GH replacement in 1034 growth hormone deficient hypopituitary adults: demographic and clinical characteristics, dosing and safety

Quality of life in growth hormone deficiency and acromegaly

Quality of life (QoL) has emerged as an end point in the evaluation of adults with growth hormone deficiency and acromegaly. QoL is measured with questionnaires designed to be used in general population or any kind of disease (generic) or aimed at the specific dimensions affected in a determined condition; these latter ones are more likely to identify the impairments caused by the underlying disease and the benefits of treatment. QoL, which is severely impaired in adults with growth hormone deficiency, improves and normalizes after growth hormone replacement therapy and this effect is maintained over several years. Acromegalic patients also exhibit severe impairment of QoL, which despite improvement after successful therapy still remains below the reference values of normal population. QoL in these chronic endocrine diseases can be used as an measure for clinical and therapeutic evaluation.

Value of insulin-like growth factor system markers in the assessment of growth hormone status

Insulin-like growth factor-I (IGF-I) has been measured extensively in a variety of clinical settings. Total IGF-I frequently is used to assess the clinical impact of disorders of GH secretion and to monitor patients' response to therapy. It does not have sufficient precision to be used as a stand-alone test in the diagnosis of GH deficiency. Free IGF-I, IGF binding protein-3, or acid-labile subunit may provide useful information regarding GH secretion in specific conditions but are not superior to IGF-I for making the diagnosis of GH deficiency or acromegaly.

Pituitary deficiency after brain radiation therapy

Brain radiotherapy is a frequent and overlooked cause of pituitary deficiency in adults which may alter patients' health and quality of life. Hormonal consequences have been better studied in children. The onset of hormonal deficiencies depends on the dose delivered to the pituitary-hypothalamic region while their incidence and severity depends on dose fractionating and follow-up duration. Somatotrophic function is the first affected, 90% of patients being GH deficient 10 years after radiotherapy. Other anterior pituitary functions are affected later and less frequently. While initial damage occurs in the hypothalamus, accounting for mild hyperprolactinemia in 30-50% of cases, diabetes insipidus is never observed. Direct pituitary deficiency may occur later. Responses to ACTH or GHRH-arginine tests may be normal for several years though an ACTH and/or GH deficiency has been demonstrated by an insulin tolerance test, which is considered as the gold standard. When the cranio-spinal area--including the neck--has been irradiated, primary thyroid deficiency might occur. Repeated cervical ultrasonographic follow-up is mandatory to exclude radiation-induced thyroid cancer. The gonadotrophic function might be altered after small doses of irradiation causing precocious puberty, while at higher doses delayed puberty or true gonadotrophic deficiencies are more often observed. Combined radio- and chemotherapy might result in mixed central and peripheral deficiencies that might be difficult to diagnose. When radiotherapy is performed in adulthood, GH deficiency is less common, although the sequence of hormonal deficiencies is similar to that observed in children. Prospective longitudinal studies are required to determine the time course and sequence of onset of each deficiency, in order to tailor the monitoring of these patients to their specific needs.

IGF-I measurements in the monitoring of GH therapy

Growth hormone replacement therapy has been used regularly in adult Growth hormone deficiency since the availability of recombinant GH in the 1980's. GH replacement improves quality of life, bone turnover markers, cardiovascular risk markers and adverse body composition. Originally, GH doses in replacement regimes were determined by weight and surface area and dose increases based on body composition outcomes analogous to pediatric practice. These regimens led to significant side effects related to excess GH, arthralgias, headaches and peripheral edema and IGF-I levels above the upper limit of the reference range. Newer treatment regimes therefore account for known factors affecting serum GH and IGF-I levels, i.e. age, gender, estrogen replacement and pre-treatment IGF-I levels. Monitoring is now via clinical symptomatology combined with serum total IGF-I levels, potentially this avoids excessive GH exposure and allows monitoring of compliance and dose titration. There is a lack of data relating IGF-I to biological endpoints, but analysis suggests that dose titration of IGF-I to the upper half of the age and gender related reference range is acceptable. The use of reliable IGF-I assays and extensive age and gender related reference ranges is necessary and centralized monitoring is preferable. Free IGF-I and bioavailable IGF-I measurements are available but their use in the monitoring of GH replacement remains to be determined.

Anterior pituitary hormone replacement therapy--a clinical review

This clinical review summarizes current approaches to diagnosis and treatment of anterior pituitary hormone deficiency. The diagnostic value of endocrine function tests and replacement strategies for hydrocortisone, thyroxine, sex steroids, and growth hormone replacement are reviewed. Female androgen deficiency syndrome and the current role of DHEA and testosterone replacement in women are also discussed.

Approach to the evaluation of the GH/IGF-axis in patients with pituitary disease: which test to order

The diagnosis of adult growth hormone deficiency (AGHD) and acromegaly involves assessment of serum growth hormone (GH) and insulin-like growth factor-1 (IGF-1) concentrations. The diagnosis of AGHD typically requires a provocative test of GH reserve, but is supported by demonstration of low-serum IGF-1 levels. Therapeutic monitoring of rhGH replacement is performed utilizing measurement of serum IGF-1 concentrations. In patients with suspected acromegaly, the diagnosis is confirmed by elevated serum IGF-1 levels and further validated by the presence of elevated GH levels both before and following an oral glucose load. A goal of acromegaly therapy is to normalize IGF-1 concentrations, and, depending on the therapeutic modality, GH levels as well. Using case based clinical scenarios, we have presented a standard approach to the biochemical diagnosis and therapeutic monitoring of these disorders.

Growth hormone (GH) effects on central fat accumulation in adult Japanese GH deficient patients: 6-month fixed-dose effects persist during second 6-month individualized-dose phase

Both Japanese and Caucasian adults with GH deficiency (GHD) have pronounced abdominal obesity, which is associated with increased risk of cardiovascular complications. We investigated the effects of GH treatment in 27 adult Japanese GHD patients, 15 with adult onset (AO) and 12 with childhood onset (CO) GHD. Patients initially received GH titrated to 0.012 mg/kg/day for 24 weeks in a double-blind design and the dose was then individualized for each patient according to IGF-I for a further 24 weeks. Dual-energy x-ray absorptiometry (DXA) data were evaluated for percentages of trunk fat, total body fat and lean body mass. Serum IGF-I and lipid concentrations were determined at a central laboratory. There were 25 patients who completed 48 weeks of treatment, with 7, 6 and 12 patients then receiving GH at 0.003, 0.006 and 0.012 mg/kg/day, respectively. With the reductions in dose when individualized between weeks 24 and 48, mean serum IGF-I level was reduced and excessively high values, observed in AO patients on the fixed GH dose, were no longer seen. The decrease from baseline in trunk fat was similar at week 24 (-3.8 +/- 3.3%, p<0.001) and week 48 (-3.1 +/- 3.7%, p<0.001), and the difference between changes was not significant. Total cholesterol was decreased from baseline by -24 +/- 28 mg/dl (p<0.001) at week 24 and -17 +/- 28 mg/dl (p = 0.007) at week 48. Two patients had elevated HbA1c levels: one continued GH treatment after a dose reduction and the other discontinued due to persistent impaired glucose tolerance. Therefore, excessively high IGF-I levels can be avoided by individualized dosing during long-term GH treatment. Individualized dosing maintains the decrease in abdominal fat in adult Japanese GHD patients and should reduce the cardiovascular risk.

Preliminary development of the new individualized HDQoL questionnaire measuring quality of life in adult hypopituitarism

OBJECTIVES

The objectives were (1) to report the preliminary development of the Hormone Deficiency-dependent Quality of Life (HDQoL) questionnaire, a new individualized questionnaire in which respondents rate personally applicable domains for importance and impact of hormonal deficiency and its treatment; (2) to evaluate the HDQoL's psychometric properties for adults with hypopituitarism including growth hormone deficiency (GHD).

METHODS

Internal consistency reliability, aspects of validity, and sensitivity to change of the HDQoL were investigated in: (1) a cross-sectional survey of 157 adults with treated or untreated GHD; (2) a randomized, placebo-controlled study of 3 months' growth hormone (GH) withdrawal from 12 of 21 GH-treated adults.

RESULTS

Thirteen of the original 18 HDQoL domains were relevant and important for GH-deficient adults. The shorter 13-item HDQoL had excellent internal reliability (Cronbach's alpha coefficient = 0.914, n = 109), and was sensitive to sex differences (cross-sectional study): women perceived worse present QoL than men [t(149.8) = 2.33, P = 0.021]. The HDQoL was sensitive to change (GH-withdrawal study) with a significant between-group difference in change in domain scores for things I can do physically[t(16) = 2.47, P = 0.025, 2-tailed], patients withdrawn from GH reporting greater negative impact of hormone deficiency on this domain at end-point. Qualitative work resulted in the addition of seven new HDQoL domains, including energy and bodily pain.

CONCLUSION

The HDQoL, although at an early stage of development, proved useful in identifying expected changes following GH withdrawal. The extended 20-item version is recommended for further evaluation in assessing the impact of hypopituitarism on QoL.

The impact of glucocorticoid replacement regimens on metabolic outcome and comorbidity in hypopituitary patients

BACKGROUND

Hypopituitary patients with untreated GH deficiency and patients on inappropriately high doses of glucocorticoid (GC) share certain clinical features.

OBJECTIVE

The aim of the study was to examine the influence of GC substitution on clinical characteristics in hypopituitary patients before and after GH replacement therapy.

METHOD

A total of 2424 hypopituitary patients within the KIMS (Pfizer International Metabolic Database) were grouped according to ACTH status. Comparisons were performed between subjects on hydrocortisone (HC) (n = 1186), cortisone acetate (CA) (n = 487), and prednisolone/dexamethasone (n = 52), and ACTH-sufficient patients (AS) (n = 717) before and after 1 yr of GH treatment in terms of body mass index, waist and hip circumference, blood pressure, glucose, glycosylated hemoglobin (HbA1c), serum lipids, IGF-I, and comorbidity. Hydrocortisone equivalent (HCeq) doses were calculated, and measurements were adjusted for sex and age.

RESULTS

At baseline, the HC group had increased total cholesterol, triglycerides, waist circumference, and HbA1c, and the prednisolone/dexamethasone group had increased waist/hip ratio as compared with AS. After HCeq dose adjustment, the HC group retained higher HbA1c than the CA group. GC-treated patients showed a dose-related increase in serum IGF-I, body mass index, triglycerides, low-density lipoprotein cholesterol and total cholesterol levels. Subjects with HCeq doses less than 20 mg/d (n = 328) at baseline did not differ from AS in metabolic endpoints. The 1-yr metabolic response to GH was similar in all GC groups and dose categories. All new cases of diabetes (n = 12), stroke (n = 8), and myocardial infarction (n = 3) during GH treatment occurred in GC-treated subjects.

CONCLUSION

HCeq doses of at least 20 mg/d in adults with hypopituitarism are associated with an unfavorable metabolic profile. CA replacement may have metabolic advantages compared with other GCs.

Clinical utility of measurements of insulin-like growth factor 1

Plasma insulin-like growth factor 1 (IGF-I) concentrations are regulated by genetic factors, nutrient intake, growth hormone (GH) and other hormones such as T4, cortisol and sex steroids. The accuracy of IGF-I measurement in diagnosing GH deficiency or excess depends, in part, on the relative contributions of each of these variables. Since their respective influence may vary widely between individuals, the establishment of well-defined normal ranges is necessary, which requires adequate numbers of normal individuals, in order for IGF-I measurements to have maximum utility. In states of GH deficiency, the influence of these non-GH-related factors predominates. Although IGF-I levels have utility as a screening test in children and young adults, they cannot be used as a stand-alone test for the diagnosis of GH deficiency. By contrast, in acromegaly, GH is the predominant determinant of IGF-I levels and, therefore, measurement of IGF-I is a very useful diagnostic test. In acromegaly, IGF-I levels are useful for assessing the relative degree of GH excess, because changes in IGF-I correlate with changes in symptoms and soft-tissue growth. IGF-I is also very useful in monitoring the symptomatic response to therapy.

Craniopharyngiomas

Craniopharyngiomas are rare, mainly sellar/parasellar, epithelial tumors diagnosed during childhood or adult life. Histologically, two primary subtypes have been recognized (adamantinomatous and papillary) with an as yet, unclarified pathogenesis. They may present with a variety of manifestations (neurological, visual, and hypothalamo-pituitary). Despite their benign histological appearance, they often show an unpredictable growth pattern, which, combined with the lack of randomized studies, poses significant difficulties in the establishment of an optimal therapeutic protocol. This should focus on the prevention of recurrence(s), improvement of survival, reduction of the significant disease and treatment-related morbidity (endocrine, visual, hypothalamic, neurobehavioral, and cognitive), and preservation of the quality of life. Currently, surgical excision followed by external beam irradiation, in cases of residual tumor, is the main treatment option. Intracystic irradiation or bleomycin, stereotactic radiosurgery, or radiotherapy and systemic chemotherapy are alternative approaches; their place in the management plan remains to be assessed in adequately powered long-term trials. Apart from the type of treatment, the identification of clinical and imaging parameters that will predict patients with a better prognosis is difficult. The central registration of patients with these challenging tumors may provide correlates between treatments and outcomes and establish prognostic factors at the pathological or molecular level that may further guide us in the future.

Peripheral fibrinolytic markers, soluble adhesion molecules, inflammatory cytokines and endothelial function in hypopituitary adults with growth hormone deficiency

BACKGROUND

Increased mortality due to cardiovascular disease has been described in adult patients with untreated GH deficiency (GHD). GH replacement has been demonstrate to improve vascular reactivity and reverse early atherosclerotic changes in adults with GHD.

OBJECTIVE

Assessment of fibrinolytic markers, soluble adhesion molecules, inflammatory cytokines and endothelial function in hypopituitary adults with GHD at baseline and 1 year after GH replacement therapy.

METHODS

We studied 10 patients with GHD (five men and five women; aged 45.6 +/- 10.4 years) at baseline and 1 year after GH replacement therapy compared with a control group (nine men and 16 women) matched for age and body mass index (BMI). All subjects, patients and controls, were life-long nonsmokers, normotensive and nondiabetic. The following variables were recorded: anthropometric and body composition variables, serum concentrations of glucose, insulin and C-peptide; thrombin anti-thrombin (TAT) fragments and fibrin degradation product D-dimer, which were determined by an enzyme-linked immunosorbent assay (ELISA); IGF-I by radioimmunoassay (RIA); C-reactive protein (CRP) by highly sensitive immunonephelometry; E-selectin, P-selectin, soluble intercellular cell adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1) by ELISA. The assessment of endothelial function in vivo was measured with a Doppler device.

RESULTS

Patients with GHD without GH substitution had higher hip/waist ratio and body fat than controls. Insulin, C-peptide and triglyceride concentrations were also higher. Our results demonstrated no difference in fibrinogen and in TAT fragment concentrations among patients and controls. E-selectin concentrations were higher in patients than in controls (26.1 +/- 11 vs. 10.7 +/- 6.2 microg/l, P = 0.0001). P-selectin, sICAM-1, sVCAM-1, IL-6, MCP-1 and CRP were similar in the two groups. Vascular reactivity and carotid intima-media thickness (IMT) were also similar in patients and controls. After 1 year of GH treatment we found no changes in biochemical parameters, fibrinolytic markers, soluble adhesion molecules, inflammatory cytokines and endothelial function.

CONCLUSION

Adults with GHD show some subtle changes in soluble adhesion molecules but our data suggest no beneficial effects of GH over these markers in relationship to endothelial function. Factors other than GH treatment, such as differences in age, degree of obesity, the presence of diabetes mellitus and arterial hypertension or tobacco consumption, could explain the observed increase in markers of vascular risk in GH-deficient patients.

The influence of growth hormone status on physical impairments, functional limitations, and health-related quality of life in adults

The availability of recombinant human GH and somatostatin analogs has resulted in widespread treatment for adults with GH deficiency (GHD) and those with GH excess (acromegaly). Despite being at opposite ends of the spectrum in terms of their GH/IGF-I axis, both of these populations experience overlapping somatic impairments. Adults with untreated GHD have low circulating levels of IGF-I that manifest as altered body composition with increased fat and reduced lean body and skeletal muscle mass. At the other end of the spectrum, adults with GH excess, who have elevated levels of IGF-I, also have altered body composition. Impairments that result from disorders of either GHD or GH excess are both associated with increased functional limitations, such as reduced ability to walk quickly for prolonged periods, and poorer health-related quality of life (HR-QoL). Adults with untreated GHD and GH excess both commonly complain of excessive fatigue that seems to be associated more with impaired aerobic than muscular performance. Several studies have documented that administration of GH or somatostatin analogs to adults with GHD or GH excess, respectively, ameliorates abnormal biochemical profile and the associated somatic impairments. However, whether these improvements translate into improved physical function in adults with GHD or GH excess remains largely unknown, and their impact on HR-QoL controversial. Review of placebo-controlled trials to date suggests that GH and somatostatin analogs have greater effects on gas exchange and aerobic performance than as anabolic agents on skeletal muscle mass and function. Future investigations should include dose-response studies to establish the optimal combination of pharmacological agents plus exercise required to improve not only biochemical markers but also physical function and HR-QoL in adults with GHD or GH excess.

GH replacement does not increase the risk of recurrence in patients with craniopharyngioma

BACKGROUND

A significant number of patients with craniopharyngioma are GH deficient. The safety of GH replacement in these subjects has not been established.

OBJECTIVE

To assess the effect of GH replacement upon recurrence in patients with craniopharyngioma.

PATIENTS AND METHODS

All the patients with craniopharyngioma followed-up at the Departments of Endocrinology or Paediatrics in Oxford and treated or not with GH were studied retrospectively. These were recruited from the databases of the departments consisting of subjects diagnosed between January 1964 and July 2005. The impact of GH replacement upon recurrence was evaluated after adjusting for possible confounding factors.

RESULTS

Forty-one subjects received GH replacement. Nine of them did not have follow-up imaging during GH therapy and were not included in the statistical analyses. The remaining 32 (22 males/10 females) received GH for a mean period of 6.3 +/- 4.6 years (median 5.1, range 0.8-22); 21 started during childhood (13 of them continued after the achievement of final height with an adult dose) and 11 during adult life. The mean duration of their follow-up (from surgery until last assessment) was 10.8 +/- 9.2 years (range 1.9-40). Fifty-three subjects had not received GH therapy (30 men/23 women). The mean duration of their follow-up (from surgery until last assessment) was 8.3 +/- 8.8 years (range 0.5-36). During the observation period, 4 patients treated with GH and 22 non-GH treated ones developed tumour recurrence. After adjusting for sex, age at tumour diagnosis and type of tumour therapy (gross total removal, partial removal, surgery + irradiation), GH treatment was not a significant independent predictor of recurrence (P = 0.06; hazard ratio = 0.309). Similar results were obtained when the impact of GH replacement was assessed according to its duration (P = 0.18; hazard ratio = 0.991/month of treatment). None of the nine patients with insufficient imaging data for inclusion in the statistical analyses [5 men/4 women, 3 treated with GH during childhood/6 during adult life, mean duration of GH therapy 2.9 +/- 2.4 years (median 1.8, range 0.4-7)] showed clinical features suggestive of recurrence during the period of GH replacement. CONCLUSION Based on the data of the craniopharyngiomas database in Oxford, there is no evidence that GH replacement is associated with an increased risk of tumour recurrence.

Isolated growth hormone (GH) deficiency in adult patients: baseline clinical characteristics and responses to GH replacement in comparison with hypopituitary patients. A sub-analysis of the KIMS database

BACKGROUND

Isolated growth hormone deficiency (IGHD) provides the ideal model to characterize GHD without interference from other pituitary deficiencies or their treatment. No study has addressed the question whether adult patients with IGHD differ in clinical presentation or in responsiveness to GH replacement from adult patients with multiple pituitary hormone deficiencies (MPHD) receiving conventional replacement therapy.

PATIENTS AND METHODS

Data were retrieved from the outcomes research database KIMS (Pfizer international metabolic database). Patients with IGHD accounted for 9.6% (274/2868) of all GHD patients. Patients were separated according to the timing of onset. In the adult-onset (AO) group, 167 patients with IGHD were compared to 1992 patients with MPHD. In the childhood-onset (CO) group, 107 patients with IGHD were compared to 602 patients with MPHD. To assess the effect of GH replacement after one year, a longitudinal sub-analysis in the AO group was performed comparing 89 IGHD patients to 1234 MPHD patients. The same study was done in the CO group comparing 66 IGHD patients to 386 MPHD patients. Because IGHD patients were significantly younger than MPHD patients, data analysis was also performed after adjustment for gender and age.

RESULTS

In the AO group, non-functioning and secreting pituitary adenomas were the most common primary diagnoses in both IGHD and MPHD. Medical history revealed a high prevalence of hypertension and fractures in both subgroups, but also of non-insulin dependent diabetes mellitus. The prevalence of obesity was high and the waist circumference was elevated. The lipid profile was unfavourable in both IGHD and MPHD. IGF-I concentration and SDS were comparable in both subgroup. Quality of life assessed by QoL-AGHDA was equally poor in both IGHD and MPHD. GH replacement therapy induced favourable changes without distinction. In the CO group, the most common cause in both subgroups was idiopathic. Fracture rate was similarly prevalent in both IGHD and MPHD. Obesity was prominent in both subgroups, but BMI and waist circumference were lower in IGHD. Adverse lipid changes were similarly found in both IGHD and MPHD. IGF-I concentration and SDS were significantly higher in the IGHD subgroup compared to the MPHD subgroup. The QoL-AGHDA score was equally abnormal in both IGHD and MPHD. GH replacement achieved similar significant improvement in both subgroups.

CONCLUSIONS

GHD patients with AO-IGHD and AO-MPHD present with a similar clinical expression and respond similarly to GH replacement. Patients with CO-IGHD are less severely affected by GHD than CO-MPHD patients, but, nevertheless, both groups show a comparable adverse lipid profile and poor quality of life and respond favourably to GH replacement. These findings support the concept that GH alone is responsible for most if not all metabolic aspects of hypopituitary patients receiving conventional replacement therapy, regardless of age of onset or aetiology. As a consequence, GH replacement therapy not only has potential benefit in GHD patients with additional hormonal deficits, but also the indication of treatment must be extended to patients with isolated GHD.

Tumour surveillance imaging in patients with extrapituitary tumours receiving growth hormone replacement

OBJECTIVE

GH replacement is widely used in the management of patients with adult-onset (AO)-GH deficiency (GHD). In most cases, AO-GHD arises as a result of pituitary/peripituitary tumours and/or their treatment, but the effect of GH replacement on recurrence/regrowth of these tumours is unknown. The aim of this study was to examine the effect of GH replacement in a group of patients with primary tumours of the parasellar region, many of which (e.g. craniopharyngioma, glioma or germ cell tumours) might be anticipated to have a higher recurrence rate than secretory and nonsecretory anterior pituitary tumours.

PATIENTS AND DESIGN

We report here our experience of prospective imaging in 50 consecutive patients (21 males; mean age 45.9 years) with nonanterior pituitary parasellar tumours treated with GH. All had severe GHD (peak serum GH 9 mU/l or less on dynamic testing) and were treated with an identical dose-titration regimen to maintain serum IGF-I concentrations between the median and upper end of the age-adjusted normal range. The primary diagnoses were: craniopharyngioma (28), germ cell tumour (8), arachnoid cyst (4), meningioma (4), glioma (4) and mensenchymal tumour (2). External pituitary irradiation had been given to 37 (74%) of patients. Measurements Surveillance imaging (magnetic resonance imaging (MRI) 70%, computed tomography (CT) 16%, both 14%) was performed at baseline (prior to GH), at 6--12 months, and then again yearly or as clinically indicated. Median follow-up was 36 months (range 7--129 months). All images were reviewed by the same radiologist.

RESULTS

Four patients had an apparent increase in tumour volume but in only one patient was it considered necessary to abandon GH replacement. In two of the four cases marginal increases in cystic parasellar tumours were not progressive; and in the fourth case apparent recurrence of a suprasellar germ cell tumour was shown to be acellular fibrous tissue only on biopsy. In all other cases either the appearances were unchanged or the amount of tissue was reduced during long-term follow-up on GH.

CONCLUSIONS

Overall, GH appears safe with respect to tumour recurrence over this time period in this patient group. Comparison with similar prospective series in patients not receiving GH replacement is desirable.

Quality of life assessment of growth hormone deficiency in adults (QoL-AGHDA): comparison of normative reference data for the general population of England and Wales with results for adult hypopituitary patients with growth hormone deficiency

BACKGROUND/AIM

Age- and gender-specific reference values for the quality of life (QoL) measures used in assessing the impact of growth hormone deficiency (GHD) are important. The objective of this study was to develop such data for the QoL-AGHDA instrument for the population of England and Wales and to demonstrate the QoL deficit in patients with GHD.

METHODS

For the purpose of this study, a questionnaire was developed that contained the EurQoL EQ-5D, QoL-AGHDA, questions recording an individual's general situation and social functioning, and a self-reported five-point rating scale of general health. The questionnaire was mailed out to a sample of 1,190 individuals drawn from the general population of England and Wales. Corresponding data for 836 patients were retrieved from KIMS (Pfizer International Metabolic Database). The postal survey data were weighted to ensure that they were representative of the general population.

RESULTS

The mean weighted QoL-AGHDA scores for the general population were 6.2 and 7.1 for men and women, respectively, compared with 13.6 and 15.7 for patients. For both males and females the differences in mean QoL-AGHDA scores between the general population and patients were statistically significant for all age categories (p < 0.01). In the general population the mean QoL-AGHDA score for each category of self-assessed health status increased progressively, indicating a poorer QoL as health status declined.

CONCLUSIONS

This study reports QoL-AGHDA normative values for the population of England and Wales and confirms the extent of QoL impairment in patients with GHD in comparison with the general population.

Limited efficacy of growth hormone (GH) during transition of GH-deficient patients from adolescence to adulthood: a phase III multicenter, double-blind, randomized two-year trial

CONTEXT

Treatment of GH-deficient adolescents in transition to adulthood remains challenging.

OBJECTIVE

The objective was to assess the safety and efficacy of GH in GH-deficient adolescents in transition.

PATIENTS

Fifty-eight GH-deficient adolescents (mean age, 15.8 +/- 1.8 yr; 33 males) at near completion of their linear growth participated in the study.

INTERVENTION

Baseline studies were done while subjects were on GH. Subjects were retested (insulin-induced hypoglycemia) 4 wk after GH discontinuation and reclassified as persistently GH-deficient or controls (n = 18). GH-deficient subjects were randomized to GH (n = 25, approximately 20 microg/kg.d) or placebo (n = 15).

SETTING

The multicenter study was conducted over a 2-yr period.

MAIN OUTCOMES

Changes in body composition, bone mineral density (BMD), quality of life (QOL), cardiovascular and metabolic markers were measured.

RESULTS

All groups had normal measures of lipid and carbohydrate metabolism, body composition, BMD, cardiac function, muscle strength, and QOL at baseline and after 2 yr. IGF-I concentrations decreased in all, but less so in the GH-group (P = 0.013). There was a greater increase in lean body mass (lesser adiposity) in the GH group than placebo at 12 months, but not at 24 months.

CONCLUSIONS

1) GH-deficient patients properly treated in childhood can have normal BMD, body composition, cardiac function, muscle strength, carbohydrate and lipid metabolism, and QOL when reaching adult height; and 2) continuation of GH therapy for 2 yr did not change these measures as compared to placebo-treated or control subjects. GH-deficient adolescents in good metabolic status at the time of epiphyseal fusion may safely discontinue GH for at least 2 yr. Follow-up is needed to determine whether GH therapy is eventually warranted in subjects treated with GH during childhood.

Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome

OBJECTIVE

Growth hormone deficiency (GHD) in adults is associated with abnormal body composition, altered lipid profile, reduced quality of life and osteoporosis. Replacement with recombinant GH results in significant improvements in most of these altered parameters. The most common cause of adult GHD in previous studies was due to pituitary tumors or their treatment. Sheehan's syndrome classically refers to postpartum hypopituitarism due to pituitary necrosis occurring secondary to massive bleeding at or just after delivery. While severe GHD is a well-established feature of Sheehan's syndrome, the effects of Growth hormone replacement therapy (GHRT) in these patients has not been extensively investigated. The present study was therefore designed to investigate the effects of GHD and GHRT in patients with Sheehan's syndrome.

DESIGN

The study comprised 14 severely GH-deficient patients with Sheehan's syndrome with a mean age of 49.4+/-7.9 yr. Treatment with GH was started at a dose of 0.15 mg per day in month 1, was increased to 0.30 mg per day in month 2, and was maintained at 0.66 mg per day until the end of month 18. With the similar maintenance dose adequate age adjusted IGF-I levels for each patient has been achieved. Blood pressure, lipid profile, biochemical parameters, anthropometric measurements including body mass index (BMI), waist and waist to hip ratio (W/H), and bone mineral density (BMD) were investigated before and at 3, 6, 12 and 18 months of the GHRT.

RESULTS

The duration of GHD from the onset of the disease was 19.4+/-1.6 yr. The majority of the patients (78%) had panhypopituitarism. At baseline mean total cholesterol, LDL-cholesterol and triglyceride levels were higher than the normal reference ranges but HDL-cholesterol levels were within the lower normal range. During the treatment period total cholesterol and LDL-cholesterol levels decreased and HDL-cholesterol levels increased significantly (P < 0.05). Waist circumference and waist to hip ratio were decreased significantly during the GHRT when compared to basal measurements (P < 0.05). There was a significant positive correlation between the basal waist circumference and the duration of GHD (P < 0.05).

CONCLUSIONS

This study clearly demonstrates that Sheehan's syndrome is characterized by severe and long-standing GHD. GHRT have beneficial effects in several parameters including lipid profile and waist circumference. But we could not observe any improvement in BMD after 18 months of GHRT. However interpretations of the present results need to be made with caution because of the uncontrolled design. Further placebo controlled studies with high number of patients with Sheehan's syndrome are warranted.

Adult growth hormone replacement therapy and neuroimaging surveillance in brain tumour survivors

OBJECTIVE

Systematic collections of neuroimaging data are nonexistent in brain tumour survivors treated with adult growth hormone replacement therapy (AGHRT). We present our surveillance data.

DESIGN

In 1993, our unit implemented a policy of performing brain scans on every brain tumour survivor before starting AGHRT, with repeat neuroimaging at least once after 12-18 months' treatment. Reports for baseline scans and most recent scans were analysed for this retrospective study.

PATIENTS

All brain tumour survivors who received AGHRT (60 patients) were included in the analysis.

MEASUREMENTS

Evidence and extent of residual tumour, tumour progression, tumour recurrence, and secondary neoplasms (SN) on baseline scan and latest follow-up scan.

RESULTS

All patients had baseline scans performed. Follow-up scans were available in 41/45 (91%) patients who received AGHRT for more than 1 year (mean duration +/- SD of GHRT was 6.7 +/- 3.6 years). Sixteen patients had residual tumours, and SNs (all meningiomas) were demonstrated in three patients on baseline scans. Appearances remained stable in 34 (83%) patients during follow-up (extending to 17.4 +/- 8.3 years after tumour diagnosis). Of the 16 residual primary tumours, an incurable ependymoma continued to grow, and one meningioma progressed slightly in size over 7.7 years. Follow-up scans also revealed continued growth of the SNs detected at baseline, and five additional meningiomas (two in patients with a previous SN, confirming an excess risk in this subgroup, P = 0.02). All SNs occurred on average 22.8 (range 17-37) years after radiotherapy.

CONCLUSIONS

Our data do not suggest an increased rate of recurrence or progression of childhood brain tumours during AGHRT. Nonetheless, vigilance and long-term surveillance are needed in these patients in order to detect and monitor SNs, in particular in patients with a previous history of a SN. We endorse a proactive neuroimaging policy, preferably as part of a larger, controlled trial in the future.

Cognitive, emotional, physical and social effects of growth hormone treatment in adults with Prader-Willi syndrome

BACKGROUND

Prader-Willi syndrome (PWS) is a multisystem genetic disorder characterized by short stature, muscular hypotonia, hyperphagia, obesity, maladaptive behaviour, hypogonadism and partial growth hormone (GH) deficiency (GHD). Severe GHD of other aetiologies has been shown to affect mood and quality of life negatively, and there are reports of improvements with GH replacement. We have studied cognitive, emotional, physical and social parameters in PWS adults at baseline, during and after GH treatment.

PATIENTS AND METHODS

Nineteen patients, 9 females and 10 males, median age 25 years, mean BMI 35 kg/m2 participated in this study. Approximately half of the group had GHD. All patients fulfilled the clinical criteria for PWS and 13 had a positive genotype. The patients were randomized to 6 months of treatment with either GH [1.6 IU/day (0.53 mg/day)] or placebo, followed by 12 months of active GH treatment. Treatment was then stopped, and the patients were followed for an additional period of 6 months. A test battery for general cognitive evaluation and a computer-based measurement of reaction time, motor speed and fluency were employed at baseline, after 6 months and at the end of GH treatment. At the same time intervals, a self-evaluation questionnaire was answered at the end of each test session. Other questionnaires reflecting the patients' cognitive, emotional, physical and social status were answered by relatives/caretakers at baseline and at 3 and 6 months following cessation of GH treatment.

RESULTS

Baseline cognitive level was estimated to be moderately to mildly impaired; IQ range was 40-90. The results from some of the cognitive and the motor performance tests improved significantly after 6 and 18 months of GH treatment. According to the questionnaires, both the patients and the relatives/caretakers evaluated physical status rather negatively at baseline, but still, impairments in both physical and social status and overall functioning were observed when GH treatment was discontinued. The self-evaluation did not change in any aspect during GH treatment.

CONCLUSIONS

In this pilot study of an adult PWS cohort, we were able to document beneficial effects in mental speed and flexibility and in motor performance during GH treatment. Impairment was seen in physical and social status as well as overall functioning, when GH treatment stopped. Studies of larger cohorts are needed to further elucidate the role of GH treatment in this group of patients.

Sheehan's syndrome: baseline characteristics and effect of 2 years of growth hormone replacement therapy in 91 patients in KIMS - Pfizer International Metabolic Database

OBJECTIVE

Sheehan's syndrome occurs as a result of ischaemic pituitary necrosis due to severe postpartum haemorrhage. It is one of the most important causes of hypopituitarism, and hence growth hormone deficiency (GHD), in developing countries. However, little is known about the effects of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome.

DESIGN

The demographic background characteristics of 91 GH-deficient patients with Sheehan's syndrome (mean age +/- s.d., 46.3 +/- 9.4 years) were compared with those of a group of 156 GH-deficient women (mean age +/- s.d., 51.5 +/- 13.1 years) with a non-functional pituitary adenoma (NFPA). The baseline characteristics and the effects of 2 years of GH replacement therapy were also studied in the 91 patients with Sheehan's syndrome and an age-matched group of 100 women with NFPA (mean age +/- s.d. 44.5 +/- 10.2 years).

RESULTS

All patients were enrolled in KIMS (Pfizer International Metabolic Database). Patients with Sheehan's syndrome were significantly younger at pituitary disorder onset, diagnosis of GHD and at entry into KIMS than patients with NFPA (P < 0.01), and had significantly lower insulin-like growth factor I levels (P < 0.001). At baseline, quality of life (QoL) was significantly (P < 0.05) reduced in patients with Sheehan's syndrome compared with those with NFPA (P < 0.001). With regard to treatment effects, lean body mass increased significantly (P < 0.05), QoL improved significantly (P < 0.05) and total and low-density lipoprotein-cholesterol decreased significantly (P < 0.05) in patients with Sheehan's syndrome after 1 year of GH replacement therapy. Similar significant changes in QoL and lipid profiles occurred in patients with NFPA after 2 years of GH replacement. Blood pressure remained unchanged in patients with Sheehan's syndrome, but decreased significantly (P < 0.01) in the group with NFPA after 1 year, before returning to pretreatment levels at 2 years.

CONCLUSIONS

In conclusion, patients with Sheehan's syndrome have more severe GHD compared with individuals with NFPA. GH replacement therapy in patients with Sheehan's syndrome may have beneficial effects on QoL, body composition and lipid profile.

The clinical, metabolic and endocrine features and the quality of life in adults with childhood-onset craniopharyngioma compared with adult-onset craniopharyngioma

BACKGROUND

Craniopharyngioma is a parasellar tumour that, although benign, tends to behave aggressively. It can occur at any age but most commonly presents in childhood or adolescence.

OBJECTIVES

To investigate the frequency and severity of problems associated with craniopharyngioma, using the large international database (KIMS) for adult patients with GH deficiency (GHD), and to assess the differences between the adult onset (AO, aged 18 or above) disease and adults with childhood onset (CO) craniopharyngioma.

DESIGN

Inclusion criteria were: an established diagnosis of craniopharyngioma, severe GHD and no recent GH treatment. These criteria were fulfilled by 393 (184 female, 209 male) patients; 241 had AO (mean age 28.7 +/- 8.7 years) and 152 had CO disease (age 42.0 +/- 12.3 years). Disease history, clinical features and anthropometric data were recorded at the time of enrolment in the database, and body composition, serum IGF-I, serum lipids and quality of life (QoL) were assessed.

RESULTS

Peak age at onset of craniopharyngioma was 15-20 years. Ninety percent of patients had been treated surgically. CO patients were shorter than AO patients and had much lower IGF-I standard deviation scores (SDS). The majority had hypopituitarism and over 60% had diabetes insipidus. Body mass index (BMI) was higher in AO males (30.2 +/- 5.5) than in CO males (28.5 +/- 7.5); waist circumference was also greater. Obesity was more common in AO patients (51.8% vs 39.1%). Body composition did not differ between groups. Cholesterol and triglycerides were higher in AO than in CO patients, but high density lipoprotein (HDL)- and low density lipoprotein (LDL)-cholesterol did not differ. Quality of life, assessed by Quality of Life-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA) and the Nottingham Health Profile, was markedly reduced in all groups with no significant differences between them; the QoL-AGHDA score correlated with age at onset of both craniopharyngioma and GHD, and also with BMI in AO patients.

CONCLUSIONS

These data emphasise the generally poor state of health of patients treated for craniopharyngioma, with respect to endocrine and metabolic function, and also the markedly reduced quality of life. In addition to GHD, most patients have evidence of hypothalamic damage with associated obesity, diabetes insipidus and hypopituitarism. Adults with CO craniopharyngioma were shorter, had lower IGF-I, lower BMI, less obesity and slightly lower blood lipid levels than patients with AO craniopharyngioma.

Justified and unjustified use of growth hormone

Growth hormone (GH) replacement therapy for children and adults with proven GH deficiency due to a pituitary disorder has become an accepted therapy with proven efficacy. GH is increasingly suggested, however, as a potential treatment for frailty, osteoporosis, morbid obesity, cardiac failure, and various catabolic conditions. However, the available placebo controlled studies have not reported many significant beneficial effects, and it might even be dangerous to use excessive GH dosages in conditions in which the body has just decided to decrease GH actions. GH can indeed induce changes in body composition that are considered to be advantageous to GH deficient and non-GH deficient subjects. In contrast to GH replacement therapy in GH deficient subjects, however, excessive GH action due to GH misuse seems to be ineffective in improving muscle power. Moreover, there are no available study data to indicate that the use of GH for non-GH deficient subjects should be advocated, especially as animal data suggest that lower GH levels are positively correlated with longevity.

Hormones and Supplements: Do They Work?: Use of Growth Hormone for Prevention or Treatment of Effects of Aging

Decreases in growth hormone (GH) and insulin-like growth factor-I, estrogen deficiency in women, diminished testosterone in men, and loss of lean body mass, increased fat, and other changes consistent with hormone deficiencies occur during aging. Treatment of nonelderly GH-deficient adults with recombinant human GH (rhGH) improves body composition, muscle strength, physical function, and bone density, and reduces blood cholesterol and cardiovascular disease risk, but is often accompanied by carpal tunnel syndrome, peripheral edema, joint pain and swelling, gynecomastia, glucose intolerance, and possibly increased cancer risk. Reports that rhGH augments lean body mass and reduces body fat in aged individuals increased use of rhGH to delay aging effects. However, clinically significant functional benefits, prolongation of youth, and life extension have not been demonstrated. Moreover, marketing of rhGH and other hormone supplements largely ignores adverse effects. Until more research has better defined the risk/benefit relationships, treatment of elderly individuals with rhGH should be confined to controlled research studies.

Aspects of growth hormone deficiency and replacement in elderly hypopituitary adults

Normal ageing is associated with a decline in spontaneous growth hormone (GH) secretion, and although elderly hypopituitary adults demonstrate an increase in total and central fat compared with age-matched controls and are distinguishable from control subjects in terms of GH responsiveness on dynamic testing, there are few data available on the response to GH replacement in older subjects. We have studied the baseline characteristics of 295 patients (173 males and 122 females) aged >65 years of age who began GH replacement therapy at the time of entry into the KIMS program (Pfizer International Metabolic Database) and the effects of GH replacement in 125 patients who completed at least 12 months of GH replacement therapy. Data were compared with those of 2469 (1249 males and 1220 females) patients aged <65 years with adult-onset GH deficiency (GHD). The patients were selected using strict criteria in accordance with the recommendations from the Growth Hormone Research Society. There was a higher proportion of pituitary adenoma relative to craniopharyngioma in the older age group (P<0.001), but there was no difference between groups in the degree of hypopituitarism (number of additional hormone deficiencies). Blood pressure, cholesterol and low-density lipoprotein (LDL) cholesterol levels were positively correlated with age, and older patients had a predictably higher prevalence of diabetes mellitus, coronary heart disease, stroke and history of hypertension. Quality of life (Assessment of Growth Hormone Deficiency in Adults (AGHDA) score) was impaired in both groups before the start of GH therapy. GH replacement doses were lower in older patients with GHD as compared with patients <65 years old. After 12 months of GH replacement, significant improvements were evident in waist circumference, waist/hip ratio, lean body mass, diastolic blood pressure, total and LDL cholesterol levels and AGHDA scores in patients aged <65 years. Similar significant reductions were evidenced in patients >65 years old compared with those observed in younger patients. The total number of adverse events was similar in younger and older patients with GHD. However, younger patients had more fluid retention-related adverse events such as headache, oedema and arthralgia; whereas, older patients with GHD had more adverse events related to glucose metabolism, cardiovascular events and neoplasms. These data indicate a positive benefit from GH replacement in older patients with hypopituitarism - particularly in relation to quality of life - using a lower dose of GH for replacement and with appropriate age-related safety controls.

Three-years of growth hormone (GH) replacement therapy in GH-deficient adults: effects on quality of life, patient-reported outcomes and healthcare consumption

OBJECTIVE

The objective was to investigate the effects of 3 years of growth hormone (GH) replacement therapy in GH deficient (GHD) patients in Sweden.

DESIGN AND PATIENTS

An open label study in 237 adults with GHD (116 men and 121 women), consecutively enrolled in KIMS (Pfizer's international metabolic database) in Sweden.

MEASUREMENTS

QoL and healthcare consumption were determined using questionnaires [QoL-assessment of GHD in Adults (QoL-AGHDA), the psychological general well-being (PGWB) index and the patient life situation form (PLSF)].

RESULTS

The mean starting dose of GH was 0.13 mg/day and the mean maintenance dose was 0.37 mg/day. The mean insulin-like growth factor I (IGF-I) SD score increased from -1.92 at baseline to 0.38 after 3 years. There was a sustained increase in QoL as measured by the QoL-AGHDA and PGWB questionnaires. The number of doctor visits and the number of days in hospital were reduced after 3 years of GH replacement. The number of days of sickleave decreased during the first 2 years of treatment, but returned towards baseline values after 3 years. Leisure-time physical activity and satisfaction with physical activity increased.

CONCLUSION

Three years of GH replacement therapy induced a sustained improvement in QoL. Healthcare consumption was reduced, although the reduction in the number of days of sickleave was not statistically significant after 3 years of treatment.

Apparent induction of partial thymic regeneration in a normal human subject: a case report

Magnetic resonance imaging was used to detect signs of regeneration of the thymus after approximately one month of human growth hormone administration. A 46-year-old human volunteer was placed on a regimen of recombinant human growth hormone and pharmaceutical grade dehydroepiandrosterone for one month. Mediastinal magnetic resonance images were collected at baseline and after the study period. Thymic cross sections were analyzed for total area and for the total gray area, which was taken to represent functional mass. Baseline and post-treatment blood samples were taken to follow changes in IGF-1 levels and related metabolites. The setting was an informal, non-institutional trial supervised by a physician will full informed consent of the volunteer. Visual inspection and image analysis demonstrated limited but distinct enlargement of the thymus after treatment, and an increase in the percent of thymic cross section represented by gray-appearing (functional) mass. Estimated total thymic functional volume was within the normal range at baseline, but after treatment was more than three standard deviations above the expected mean for a subject of this age, thus meeting a proposed definition of thymic hyperplasia for individuals. IGF-1 levels were confined to the upper range of normal for young adults. The present observations apparently provide the first demonstration of growth hormone induced partial reversal of established thymic involution in a normal human subject, and are consistent with previous measurements of restored immune function after the administration of human growth hormone to elderly individuals.

Advances in Growth Hormone Therapy: A New Registry Tool

Growth hormone (GH) deficiency is a rare condition, and physicians may lack clinical experience of its treatment. Despite evidence for the efficacy and tolerability of GH therapy, a substantial proportion of patients remain untreated. Registries and other large-scale databases are an important tool for expanding the evidence base for GH treatment. Since the mid-1980s, registries have provided data on important aspects of the safety and efficacy of GH treatment. Registries have also allowed pooling of data from patients with rare conditions that could otherwise not be recruited in sufficient numbers for clinical trials. Importantly for patients and their relatives, use of registry data has allowed the development of prediction models that indicate the likely outcomes of treatment. MEGHA (Metabolic Endocrinology and Growth Hormone Assessment) is a recently developed, observational database with a number of features not found in existing registries, including its use as a day-to-day clinical management tool, the ability to create individual sub-studies, direct comparison of personal data against the full database, and a particular focus on the transition from childhood to adulthood. This creative registry is a promising instrument for further research into GH-related disorders that will improve GH therapy and thus provide benefits for patients.

Long-Term Challenges in Growth Hormone Treatment

Growth hormone deficiency (GHD) is defined biochemically as a response to hypoglycaemia with a peak GH concentration of less than 5 microg/l. The 'GHD syndrome' is a range of psychological and physical symptoms that are associated with GHD, which include increased central adiposity, decreased bone mineral density, abnormal lipid profiles, decreased cardiovascular performance, reduced lean body mass (LBM), social isolation, depressed mood and increased anxiety. Importantly, the combination of physical and psychological problems can often result in a reduced quality of life. A number of trials have shown that GH replacement therapy can lead to a substantial improvement in GHD associated symptoms. Following up to 12 months of treatment with GH, LBM increased, left ventricular systolic function improved and the mean volume of adipose tissue fell. After only 4 months of treatment, a rise in exercise capacity was recorded, and after 2 years' treatment, isokinetic and isometric muscle strength had normalized in proximal muscle groups. Feelings of well-being and vitality also improved significantly. However, studies on the effects of treatment on insulin sensitivity in GH-deficient patients have had conflicting results. In this paper, we will discuss the long-term consequences of GHD and the effects of GH replacement therapy.

Hypercholesterolemia and obesity in adult patients with hypopituitarism: a report of a nation-wide survey in Japan

Dyslipidemia and obesity are common in adult patients with hypopituitarism. Possible contributions of age, sex and hormone deficiencies to hypercholesterolemia and obesity in adult hypopituitary patients were analyzed in 1, 272 Japanese cases based on a database of a national survey on adult hypopituitarism. In patients on routine hormone replacement therapy, 30.5% of male and 40.7% of female subjects were considered hypercholesterolemic. In univariate analysis, hypercholesterolemia was more prevalent in female, aged, untreated Gn-deficient and TSH-deficient groups. In multivariate analysis, sex of female, age older than 40 yr and TSH deficiency were the independent contributing factors to hypercholesterolemia. Obesity (body mass index (BMI) > or = 25 kg/m2) was more prevalent in male, TSH-deficient and ADH-deficient groups. Severe obesity (BMI > or = 30) was observed in high prevalence in the youngest group. These findings suggest that hypercholesterolemia and obesity were prevalent in different age and gender groups in Japanese adult patients with hypopituitarism. Insufficient replacement of thyroid hormone and possibly gonadotropin deficiency might contribute to hypercholesterolemia. In contrast, hypothalamic dysfunction as well as hormone deficiencies might play roles in obesity in these patients.

Assessment of quality of life in adults receiving long-term growth hormone replacement compared to control subjects

OBJECTIVE

There are few studies of quality of life (QOL) in adults with growth hormone deficiency (GHD) compared to matched control populations without GHD. These have shown impairments in a variety of QOL measures, which improve but do not normalize after short-term replacement with GH. There is little information on QOL in long-term treated GHD patients compared with controls without GHD.

PATIENTS AND METHODS

A total of 120 adults with GHD who had received GH replacement for at least 1 year were identified from the neuroendocrine clinic. Patients were asked to complete eight QOL questionnaires and an Energy Visual Analogue Scale (VAS). Results were compared with 83 control subjects without GHD from the local population who agreed to complete seven of the QOL questionnaires (excluding Disease Impact scale) and the energy VAS. The eight questionnaires were a combination of generic and disease-specific questionnaires used to assess health related QOL, namely: Short Form-36 (SF-36), Nottingham Health Profile (NHP), Disease Impact, Life Fulfilment and Satisfaction scales, Mental Fatigue Questionnaire (MFQ) and Self Esteem scale, Hospital Anxiety Depression (HAD) scale and QOL-AGHDA (assessment of GHD in adults).

RESULTS

Eighty-nine patients returned questionnaires and 85 (71%) had complete data for analysis. The mean (SD) duration of GH replacement was 36.0 +/- 26.4 (range 13-159) months. Mean age was 43.9 +/- 15.8 years (37 males) in treated GHD patients compared to a mean age 41.7 +/- 10.5 years (32 males) in the controls. Mean IGF-1 levels were 22.5 +/- 13.6 nmol/l in the GHD patients and the mean dose of GH replacement was 1.2 +/- 0.4 IU daily. Analysis of the QOL questionnaires from the GH treated patients revealed highly significant impairments in all measures (most P </= 0.0001, except life fulfilment-material, P = 0.33) compared to the control population.

CONCLUSIONS

This large population with treated GH deficiency have significant impairments in multiple aspects of QOL despite replacement with GH and other pituitary hormones for at least 1 year (mean 3 years). It is likely therefore that other factors in addition to GH deficiency must influence QOL in these patients. Further strategies to improve QOL in these individuals should therefore be considered, e.g. psychological support and treatments and physical treatments (such as exercise programmes).

Growth hormone therapy in adults

Growth hormone (GH) is classically linked with linear growth in childhood but continues to have important metabolic actions throughout life. GH deficiency in adulthood causes a distinct syndrome with significant morbidities. These include increased total and visceral fat, decreased muscle mass and aerobic capacity, affective disturbances, abnormal lipids, and increased vascular mortality, all of which are ameliorated with GH replacement. The possibility of adult GH deficiency (AGHD) should always be considered in individuals with a history of childhood GH deficiency or significant hypothalamic-pituitary damage, and the diagnosis should then be confirmed by biochemical testing. Adult GH dosing is much lower than that in pediatric practice, as appropriate for physiologic reconstitution. Hormonal side effects are minimized by stepwise dose titration. Lingering concerns remain regarding the possibility of increased cancer risk with long-term treatment, but this hazard has not been unequivocally demonstrated. Compared with AGHD, there is much less information about GH replacement in other diseases or in normal aging, or about the use of supraphysiologic GH doses to treat catabolic states. In critical illness, high-dose GH therapy has proven clearly harmful, and the balance of risks and benefits of GH administration in most adult contexts other than AGHD has not been defined.

Long-term growth hormone replacement therapy in hypopituitary adults

Growth hormone deficiency (GHD) in the adult has now been fully recognised as a clinical entity characterised by abnormal body composition, osteopenia, impaired quality of life, cardiac dysfunction and an adverse lipid profile. While short-term studies of GH replacement have demonstrated irrefutably a favourable effect on all if not most features of GHD, data on long-term administration spanning more than 2 years are still scarce. Experience of GH replacement up to 5 to 10 years indicate that the beneficial effects on body composition, predominantly a decrease in body fat and an increase in lean mass, is maintained during treatment. Long-term GH therapy also increases muscle strength and exercise performance. All data, with one exception, are consistent with a significant increase in bone mass during prolonged GH therapy. The most distinct effect on bone was observed in the worst affected individuals and in males. Improvement in quality of life is documented shortly after initiation of GH replacement and is maintained during long-term studies. This may explain the reduction in days of sick leave seen during GH therapy. The beneficial effect on cardiovascular risk factors is sustained over a prolonged period of time, revealing a reduction in intima wall thickness, and an improvement in serum lipid levels and clotting parameters. The increase in lipoprotein(a) levels with GH therapy in some studies may be disturbing, but difficulties in measuring this parameter and inconsistencies between the different studies makes it difficult to estimate its real impact. No data are yet available to show that GH replacement will normalise or even improve mortality rate and fracture rate. Adverse events associated with GH replacement therapy are mainly secondary to fluid retention as a result of excess dose administration. This can be adequately prevented by monitoring GH replacement according to serum insulin-like growth factor (IGF)-I levels. From what is currently known, GH replacement does not increase the prevalence of diabetes mellitus, and does not induce new neoplasms or recurrence of the primary brain tumour; however, longer follow-up studies are needed to provide definitive answers. In conclusion, it appears not only that long-term GH replacement therapy in adults with GHD is a procedure that can be safely used, but that GH replacement should be considered as a possible life-long therapy in order to maintain its benefits.

Evaluation of two health status measures in adults with growth hormone deficiency

OBJECTIVE

To evaluate the psychometric properties of two health status measures for adults with growth hormone deficiency (GHD): Nottingham Health Profile (NHP) and Short-Form Health Survey (SF-36).

DESIGN

(1) A cross-sectional survey of adults with treated or untreated GHD to assess reliability and validity of the questionnaires. (2) A randomized, placebo-controlled study of 3 months' GH withdrawal from GH-treated adults to assess the sensitivity of the questionnaires to change.

PATIENTS

(1) A cross-sectional survey of 157 patients with severe GHD (peak GH < 10 mU/l on provocative testing), mean age 48.9 years (range 23-70 years), who had either received GH replacement therapy for at least 6 months immediately prior to the study or had not received GH treatment in the previous 6 months. (2) GH treatment was withdrawn from 12 of 21 GH-treated adults, all with severe GHD (peak GH < 7.7 mU/l on provocative testing), mean age 44.9 years (range 25-68 years).

MEASUREMENTS

The NHP and SF-36 were used once in the cross-sectional survey, but twice in the GH-withdrawal study, at baseline and end-point (after 3 months).

RESULTS

(1) Cross-sectional survey. Both questionnaires had high internal consistency reliability with subscale Cronbach's alphas of > 0.73 (NHP) and > 0.78 (SF-36). Calculation of an NHP Total Score, occasionally reported in the literature, was shown to be inadvisable. Overall, patients with GHD were found to have significantly worse perceived functioning than the UK general population in SF-36 subscales of General Health, Bodily Pain, Social Functioning, Physical Functioning, Role-Emotional, Role-Physical, and Vitality. Although neither questionnaire found significant differences between GH-treated and non-GH-treated patients, there were correlations with duration of GH treatment (P < 0.01) for GH-treated patients in SF-36 Mental Health (r = 0.29, N = 87) and SF-36 Vitality (r = 0.33, N = 88), indicating improvement with increasing treatment duration. The SF-36 was also more sensitive than the NHP to sex differences: men had significantly better health status compared with women (P < 0.05) in all SF-36 subscales but Mental Health, but only in one NHP subscale (Physical Mobility). (2) GH-withdrawal study. Significant between-group differences in change were found in SF-36 General Health [t(17) = 2.76, P = 0.013, two-tailed] and SF-36 Mental Health [t(17) = 2.41, P = 0.027, two-tailed]: patients withdrawn from GH reported reduced general health and mental health at end-point. The NHP found no significant change.

CONCLUSIONS

The SF-36 is a better measure than the NHP of health status of people with GH deficiency because of its greater discriminatory power, with ability to detect lesser degrees of disability. It also has superior sensitivity to some subgroup differences and superior sensitivity to change compared with the NHP. The SF-36 is highly acceptable to respondents, and has very good internal consistency reliability. The SF-36 is recommended to measure the health status of adults with GH deficiency.

[Growth hormone deficiency in adults: effects of replacement therapy on body composition and health-related quality of life]

BACKGROUND AND OBJECTIVE

Deficiency of growth hormone (GH) in the adult is accompanied by changes in the body composition and a diminished health-related quality of life (HR-QoL). The aim of the study was to assess the biochemical response to GH replacement therapy and its safety as well as the resulting body composition and HR-QoL.

PATIENTS AND METHODS

One hundred sixty-five patients with hypopituitarism and GH deficiency were studied. A double-blind,randomized, placebo-controlled, 6-months study was first designed,then followed by a further 6-months period in which all patients received GH. The initial GH dose was 0.125 IU/Kg/week followed by 0.250 IU/Kg/week. The body composition was determined by bioelectric impedanciometry and the HR-QoL was evaluated by the Nottingham Health Profile (NHP) and the QoL-AGHDA questionnaire.

RESULTS

A significant increase in fat-free mass was observed during treatment with GH, which was accompanied with a simultaneous decrease in fat mass. Total body water increased during GH treatment. Energy and emotional reaction areas evaluated by the NHP showed changes at 6 months; no changes were observed in the remaining dimensions. A progressive improvement was observed in the QoL-AGHDA score in the treated group but not in the placebo group. Adverse events mainly consisted of fluid retention which resolved upon decrease of the dose.

CONCLUSIONS

GH treatment in GH-deficient adults is in general well tolerated and leads to beneficial effects on body composition and HR-QoL.

Do all adults with growth hormone deficiency require growth hormone treatment?

Adult growth hormone (GH) deficiency results mainly from pituitary or peri-pituitary disease and/or its treatment and is frequently accompanied by other anterior pituitary hormone deficiencies. GH deficiency (GHD) results in a number of psychological and physical symptoms and signs which in combination constitute the adult 'GHD syndrome'. The psychological symptoms include decreased energy levels, social isolation, and lack of positive well being, depressed mood and increase in anxiety. The physical symptoms and signs include abnormal body composition with reduced lean body mass, increased central adiposity, and decreased extracellular fluid volume, decreased bone mineral density with an increased risk of fracture, reduced muscle strength, reduced exercise capacity, increased LDL cholesterol and reduced insulin sensitivity. Hypopituitarism and GHD are associated with an increased standardised mortality ratio. The diagnosis of GHD is confirmed by the insulin tolerance test or alternative stimulation test in the presence of structural pituitary disease and/or additional pituitary hormone deficiencies. Replacement with synthetic growth hormone by once daily subcutaneous injection can reverse many of the symptoms and signs of growth hormone deficiency, but the long-term effects are yet to be established. Whether or not all patients with GHD should receive GH replacement remains a matter for debate: a selective approach to therapy based on psychological well being and quality of life has been adopted in many centres.

Long-Term Efficacy and Safety of Somatropin for Adult Growth Hormone Deficiency

The beneficial effects of somatropin (growth hormone [GH] replacement therapy) in adults are now established. Long-term somatropin administration in GH-deficient adults improves body composition, muscle strength, quality of life, bone mass and density, and lipoprotein pattern. The extent to which somatropin therapy can also reduce cardiovascular morbidity and mortality in GH-deficient adults remains to be determined. By starting with a low dose of somatropin, which is gradually increased based on clinical response (body composition, well-being, and serum insulin-like growth factor-1 concentration), effective treatment can be achieved with a minimum of fluid-related adverse effects. Thorough long-term monitoring of glucose metabolism, cardiovascular measurements, and underlying pituitary disease, is, however, mandatory.

Suprasellar germ cell tumours: specific problems and the evolution of optimal management with a combined chemoradiotherapy regimen

OBJECTIVE

Suprasellar germ cell tumours are rare, and there are few series of patients outlining the problems in diagnosis and management, and providing clear guidelines for optimal therapy. We have therefore reviewed our own series of 11 such patients who were managed in a joint endocrinology/clinical oncology setting.

PATIENTS AND DESIGN

A retrospective case review assessment of all patients seen within a given time. Clinical, biochemical and radiological findings were reviewed, the types of therapy administered noted, and the responses to treatment analysed.

RESULTS

In the years 1977-2001, 11 patients with suprasellar (SS) germ cell tumours (GCT) were seen (germinomatous : nongerminomatous = 8 : 3). SSGCT had an approximately equal sex incidence (M : F, 6 : 5), in contrast to pineal tumours, the commonest site of origin of intracranial GCT and which occur predominantly in men. The median age at presentation was 20 years (range 6-49 years) with a median duration of symptoms before diagnosis of 17 months (range 1-35 months). Polyuria was the commonest presenting symptom (10 patients). Diabetes insipidus occurred in all patients, as did partial or complete anterior pituitary failure. Visual failure was present in 55% of cases. Anorexia, weight loss and disturbed thirst sensation were also common. Positron emission tomography scanning was occasionally useful in the evaluation of suprasellar tumours/pituitary stalk lesions deemed too risky to biopsy. A "central nervous system-friendly" chemoradiotherapy regimen comprising vincristine, etoposide and carboplatin and differential daily dose irradiation, usually administered using a partial transmission block technique, produced a 5-year survival of 100% with low morbidity. Treatment did not correct previously abnormal endocrine function although it did improve vision in three of six patients.

CONCLUSIONS

We therefore emphasize the use of techniques other than biopsy in the diagnosis of these patients, note the problems in the management of their fluid control, and highlight the favourable response to a combined chemotherapy-radiotherapy protocol.

Improvement of fracture healing by systemic administration of growth hormone and local application of insulin-like growth factor-1 and transforming growth factor-beta1

Fracture healing is influenced by numerous hormones, growth factors, and cytokines. The systemic administration of growth hormone (GH) has shown to accelerate bone regeneration. Local application of growth factors, such as insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta-1 (TGF-beta1), are known to stimulate bone metabolism. Until now, the exact local and systemic mechanisms that lead to improved bone regeneration remain unclear. In addition, the effect of systemic administration of GH as compared with locally delivered growth factors on fracture healing in rats is not known. A midshaft fracture of the right tibia of 5-month-old female Sprague-Dawley rats (n = 80) was intramedullary stabilized with IGF-1 and TGF-beta1 coated vs. uncoated titanium K-wires. The growth factors were incorporated in a poly(D,L-lactide) (PDLLA) coating and released continuously throughout the experiment. Recombinant species-specific (rat) GH was applied systemically (2 mg/kg body weight) by daily subcutaneous injection and compared with a placebo group. The healing process was radiologically monitored. Twenty-eight days after fracture biomechanical torsional testing was performed. The consolidation and callus composition, including quantification of cartilage and mineralized tissue, was traced in histomorphometrical investigations using an image analysis system. Both methods, the systemic administration of GH and the local application of growth factors, showed significant biomechanical and histological effects on fracture healing. The local growth factor application showed a stronger effect on fracture healing than the systemic GH injection. The combined application of both methods did not accelerate the effect on bone healing compared with the single application. It is therefore concluded that combining local and systemic stimulating methods does not provide further additive effects with regard to fracture healing.

Growth hormone therapy and its relationship to insulin resistance, glucose intolerance and diabetes mellitus: a review of recent evidence

It is widely recommended that consideration should be given to the therapeutic use of growth hormone (GH) in adults with GH deficiency, whether the condition is of childhood or adult onset. One reason for this recommendation is the possibility that such treatment may reduce the excess cardiovascular risk which is associated with hypopituitarism. This excess risk has been well documented, with mortality ratios of 1.7 to 2.2 being quoted in different studies, and may be a result of the insulin resistance which occurs in hypopituitarism. However, it has also been suggested that this insulin resistance may itself be the result of GH deficiency, especially as GH deficiency is accompanied by suggestive morphological features such as central adiposity. There is, however, no direct evidence that the increase in cardiovascular risk in hypopituitarism is the result of GH deficiency, and the only prospective study designed to examine the relationship failed to find a statistically significant correlation between the two. Since GH administration may also have an independent adverse effect on insulin sensitivity and could thus cause a theoretical worsening of cardiovascular risk, it is important to review the observed effects of GH administration on carbohydrate metabolism in practice. Interpretation of the literature is made difficult by many confounding factors, including differences in study duration, biochemical tools adopted, the use of selected populations and the dose-dependent effect of GH on synthesis of insulin- like growth factor-1. One of the most sensitive markers of a deterioration in insulin sensitivity is the serum insulin level. A rise in serum insulin (fasting, or post-glucose load) was reported in all studies in which it was measured. The majority of studies have also reported a rise in fasting blood glucose. A smaller proportion of reports noted an associated increase in postprandial glucose and in glycosylated haemoglobin (HbA(1c)) while a few reported new cases of either impaired glucose tolerance or frank diabetes mellitus. In general, however, the observed deterioration in insulin sensitivity was small and increases which occurred in blood glucose were small. Nevertheless, these data indicate that rather than lead to an improvement in insulin resistance in hypopituitarism, GH treatment may actually make it worse. As it is also known that even minor reductions in insulin sensitivity may be associated with a clinically significant increase in cardiovascular risk, further large-scale controlled trials are required before the efficacy and safety of GH treatment of adults can be established.

Human growth hormone replacement in adult hypopituitary patients: long-term effects on body composition and lipid status--3-year results from the HypoCCS Database

The Hypopituitary Control and Complications Study is an international surveillance study evaluating efficacy and safety of GH therapy of adult GH-deficient patients in clinical practice. The present report examined baseline data from 1,123 adult onset (AO) and 362 childhood onset (CO) patients, as well as efficacy in 242 patients who had completed 3 yr of GH treatment. At study entry, mean height, body mass index, waist to hip ratio, and lean body mass were significantly (P < 0.001 for each) lower in CO compared with AO patients. After 3 yr on GH, lean body mass was significantly increased in AO males and females and CO males but not CO females, whereas fat mass was significantly decreased in AO males only. Serum total cholesterol was decreased in females (-0.32 +/- 1.00 mmol/liter; P = 0.045) and males (-0.36 +/- 0.96 mmol/liter; P = 0.004). High-density lipoprotein (HDL) cholesterol was increased for females (0.10 +/- 0.26 mmol/liter; P = 0.026) and males (0.10 +/- 0.34 mmol/liter; P = 0.022). The low-density lipoprotein/HDL ratio was decreased in AO males (-0.93 +/- 2.00; P = 0.003), AO females (-0.65 +/- 0.74; P < 0.001), and CO females (-0.69 +/- 0.76; P = 0.038), but the decrease in CO males was not significant (-0.84 +/- 2.85; P = 0.273). In AO patients, lean body mass increase from baseline was greatest in the those younger than 40 yr old, less but still significant in the middle group (40-60 yr) and unchanged in older (>60 yr) patients; conversely, decreases in the low-density lipoprotein/HDL ratio were small and not significant in the younger patients but greater and significant in the middle and older age groups. During the 3-yr treatment, 114 (7.7%) patients discontinued, including 9 (0.6%) for tumor recurrences, 9 (0.6%) for neoplasia, and 9 (0.6%) for side effects. Therefore, these observational data showed significant long-term efficacy of adult GH replacement therapy on body composition and lipid profiles and indicate that age is an important predictor of response.

Diagnosis and management of growth hormone deficiency in adults

In adults, GHD is a clinical syndrome that occurs in patients with pituitary or hypothalamic disease. It may be asymptomatic or present with relatively nonspecific constitutional symptoms. Most patients have abnormal body composition, consisting of increased fat mass and decreased lean mass. Life expectancy is significantly decreased in hypopituitary patients with GHD, with cardiovascular disease a common cause of death. Treatment with growth hormone reverses abnormalities in body composition and may reduce cardiovascular risk factors; however, the long-term treatment outcomes regarding mortality, the incidence of cardiovascular disease, bone fractures, tumor development, and recurrence are not known. Longer prospective clinical studies are needed. The major manufacturers of growth hormone have initiated postmarketing surveillance databases to monitor the safety of growth hormone treatment.