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mechanism unexplained Relative contributions of direct peptide effects versus downstream IGF-1 actions inadequately characterized Long-term receptor sensitivity and potential for desensitization inadequately studied Individual patient variability in response not well-characterized Potential for differential effects based on endogenous growth hormone status unclear Long-Term Safety Considerations Critical safety questions remain unanswered regarding chronic peptide administration: Cardiovascular safety concerns FDA warnings cite risks of increased heart rate, systemic vasodilation, flushing, and transient hypotension Immunogenicity risks FDA identifies both peptides as potentially immunogenic with risk of serious immune reactions including anaphylaxis Cancer risk theoretical concern that chronic growth hormone/IGF-1 elevation could promote cellular proliferation

coli strain overproducing L-lysine to a titer of 194 g L 1 from glucose and ammonium has recently been described (Ye et al., 2020)

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Indeed, continuous exenatide exposure once weekly elicited a greater response than did short-acting exenatide, improving glycemic and lipids controls and lipoprotein metabolism, and decreasing systemic inflammation