Evaluation of Metformin, Pioglitazone, and Spironolactone in Slowing Accelerated Maturation in Early Pubertal Girls with Advanced Puberty and PCOS

The primary objective of this study is to evaluate whether a low-dose combination of **metformin**, **pioglitazone**, and **spironolactone** can effectively slow accelerated maturation in early pubertal girls with a history of low prenatal weight and high postnatal weight. This is clinically relevant as it addresses the imbalance in adipogenesis and lipid storage capacity, which are critical factors in managing conditions such as advanced puberty and Polycystic Ovary Syndrome (PCOS).

Secondary objectives include:

• Determining if the pharmacological intervention with MD-spiomet reduces liver and visceral fat more significantly than placebo in girls with early puberty.
• Assessing whether the reduction in hepatic and visceral fat in girls treated with MD-spiomet is associated with a greater slowing of bone maturation, slower pubertal tempo, and more normal levels of insulin, IGF-I, inflammatory markers, sex steroids, HMW-adiponectin, CXCL14, and GDF15 compared to placebo.
• Evaluating if the benefits on hepato-visceral fat and endocrine-metabolic markers are still detectable one year after treatment discontinuation.
• Assessing the tolerability and safety of MD-spiomet over one year, as well as the acceptability of the tablet.

The clinical trial involves a study population of **girls** aged between 8.0 and 9.5 years, specifically targeting those with advanced puberty and accelerated bone maturation, including conditions such as **Polycystic Ovary Syndrome (PCOS)**. The trial exclusively includes female participants, with no male subjects involved. The selection criteria focus on girls with a history of low prenatal weight and high postnatal weight, which affects their adipogenesis and lipid storage capacity. Participants are required to be of white ethnicity, with a gestational age at birth between 34 and 42 weeks. The trial population is characterized by progressive advanced puberty, with bilateral breast development (Tanner stage 2) occurring between the ages of 7.7 and 9.3 years, and a minimum progression of two months. Height at the first visit must fall between the 3rd and 97th percentiles, adjusted for pubertal stage. The study involves a vulnerable population, and written informed consent from parents or legal guardians is mandatory. The sponsor has not provided information regarding the total number of participants in the trial.

The clinical trial is designed to evaluate the efficacy of a low-dose combination of **metformin**, **pioglitazone**, and **spironolactone** in slowing accelerated maturation in early pubertal girls with a history of low prenatal weight and high postnatal weight. This study is a randomized, placebo-controlled, multicenter trial, conducted in a double-blind manner to ensure unbiased results. The trial is expected to span approximately 42 months, with recruitment starting in December 2022 and concluding in June 2026.

Participants will undergo a series of study visits, beginning with an inclusion (screening) visit to assess eligibility based on specific criteria, such as age, birth weight, and pubertal development stage. Follow-up visits will be scheduled at regular intervals to monitor clinical and endocrine-metabolic variables, including weight, height, BMI, and hormone levels. The primary endpoint is the assessment of bone age advancement over one year, using an automated method. Secondary endpoints include various clinical, metabolic, and safety markers, as well as abdominal fat distribution analyzed by MRI. The end-of-study visit will conclude the trial, where final assessments and data collection will occur.

Participant involvement is expected to last up to 12 months, with conditions for early termination including adverse events, non-compliance with the study protocol, or withdrawal of consent. The trial aims to provide valuable insights into the potential benefits of the drug combination in managing conditions associated with advanced puberty and **Polycystic Ovary Syndrome (PCOS)**. The study will adhere to rigorous scientific and ethical standards to ensure the validity and reliability of the findings.

The clinical trial involves the administration of the experimental medication **SPIOMET**, which is formulated as a **tablet**. This medication is a combination of three active substances: **metformin**, **pioglitazone**, and **spironolactone**. Each of these substances is of chemical origin. The maximum daily dose of SPIOMET is 425 mg, and it is administered orally. The treatment period for this medication is up to 12 months. The primary objective of the trial is to assess the efficacy of this low-dose combination in slowing accelerated maturation in early pubertal girls with specific weight history characteristics.

In addition to the experimental treatment, a **placebo** is used as a comparator in this randomized, placebo-controlled study. The placebo consists of excipients such as Povidona K-30, microcrystalline cellulose, sodium croscarmellose, Polyglycol 4000, and magnesium stearate. The placebo is designed to match the experimental medication in appearance and administration route, ensuring blinding of the study. The placebo is also administered orally, with the same frequency and duration as the experimental treatment, to maintain consistency in the trial protocol.

Efficacy in the clinical trial will be assessed using both primary and secondary endpoints. The primary endpoint is the advancement of **bone age** over a period of 0-1 year, which will be measured using an X-ray of the hand and wrist of the left hand, analyzed through an automated method known as BoneXpert (Visiana, Denmark). This method provides an objective measure of bone maturation, which is crucial for evaluating the impact of the treatment on accelerated maturation in early pubertal girls.

Secondary endpoints include a range of clinical and endocrine-metabolic variables. Clinical variables to be measured are weight, height, body mass index (BMI), waist and hip circumference and their ratio, systolic and diastolic arterial pressure, and Tanner stage. Endocrine-metabolic variables include insulinaemia (fasting glucose, insulin, HOMA-IR), IGF-I, gonadotropins (LH, FSH), sex steroids (total testosterone, androstenedione, SHBG, FAI, oestradiol), lipids (total cholesterol, LDL, HDL, triglycerides), and markers of inflammation, insulin sensitivity, and brown adipose tissue activity (ultrasensitive C-reactive protein, GDF-15, HMW-adiponectin, CXCL14). Safety markers such as blood count, circulating levels of alanine transaminase, aspartate transaminase, gamma-glutamyltransferase, thyroid stimulating hormone, urea, creatinine, electrolyte panel, vitamin B12, and folic acid will also be monitored.

Additionally, abdominal fat distribution and liver fat will be analyzed using MRI to assess subcutaneous and visceral fat areas and intrahepatic fat. Other secondary outcomes include dietary habits, tablet acceptability, adherence to the study protocol, and the reporting of adverse events. These comprehensive assessments will be conducted at specified intervals throughout the trial to ensure a thorough evaluation of the treatment's efficacy and safety.