B. Both remained on therapy throughout the 18 month observational trial without serious adverse effects or clinical evidence of neutralizing antibodies. At study end, both had substantial weight loss (Sister A: 45.3 kg or 32.8% of initial weight, Sister B: 39.1 kg or 33.1% of initial weight). Clinically significant improvements in related parameters were observed, including percent body fat (Sister A: -13%, Sister B: -18%), HOMA2-IR (A: -83% , B: -80% ), ALT (A: -90%, B: -91%), triglycerides (A: -47%, B: -26%), hsCRP (A: -80%, B: -84%), FGF-21 (A: -81%, B: -67%), and adiponectin (A: +42%, B: +37%). In both sisters, hepatic steatosis improved and bone mineral density increased (A: +0.7 SD, B: +0.6 SD). At study end, Sister A's HbA1C was 5.4% off medication. Spontaneous regular menses resumed after 3 months of therapy in Sister A and four months in Sister B. Improvements were observed in mood, self-esteem, physical function, energy, quality of life, dietary disinhibition, and perceived hunger, measured by validated questionnaires.

Conclusion: Metrelepin produced significant improvements in weight, metabolic profiles, hepatic steatosis, reproductive function, mood and quality of life in our patients. Given the efficacy of metreleptin therapy, screening for CLD should be undertaken for any patient presenting with hyperphagia and early onset of obesity.

Congenital Leptin Deficiency: Metabolic, Reproductive, and Psychological Impacts of Therapy

Introduction
Changes in the expression of microRNA facilitate in the formation of various tumors. MEN1 is a rare disease caused by mutations in MEN1 gene encoding the menin protein and characterize by the occurrence of parathyroid, pituitary, gastroenteropancreatic and other tumors. If a patient with the MEN1 phenotype carry no mutations in the MEN1 gene, the condition considers a phenocopy of syndrome (phMEN1). We hypothesize that the pathogenic link among the above sporadic tumors might be represented by molecular pathways involving the MEN1 gene and epigenetic regulations — particularly microRNAs.
Materials & methods
Single-center, case-control study: assessment of plasma microRNA expression in patients with phMEN1, acromegaly (AM), primary hyperparathyroidism (PHPT) and healthy controls. Morning plasma samples were collected from fasting patients and age- and sex-matched controls and stored at –80°C. Total RNA isolation: miRNeasy Mini Kit with QIAcube. The libraries were prepared by the QIAseq miRNA Library Kit following the manufacturer. Circulating miRNA sequencing was done on Illumina NextSeq 500 (Illumina). Subsequent data processing was performed using the DESeq2 bioinformatics algorithm.
Results
We enrolled 36 consecutive patients (12 patients in each group) with phMEN1, AM, PHPT, along with 12 age and gender matched controls. Median age of phMEN1 group — 59 [52; 60.5]; AM — 59 [52; 63]; PHPT — 60.5 [54; 62.5]; control — 59 [51.5; 62.5]. The groups did not differ in age (p=0.88) and gender – in all groups were 11 women and 1 man (p=1.00).
We divided all assessed microRNAs into 3 groups based on the significance of the results; the first group consisted of samples with the highest levels of detected microRNAs (>50), the second group — moderate (10–50), the third group — the lowest (<10).
The microRNA expression pattern was almost the same between AM and phMEN1 groups (15 microRNAs upregulated, 10 — downregulated), we found slightly decreased hsa-miR-4301 (padj=0.038); it is interesting that phMEN group when compared to PHPT and control groups showed decline in hsa-miR-4301 too. PHPT and control groups had also quite similar expression profile (4 microRNAs upregulated, 19 — downregulated).
607 microRNA were differently expressed in groups phMEN1 and PHPT (473 upregulated microRNAs, 134 — downregulated). We found increased expression of some microRNAs that interferes with menin: hsa-miR-24-1-5p (padj=0.0008), hsa-miR-24-3p (padj=0.034), hsa-miR-26a-5p (padj=0.0005), hsa-miR-421 (padj=0.018), hsa-miR-762 (padj=0.027). In addition, we found decreased microRNAs with oncogene potential: miR-3182 (padj=0.007), hsa-miR-875-5p (padj<0.001), hsa-miR-6749-5p (padj<0.001).
173 microRNA differed in phMEN1 and control groups (11 microRNAs upregulated, 162 — downregulated). We detected several decreased microRNAs in phMEN1 that participate in tumor genesis: hsa-miR-625-3p (padj<0.005), hsa-miR-3168 (padj=0,028), hsa-miR-302b-3p (padj<0.001).
Conclusion
We found microRNAs, which could potentially become biomarkers in phMEN1 diagnosis. The results need to be validated using different measurement method with larger sample size. Likewise further assessment of plasma microRNA expression in genetically confirmed MEN1 patients is needed.

Plasma MicroRNA Expression in Phenocopy of Multiple Endocrine Neoplasia Type 1 Compared to Patients with Acromegaly and Primary Hyperparathyroidism: Potential Biomarkers of Multiple Endocrine Tumor Growth

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