Vosoritide for Selected Genetic Causes of Short Stature

Inclusion/Exclusion Criteria

INCLUSION CRITERIA

1. Parent(s) or guardian(s) are willing and able to provide written, signed informed consent after the nature of the study has been explained and prior to performance of any research-related procedure. Also, subjects under the age of 18 are willing and able to provide assent (if required) after the nature of the study has been explained and prior to performance of any research-related procedure.
2. Stated willingness to comply with all study procedures and availability for the duration of the study
3. Age >3 years 0 days AND <10 years 364 days for males, <9 years 364 days for females
4. Pre-pubertal defined as Tanner Stage 1 breasts in females and testicular volumes <3 cc in males. This must be confirmed at the Day 1 visit prior to initiation of vosoritide.
5. Patient height <-2.25 SDS. All height SDS values are calculated using the CDC growth charts/data tables (40).
6. Patients with pathogenic or likely pathogenic variants in genes known to cause the specific genetic subgroups of short stature listed below are eligible for inclusion in the study. Pathogenicity of variants will be classified as per the American College of Medical Genetics criteria (41). Documentation of the presence of the variant must be obtained using a lab results report from a CLIA certified laboratory. Classification of the variant’s pathogenicity status will be performed by the Children’s National study team.
7. CNP deficiency due to mutations in NPPC – Subjects with heterozygous or homozygous defects in NPPC are eligible.
8. Hypochondroplasia – Subjects with heterozygous variants in FGFR3 gene associated with hypochondroplasia are eligible. Subjects with variants in FGFR3 known to cause achondroplasia or thanatophoric dysplasia or SADDAN syndrome will be excluded.
9. Patients with heterozygous defects in NPR2 are eligible. Patients with homozygous defects in NPR2 will be excluded.
10. Rasopathy patients (including Noonan syndrome, Costello syndrome, Cardiofaciocutaneous syndrome, Neurofibromatosis Type 1) – This include patients with heterozygous variants in the following genes: BRAF, CBL, HRAS, KRAS, LZTR1, MAP2K1, MAP2K2, MRAS, NF1, NRAS, PPP1CB, PTPN11, RAF1, RRAS, RIT1, SHOC2, SOS1, SOS2
11. Patients with SHOX deficiency – Patients with heterozygous defects in SHOX including patients with heterozygous deletions of the SHOX regulatory region known to cause SHOX deficiency.
12. Absence of growth hormone deficiency defined as an IGF-1 level above the lower limit of the normal range of the assay. If a patient has an IGF-1 level below the lower limit of the normal range of the assay, two growth hormone stimulation tests must be performed using the routine local protocols. Patients with a peak growth hormone level >7 ng/ml will be considered growth hormone sufficient and will be eligible for inclusion as per the Growth Hormone Research Society International consensus (42). If indicated based on IGF-1 level from the referring clinician, the growth hormone stimulation test must be done as part of routine clinical care prior to enrollment. The rationale for using an IGF-1 below the normal range as the cut-off for further evaluation for growth hormone deficiency is that in patients with a clear genetic explanation for their short stature, an IGF-1 level anywhere within the normal range would be considered reassuring and would not lead to a growth hormone stimulation test in a routine clinical setting.
13. The subject and their guardian must speak one of the 11 languages for which the QoLISSY survey (a quality of life survey for short stature) is available. These include: English, Spanish, German, Russian, Swedish, Flemish, Italian, Turkish, French, Japanese, and Ukrainian.

EXCLUSION CRITERIA:

1. Growth plate fusion – Defined as a bone age via the Greulich and Pyle method of 13 years in females and 15 years in males. These patients have limited remaining growth potential.
2. Concomitant treatment with growth hormone or recombinant IGF-1. Patients may have been previously treated with growth hormone or IGF-1 therapy. If the patient is currently on one of these therapies, they will be required to discontinue treatment in order to begin the baseline observation period for this trial. That decision will be deferred to their treating clinical endocrinologists in conjunction with the patient’s guardians. We anticipate that only patients who are having a poor response to their therapy will be interested in enrolling in the current study as there is no rationale for a patient who is receiving growth hormone therapy and having a positive response to enroll in the current study.
3. Prior treatment with a GnRH analog, aromatase inhibitor or oxandrolone
4. History of any type of malignancy
5. Chronic medical condition known to affect growth including but not limited to:
6. Cystic fibrosis
7. Diabetes
8. Inflammatory Bowel Disease
9. Celiac Disease
10. Asthma requiring a daily inhaled steroid dose > 400 micrograms of inhaled budesonide per day or equivalent
11. Taking daily oral glucocorticoids for any reason
12. Note – ADHD treated with a stimulant and treated hypothyroidism with a normal TSH will NOT exclude the subject from participating in the trial.
13. Turner Syndrome or any other chromosomal aneuploidy
14. Congenital heart disease which places the subject at increased risk of an adverse cardiac outcome in the setting of hypotension including but not limited to: hypertrophic cardiomyopathy, aortic stenosis with peak gradient >50mmHg, severe aortic regurgitation (defined as pressure half time >500ms by echocardiogram), coronary insufficiency, or any anatomy with a need for an afterload reducing agent. Any patient with baseline abnormalities on echocardiogram will be reviewed with a pediatric cardiologist for appropriateness for inclusion in the study.
15. Malnutrition – Defined as a BMI <5^th percentile (CDC growth charts)
16. Any clinically significant abnormality on screening tests as determined by the principal investigator
17. Known or suspected allergy to trial medication, excipients, or related products
18. The receipt of any investigational drug within 90 days prior to this trial

Study Description

This is a single arm prospective interventional trial of vosoritide, a CNP analog, for the treatment of five genetic causes of short stature (hypochondroplasia, CNP deficiency, NPR2 mutations, SHOX deficiency, and Rasopathies). There will be a 6 month observational period followed by 1 year of therapy. Four study visits will occur at Children’s National Hospital (one every 6 months). All costs of travel and care will be covered by the study.

ClinicalTrials.gov link

https://clinicaltrials.gov/ct2/show/NCT04219007