Reflections from the OARSI 2022 clinical trials symposium: The pain of OA-Deconstruction of pain and patient-reported outcome measures for the benefit of patients and clinical trial design.

OBJECTIVE: Osteoarthritis (OA) drug development is hampered by a number of challenges. One of the main challenges is the apparent discordance between pain and structure, which has had a significant impact on drug development programs and has led to hesitance among stakeholders. Since 2017, the Clinical Trials Symposium (CTS) has been hosted under the Osteoarthritis Research Society International (OARSI) leadership. OARSI and the CTS steering committee yearly invite and encourage discussions on selected special subject matter between regulators, drug developers, clinicians, clinical researchers, biomarker specialists, and basic scientists to progress drug development in the OA field. METHOD: The main topic for the 2022 OARSI CTS was to elucidate the many facets of pain in OA and to enable a discussion between regulators (Food and Drug Administration (FDA) and the European Medicines Agency (EMA)) and drug developers to clarify outcomes and study designs for OA drug development. RESULTS: Signs or symptoms indicative of nociceptive pain occur in 50-70% of OA patients, neuropathic-like pain in 15-30% of patients, and nociplastic pain in 15-50% of patients. Weight-bearing knee pain is associated with bone marrow lesions and effusions. There are currently no simple objective functional tests whose improvements correlate with patient perceptions. CONCLUSIONS: The CTS participants, in collaboration with the FDA and EMA, raised several suggestions that they consider key to future clinical trials in OA including the need for more precise differentiation of pain symptoms and mechanisms, and methods to reduce placebo responses in OA trials.

Is there a role for menopausal hormone therapy in the management of postmenopausal osteoporosis?

We provide an evidence base and guidance for the use of menopausal hormone therapy (MHT) for the maintenance of skeletal health and prevention of future fractures in recently menopausal women. Despite controversy over associated side effects, which has limited its use in recent decades, the potential role for MHT soon after menopause in the management of postmenopausal osteoporosis is increasingly recognized. We present a narrative review of the benefits versus risks of using MHT in the management of postmenopausal osteoporosis. Current literature suggests robust anti-fracture efficacy of MHT in patients unselected for low BMD, regardless of concomitant use with progestogens, but with limited evidence of persisting skeletal benefits following cessation of therapy. Side effects include cardiovascular events, thromboembolic disease, stroke and breast cancer, but the benefit-risk profile differs according to the use of opposed versus unopposed oestrogens, type of oestrogen/progestogen, dose and route of delivery and, for cardiovascular events, timing of MHT use. Overall, the benefit-risk profile supports MHT treatment in women who have recently (< 10 years) become menopausal, who have menopausal symptoms and who are less than 60 years old, with a low baseline risk for adverse events. MHT should be considered as an option for the maintenance of skeletal health in women, specifically as an additional benefit in the context of treatment of menopausal symptoms, when commenced at the menopause, or shortly thereafter, in the context of a personalized benefit-risk evaluation.

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF).

Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions. INTRODUCTION: Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication. METHODS: A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken. RESULTS: Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it. CONCLUSION: These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.

Management of glucocorticoid-induced osteoporosis.

This review summarizes the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis (GIOP) management, regulatory requirements, and risk-assessment options. Glucocorticoids are known to cause bone loss and fractures, yet many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated. An European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis workshop was convened to discuss GIOP management and to provide a report by a panel of experts. An expert panel reviewed the available studies that discussed approved therapeutic agents, focusing on randomized and controlled clinical trials reporting on bone mineral density and/or fracture risk of at least 48 weeks' duration. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. The FRAX algorithm can be adjusted according to glucocorticoid dose. Available antiosteoporotic therapies such as bisphosphonates and teriparatide are efficacious in GIOP management. Several other agents approved for the treatment of postmenopausal osteoporosis may become available for GIOP. It is advised to stop antiosteoporotic treatment after glucocorticoid cessation, unless the patient remains at increased risk of fracture. Calcium and vitamin D supplementation as an osteoporosis-prevention measure is less effective than specific antiosteoporotic treatment. Fracture end-point studies and additional studies investigating specific subpopulations (pediatric, premenopausal, or elderly patients) would strengthen the evidence base and facilitate the development of intervention thresholds and treatment guidelines.

Biomarkers and personalised medicine in rheumatoid arthritis: a proposal for interactions between academia, industry and regulatory bodies.

Rheumatoid arthritis (RA) is one of the most appropriate conditions for the application of personalised medicine as a high degree of heterogeneity has been recognised, which remains to be explained. Such heterogeneity is also reflected in the large number of treatment targets and options. A growing number of biologics as well as small molecules are already in use and there are promising new drugs in development. In order to make the best use of treatment options, both targeted and non-targeted biomarkers have to be identified and validated. To this aim, new rules are needed for the interaction between academia and industry under regulatory control. Setting up multi-centre biosample collections with clear definition of access, organising early, possibly non-committing discussions with regulatory authorities, and defining a clear route for the validation, qualification and registration of the biomarker-drug combination are some of the more critical areas where effective collaboration between the drug industry, academia and regulators is needed.

Secretogranin II: molecular properties, regulation of biosynthesis and processing to the neuropeptide secretoneurin.

Secretogranin II is an acidic secretory protein in large dense core vesicles of endocrine, neuroendocrine and neuronal tissues. It comprises, together with chromogranins A and B, the class of proteins collectively called chromogranins. In this review the physico-chemical properties, genomic organization, tissue distribution, synthesis regulation, ontogeny and physiological function of this protein are discussed. Secretogranin II gained interest recently for mainly three reasons: (1) secretogranin II is an excellent marker for the regulated secretory pathway due to its simple and specific metabolic labeling by inorganic sulfate; (2) secretogranin II occurs in a variety of neoplasms arising from endocrine and neuroendocrine cells and was shown to be a useful histological tumor marker for these cells; (3) secretogranin II is the precursor of the recently discovered neuropeptide secretoneurin which induces dopamine release in the striatum of the rat brain.

Chromogranin A-processing proteinases in purified chromaffin granules: contaminants or endogenous enzymes?

It was the purpose of this study to define the chromogranin A-processing proteinases present in highly purified preparations of bovine chromaffin granules. The most active enzyme had a pH optimum of 5.0 and was inhibited by pepstatin. It could be identified immunologically as a cathepsin D-like enzyme and subcellular fractionation established its lysosomal origin. After removal of this enzyme the remaining activity at pH 5.0 was mainly due to a cathepsin B-like proteinase. The presence of this enzyme could also be attributed to lysosomal contamination. In the presence of calcium, a further proteolytic activity became apparent at pH 5.0. This enzyme which was inhibited by rho-chloromercuriphenylsulfonic acid was localized in chromaffin granules. A trypsin-like peptidase, most active at pH 8.2, was enriched in a membrane wash of chromaffin granules. Subcellular fractionation indicated that this enzyme is preferentially bound to the membranes of very dense particles probably representing a subpopulation of chromaffin granules. This study establishes that the most active chromogranin A-degrading proteinases present in highly purified chromaffin granules are attributable to lysosomal contamination. Two enzymes with low activity (a Ca2+ activated proteinase and a trypsin-like enzyme) are, apparently, true constituents of chromaffin granules.

Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice.

Trabecular bone score (TBS) is a recently-developed analytical tool that performs novel grey-level texture measurements on lumbar spine dual X-ray absorptiometry (DXA) images, and thereby captures information relating to trabecular microarchitecture. In order for TBS to usefully add to bone mineral density (BMD) and clinical risk factors in osteoporosis risk stratification, it must be independently associated with fracture risk, readily obtainable, and ideally, present a risk which is amenable to osteoporosis treatment. This paper summarizes a review of the scientific literature performed by a Working Group of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. Low TBS is consistently associated with an increase in both prevalent and incident fractures that is partly independent of both clinical risk factors and areal BMD (aBMD) at the lumbar spine and proximal femur. More recently, TBS has been shown to have predictive value for fracture independent of fracture probabilities using the FRAX® algorithm. Although TBS changes with osteoporosis treatment, the magnitude is less than that of aBMD of the spine, and it is not clear how change in TBS relates to fracture risk reduction. TBS may also have a role in the assessment of fracture risk in some causes of secondary osteoporosis (e.g., diabetes, hyperparathyroidism and glucocorticoid-induced osteoporosis). In conclusion, there is a role for TBS in fracture risk assessment in combination with both aBMD and FRAX.

Levels and molecular properties of secretoneurin-immunoreactivity in the serum and urine of control and neuroendocrine tumor patients.

We have determined the levels of secretoneurin (SN), a novel 33-amino acid neuropeptide belonging to the class of chromogranins, in the serum and urine of healthy subjects and patients suffering from various tumors. SN serum levels averaged 22.1+/-1.1 fmol/mL. They were 5-fold higher in younger children and then declined continuously. SN levels were positively correlated with serum creatinine, suggesting an influence of renal function on the clearance of SN from the serum. In the urine 80.0 fmol/mL SN was present. In patients with endocrine tumors like gut carcinoids, endocrine pancreatic tumors, oat cell lung carcinomas, and pheochromocytomas, SN serum levels were elevated up to 45-fold. Patients suffering from neuroblastomas, insulinomas, pituitary adenomas including acromegaly, and solid nonendocrine tumors had concentrations in the normal range. In human serum, SN-immunoreactivity was confined to the free peptide SN; neither larger intermediate-sized forms nor the precursor secretogranin II were detected. An efficient removal of the small molecule SN from the serum by the kidney explains why SN serum levels are lower when compared to chromogranin A, which is present as large molecule in serum.

Divergent changes of chromogranin A/secretogranin II levels in differentiating human neuroblastoma cells.

Human neuroblastoma cells were cultured either in the absence or presence of 12-O-tetradecanoylphorbol-13-acetate (TPA) known to induce neuronal differentiation. This treatment led to a marked increase in the concentration of secretogranin II but to a decrease of chromogranin A. Analogous changes were observed for the respective mRNAs. Thus during differentiation of these cells the biosynthesis of two vesicle constituents of large dense core vesicles is differentially regulated as determined both at the mRNA and the protein level. Levels of both synaptin/synaptophysin large dense core vesicles is differentially regulated as determined both at the mRNA and the protein level. Levels of both synaptin/synaptophysin and SV2 were also elevated but to a smaller degree than that of secretogranin II.

Immunological characterization of the endoproteases PC1 and PC2 in adrenal chromaffin granules and in the pituitary gland.

Specific antisera against synthetic fragment of the endoproteases, PC1 and PC2, were used to characterize these proteins. In one-dimensional immunoblots these antisera labelled components of 85 kDa for PC1 and of 70 kDa for PC2 in purified bovine chromaffin granules and anterior and posterior pituitary of ox and rat. In membranes of bovine chromaffin granules glycoprotein H was identified as the major PC2 immunoreactive spot. A major part of these endoproteases appeared membrane bound.

Processing of secretogranin II by prohormone convertases: importance of PC1 in generation of secretoneurin.

Secretoneurin is a recently characterized neuropeptide present in the primary amino acid sequence of secretogranin II. We investigated the proteolytic processing of secretogranin II by prohormone convertases in vivo in a cellular system using the vaccinia virus system. Both PC1 and PC2 can cleave the secretogranin II precursor at sites of pairs of basic amino acids to yield intermediate-sized fragments. Other convertases like PACE4, PC5 and furin were not active. For the formation of the free neuropeptide secretoneurin a different pattern was found. Only PC1 but none of the other convertases tested including PC2 were capable of generating secretoneurin. Our results demonstrate that the prohormone convertases PC1 and PC2 are involved in proteolytic processing of secretogranin II. The neuropeptide secretoneurin can only be generated by PC1 suggesting tissue-specific processing of secretogranin II in neurons expressing different subsets of the prohormone convertases.

Effects of nerve growth factor on the biosynthesis of chromogranin A and B, secretogranin II and carboxypeptidase H in rat PC12 cells.

We investigated the biosynthesis of various constituents (chromogranins A and B, secretogranin II, carboxypeptidase H and synaptin/synaptophysin) of large dense core and small vesicles in PC12 cells. These cells were treated for up to 18 days with nerve growth factor. Peptide levels were determined by quantitative immunoblotting, their mRNAs by Northern blotting. Nerve growth factor treatment changed the levels of the various peptides investigated and their mRNAs in three patterns. Peptide and mRNA levels for chromogranin A and chromogranin B were increased on day 1 and then declined. Synaptin/synaptophysin levels slightly decreased from day 1 onwards. On the other hand secretogranin II increased steadily up to 217% for peptide levels and 257% for mRNA levels. For carboxypeptidase H for which only the mRNA could be determined an analogous behaviour was seen. Its mRNA after 14 days of nerve growth factor treatment was 459% of controls. These results establish that the biosynthesis of the secretory proteins chromogranin A, chromogranin B and secretogranin II is regulated differentially during nerve growth factor treatment. We suggest that neuronal differentiation is accompanied by an increased biosynthesis of secretogranin II. For carboxypeptidase H, the marked increase in mRNA levels after nerve growth factor treatment is the first example that the biosynthesis of this peptide is significantly up-regulated. Synaptin/synaptophysin biosynthesis is not increased although this peptide is a major constituent of small vesicles which increase in number during nerve growth factor treatment.

Biosynthesis of proteins of large dense-core vesicles in rat PC12 cells: regulation by forskolin and phorbol ester.

We have investigated the influence of various second messengers on the biosynthesis of large dense-core vesicle constituents in rat PC12 cells. After treatment with forskolin, phorbol ester or a combination of both substances for up to six days, the messenger RNA levels of several vesicle components were determined by northern blotting. Forskolin increased the expression of messenger RNA encoding the soluble proteins chromogranin B, neuropeptide Y and VGF. Addition of phorbol ester markedly enhanced the effects of forskolin. On the other hand, the expression of two further soluble proteins, chromogranin A and secretogranin II, remained fairly unchanged with all treatments tested. Amongst partly membrane-bound vesicle components, the biosynthesis of glycoprotein III and peptidylglycine alpha-amidating mono-oxygenase was significantly up-regulated by combined treatment with forskolin plus phorbol ester. The carboxypeptidase H messenger RNA increased due to phorbol ester and after long-term application of both drugs. In contrast, phorbol ester alone or plus forskolin down-regulated the expression of dopamine beta-hydroxylase. Essentially the same applies to the intrinsic membrane protein cytochrome b-561, whose messenger RNA level declined in all treatment groups. In conclusion, our results show that forskolin and phorbol ester can regulate the composition of large dense-core vesicles in quite distinct patterns.

Immunological characterization of a membrane glycoprotein of chromaffin granules: its presence in endocrine and exocrine tissues.

A glycoprotein was isolated from detergent solubilized membranes of bovine chromaffin granules by high-performance liquid chromatography. Specific antisera raised against this glycoprotein reacted in one- and two-dimensional immunoblots with a heterogeneous component with a pI of 4.2-4.7 and Mr 100,000. The antiserum against bovine glycoprotein II cross-reacted with an analogous component in several species. The specific localization of glycoprotein II in chromaffin granules was established by density gradient centrifugation followed by immunoblotting. The antiserum, as shown by one- and two-dimensional immunoblotting, reacted with an analogous antigen in the posterior pituitary, in endocrine (anterior pituitary, parathyroid gland) and exocrine (parotid gland, pancreas) organs. In the pancreas the protein reacting with the antiserum was found in the membranes of zymogen granules. The results demonstrate for the first time that secretory vesicles of endocrine and exocrine tissues have at least one common antigen, i.e. the glycoprotein II. It seems likely that this protein is involved in a basic function common to all secretory vesicles.

Differential regulation of chromogranin A, chromogranin B and secretogranin II in rat brain by phencyclidine treatment.

Chromogranin A, chromogranin B and secretogranin II belong to the chromogranin family which consists of large protein molecules that are found in large dense core vesicles. Chromogranins are endoproteolytically processed to smaller peptides. This study was designed to elucidate the regulation of chromgranin expression by acute and subchronic phencyclidine administration. The behavioral syndrome produced by phencyclidine represents a pharmacological model for some aspects of schizophrenia [Jentsch and Roth (1999) Neuropsychopharmacology 20, 201-225]. Tissue concentrations of chromogranins were measured with specific radioimmunoassays. Alterations in secretogranin II gene expression were investigated by in situ hybridization. A single dose of phencyclidine (10mg/kg) led to a transient decrease in secretoneurin tissue levels in the prefrontal cortex after 4h followed by an increase in secretoneurin tissue levels after 12h. Repeated phencyclidine treatment (10mg/kg/day) for five days resulted in elevated secretoneurin levels in cortical areas whereas chromogranin A and chromogranin B tissue levels were unchanged. After the same treatment, a significant increase in the number of secretoneurin containing neurons was found in cortical layers II-III, and V-VI as revealed by immunocytochemistry. The increases in secretoneurin levels were paralleled by an increased number of secretogranin II messenger RNA containing neurons as well as by an increased expression of secretogranin II by individual neurons. The present study shows that secretoneurin II tissue concentration and secretogranin II messenger RNA expression is distinctly altered after acute and subchronic phencyclidine application. From these results we suggest that phencyclidine may induce synaptic alterations in specific brain areas and may contribute to a better understanding of synaptic dysfunction which may also occur in schizophrenia.

Nicotine and prostaglandin E induce secretogranin II levels in bovine chromaffin cells.

The synthesis regulation of secretogranin II was investigated in bovine chromaffin cells by treatment with various first messengers. Nicotine and prostaglandin E2 elevated secretogranin II mRNA and protein up to three-fold. Angiotensin II, atrial natriuretic peptide, apomorphine, bradykinin and clonidine on the other hand had no effect. The prostaglandin E induced elevation of secretogranin II mRNA was transduced via the calcium/calmodulin pathway but not via the protein kinase A or C pathways as shown by using specific inhibitors. Exposure of chromaffin cells to drugs specifically activating second messenger pathways both elevated and decreased secretogranin II mRNA. The calcium channel agonist Bay K, forskolin and phorbol esters increased secretogranin II mRNA whereas 8-Br-cGMP repressed the secretogranin II message. Thus, although secretogranin II expression can be altered by all major second messenger transduction systems, regulation of secretogranin II in vivo occurs mainly via the calcium/calmodulin pathway. Chromogranin A and B mRNA were not changed by any of the first messengers investigated indicating a differential synthesis regulation of components co-stored in bovine chromaffin granules.

Biosynthesis of large dense-core vesicles in PC12 cells: effects of depolarization and second messengers on the mRNA levels of their constituents.

mRNA levels of various constituents of large dense-core vesicles were determined in PC12 cells during depolarization and/or in the presence of BayK 8644, forskolin or phorbolester. For the soluble (secretory) proteins of the vesicles the mRNAs of chromogranin A and B, secretogranin II, neuropeptide Y and VGF were analyzed. Depolarization in the presence of BayK induced a strong up-regulation of the messages for chromogranin B, neuropeptide Y and VGF. Addition of forskolin enhanced this response for neuropeptide Y and VGF, phorbolester did the same only for VGF. Partly membrane-bound and membrane-spanning components analyzed were carboxypeptidase H, dopamine beta-hydroxylase and glycoprotein III (clusterin), peptidylglycine alpha-amidating mono-oxygenase and cytochrome b-561, respectively. Changes of mRNAs for these components were in general smaller and delayed. Six days of depolarization caused an up-regulation of glycoprotein III, peptidylglycine alpha-amidating mono-oxygenase and carboxypeptidase H mRNA levels which were not further increased by cyclic AMP and phorbolester. The dopamine beta-hydroxylase message increased after 6 days of depolarization, however, addition of phorbolester reduced this effect. For cytochrome b-561 there was no change after any of the conditions employed. These in vitro results are compared with those obtained for the biosynthesis regulation of large dense-core vesicles under in vivo conditions. It is suggested that in vivo acetylcholine and vasoactive intestinal polypeptide released from splanchnic nerve induce a differential change in the biosynthesis of large dense-core vesicles by acting via calcium and protein kinase A and C.

Sex-Related Differences in Chromogranin A, Chromogranin B and Secretogranin II Gene Expression in Rat Pituitary.

Chromogranin A, an acidic secretory protein, is widely distributed throughout diverse endocrine cells and the central and peripheral nervous systems. Chromogranin A is co-stored and co-secreted from secretory vesicles together with the endogenous hormones or neurotransmitters. Recently, two peptides derived from the Chromogranin A precursor have been shown to inhibit secretion from endocrine cells. In the present study, we investigated the regulation of the biosynthesis of Chromogranin A by estrogen in various tissues. In the pituitary, steady-state levels of Chromogranin A mRNA were markedly reduced by 64% in estrogen-treated male rats. At the protein level, a comparable decrease was found. Chromogranin B and secretogranin II, two other secretory proteins co-stored with Chromogranin A, were slightly increased by estrogen. In pituitaries of female rats Chromogranin A mRNA and protein levels were significantly lower than in males. For Chromogranin B on the other hand, a 2-fold increase of mRNA levels was found. Our observations demonstrate that physiologic concentrations of estrogen strongly affect Chromogranin A levels in the pituitary resulting in a sex-related difference in Chromogranin A gene expression. Based on these and previous results demonstrating increased biosynthesis of Chromogranin A by glucocorticoids and calciferol, we suggest that a typical and characteristic feature of the Chromogranin A gene is its regulation by at least three different classes of steroid hormones.

Regulation of chromogranin biosynthesis by neurotrophic growth factors in neuroblastoma cells.

Polypeptide growth factors secreted from the target tissue determine the choice of transmitter synthesis in the innervating nerves. We have investigated whether they also influence the expression of chromogranins and neuropeptide Y, components co-stored with the neurotransmitters within large dense-core vesicles. IMR-32 and SH-SY5Y human neuroblastoma cells were treated for up to six days with various neurotrophic growth and differentiation factors. For chromogranins A and B, no significant changes at the mRNA level were observed and for chromogranin A this was confirmed at the protein level. The expression of secretogranin II/pro-secretoneurin mRNA, however, was considerably enhanced in both cell lines after basic fibroblast growth factor treatment. In IMR-32 cells we determined a fast and continuous induction, whereas the up-regulation in SH-SY5Y cells was more delayed. A transient elevation of secretogranin II/pro-secretoneurin mRNA levels was seen in SH-SY5Y cells in response to epidermal growth factor. In these cells we also measured the amounts of secretogranin II/pro-secretoneurin protein which were increased by both growth factors. In addition to the above described changes in secretogranin II/pro-secretoneurin biosynthesis we extended and confirmed data available on neuropeptide Y. We found a qualitatively similar pattern of biosynthesis regulation as for secretogranin II/pro-secretoneurin, indicating that the ultimately increased expression of the two proteins may be characteristic of the phenotypic differentiation after growth factor treatment. Moreover, this finding of a concomitant regulation further emphasizes the concept of secretogranin II/pro-secretoneurin being a neuropeptide precursor from which the functional peptide secretoneurin is proteolytically liberated.