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Sánchez Malo MJ, Hidalgo Sanz J, Ferrer Lozano M, Labarta Aizpún JI, de Arriba Muñoz A. Importance of Growth Factors and Bone Maturation Ratio in the Response to Growth Hormone Therapy. Endocr Pract 2024; 30:57-63. [PMID: 37923058 DOI: 10.1016/j.eprac.2023.10.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim was to identify the influence of insulin-like growth factor I (IGF-1), IGF-binding protein-3 (IGFBP-3), and bone age (BA)/chronological age (CA) ratio on the response to GH therapy after 1 and 2 years of treatment and upon reaching final height. METHODS Longitudinal, retrospective, observational study of 139 patients treated for idiopathic growth hormone deficiency. Variables examined during follow-up: (1) genetic background; (2) perinatal history; (3) anthropometry; (4) height velocity, BA, BA/CA and height prognosis; (5) analytical results (IGF-1, IGFBP-3). Final response variables: adult height (AH), AH with respect to target height, AH with respect to initial height prognosis, AH with respect to height at the start of treatment, and AH with respect to height at onset of puberty. RESULTS Lower pretreatment IGF-1 levels and a greater increase in IGF-1 at the end of treatment imply a better response (r = -0.405, P = .007 and r = 0.274, P = .014, respectively), as does a greater increase in IGFBP-3 after 2 years of treatment and at the end of treatment (r = 0.207, P = .035 and r = 0.259, P = .020, respectively). A lower BA/CA ratio pretreatment and at the onset of puberty results in a better response (r = -0.502, P = .000 and r = -0.548, P = .000, respectively), as does a lower increase in BA and BA/CA ratio after the 1 and 2 years of treatment (r = -0.337, P = .000 and r = -0.332, P = .000, respectively). CONCLUSION Low pretreatment IGF-1, a greater BA delay with respect to CA pretreatment and at the onset of puberty, a greater increase in IGFBP-3 after 2 years of treatment, and a lower increase in BA and BA/CA ratio after 1 and 2 years of treatment imply a better long-term response.
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Affiliation(s)
| | | | - Marta Ferrer Lozano
- Department of Pediatric Endocrinology, Miguel Servet University Hospital, Zaragoza, Spain
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Kim JH, Kim SJ, Lee J, Shin CH, Seo JY. Factors affecting IGF-I level and correlation with growth response during growth hormone treatment in LG Growth Study. PLoS One 2021; 16:e0252283. [PMID: 34280192 PMCID: PMC8289015 DOI: 10.1371/journal.pone.0252283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 05/12/2021] [Indexed: 11/30/2022] Open
Abstract
Growth hormone treatment strategies to achieve the goal include the titration of GH doses according to serum insulin-like growth factor I (IGF-I) concentrations. However, IGF-I levels do not always correlate well with the growth response. This study aims to identify the factors affecting the IGF-I concentration and identify the relationship between IGF-I and the treatment response. The data of prepubertal children treated with recombinant human GH for more than one year were obtained from the LG Growth Study (LGS) Database. This study includes patients with idiopathic growth hormone deficiency (IGHD), organic growth hormone deficiency (OGHD), or Turner syndrome (TS) or small for gestational age (SGA). Among 2,021 participants registered in LGS, 366 subjects were selected, 252 had IGHD, 16 had OGHD, 31 had TS, and 67 were SGA. In the IGHD and SGA groups, IGF-I levels had a positive correlation with weight SDS. There was no significant relationship between the pre-treatment IGF-I level and growth response. However, in the IGHD group, the growth response was significantly higher when the change in the IGF-I SDS value was 1 or more (p = 0.0013). Therefore, IGF-I concentrations should be used as an indicator to monitor the treatment compliance rather than for efficacy determination in Korean children of short stature with GH treatment.
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Affiliation(s)
- Ji Hyun Kim
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Su Jin Kim
- Department of Pediatrics, Inha University School of Medicine, Incheon, Korea
| | - Jieun Lee
- Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Young Seo
- Department of Pediatrics, Eulji General Hospital, Eulji University College of Medicine, Seoul, Korea
- * E-mail:
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Léger J, Mohamed D, Dos Santos S, Ben Azoun M, Zénaty D, Simon D, Paulsen A, Martinerie L, Chevenne D, Alberti C, Carel JC, Guilmin-Crepon S. Impact of the underlying etiology of growth hormone deficiency on serum IGF-I SDS levels during GH treatment in children. Eur J Endocrinol 2017; 177:267-276. [PMID: 28760908 DOI: 10.1530/eje-17-0215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/14/2017] [Accepted: 06/29/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT Regular monitoring of serum IGF-I levels during growth hormone (GH) therapy has been recommended, for assessing treatment compliance and safety. OBJECTIVE To investigate serum IGF-I SDS levels during GH treatment in children with GH deficiency, and to identify potential determinants of these levels. DESIGN, PATIENTS AND METHODS This observational cohort study included all patients (n = 308) with childhood-onset non-acquired or acquired GH deficiency (GHD) included in the database of a single academic pediatric care center over a period of 10 years for whom at least one serum IGF-I SDS determination during GH treatment was available. These determinations had to have been carried out centrally, with the same immunoradiometric assay. Serum IGF-I SDS levels were determined as a function of sex, age and pubertal stage, according to our published normative data. RESULTS Over a median of 4.0 (2-5.8) years of GH treatment per patient, 995 serum IGF-I SDS determinations were recorded. In addition to BMI SDS, height SDS and GH dose (P < 0.01), etiological group (P < 0.01) had a significant effect on serum IGF-I SDS levels, with patients suffering from acquired GHD having higher serum IGF-I SDS levels than those with non-acquired GHD, whereas sex, age, pubertal stage, treatment duration, hormonal status (isolated GHD (IGHD) vs multiple pituitary hormone deficiency (MPHD)) and initial severity of GHD, had no effect. CONCLUSIONS These original findings have important clinical implications for long-term management and highlight the need for careful and appropriate monitoring of serum IGF-I SDS and GH dose, particularly in patients with acquired GHD, to prevent the unnecessary impact of potential comorbid conditions.
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Affiliation(s)
- Juliane Léger
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Institut National de la Santé et de la Recherche Médicale (Inserm), Unité 1141, DHU Protect, Paris, France
| | - Damir Mohamed
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Unit of Clinical Epidemiology, Paris, France
- Inserm, CIC-EC 1426, Paris, France
| | - Sophie Dos Santos
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
| | - Myriam Ben Azoun
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
| | - Delphine Zénaty
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
| | - Dominique Simon
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
| | - Anne Paulsen
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
| | - Laetitia Martinerie
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Institut National de la Santé et de la Recherche Médicale (Inserm), Unité 1141, DHU Protect, Paris, France
| | - Didier Chevenne
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service de Biochimie-Hormonologie, Paris, France
| | - Corinne Alberti
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Unit of Clinical Epidemiology, Paris, France
- Inserm, CIC-EC 1426, Paris, France
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Institut National de la Santé et de la Recherche Médicale (Inserm), Unité 1141, DHU Protect, Paris, France
| | - Sophie Guilmin-Crepon
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du développement, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Unit of Clinical Epidemiology, Paris, France
- Inserm, CIC-EC 1426, Paris, France
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De Pedro S, Murillo M, Salinas I, Granada ML, Martinez M, Puig-Domingo M, Andreu A, Bel J. Variability in adherence to rhGH treatment: Socioeconomic causes and effect on children's growth. Growth Horm IGF Res 2016; 26:32-35. [PMID: 26774403 DOI: 10.1016/j.ghir.2015.12.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 09/28/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In children with growth disorders, mean final height is associated to poor adherence to Growth Hormone therapy. The primary goal of this study is to identify patients who do not adhere to GH therapy and determine the influence of adherence in response to the treatment. The role of serum IGF-I and influence of socio-economic factors on the therapeutic adherence will also be evaluated. METHODS 158 children under treatment with rhGH were included in the study. Age, gender, etiology, Tanner stage, duration of treatment, growth rate, IGF-I serum values, daily dose, and annual rhGH dose data were collected. Adherence to therapy was defined as moderate-to-poor when the patient had taken less than 92% of the prescribed medication. A subgroup of 106 patients completed a questionnaire to assess social and environmental effects. RESULTS Moderate-to-poor adherence to rhGH treatment was determined in 33.5% of study patients. A decrease in adherence was associated to treatment duration (p=0.001). A significant correlation was determined between adherence and height velocity (p=0.002) and IGF-I (p<0.0001) levels. Adherence rates were associated to the mother's educational level (p=0.007). CONCLUSION Poor adherence to GH therapy was observed in one-third of study patients, resulting in suboptimal growth. IGF-I levels can be helpful to identify patients with poor adherence to GH medication. Physicians should pay special attention to certain characteristics of the patient and their environment, and encourage desirable therapeutic compliance.
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Affiliation(s)
- Silvina De Pedro
- Department of Endocrinology and Nutrition, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain.
| | - Marta Murillo
- Department of Pediatric Endocrinology, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - Isabel Salinas
- Department of Endocrinology and Nutrition, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - Maria-Luisa Granada
- Clinical Biochemistry, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - María Martinez
- Department of Pediatric Endocrinology, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - Angels Andreu
- Pharmaceutics Department, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
| | - Joan Bel
- Department of Pediatric Endocrinology, Hospital Universitari "Germans Trias i Pujol" Badalona, Barcelona, Spain
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Fisher BG, Acerini CL. Understanding the growth hormone therapy adherence paradigm: a systematic review. Horm Res Paediatr 2013; 79:189-96. [PMID: 23635797 DOI: 10.1159/000350251] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/25/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Growth hormone (GH) therapy is used to treat a variety of growth disorders in childhood/adolescence. Its efficacy is thought to be dependent on patients' adherence to their treatment regimen. METHODS PubMed was searched using the keywords 'growth hormone', 'child'[Mesh], 'adolescent'[Mesh], and 'patient compliance'[Mesh]. RESULTS Most studies of adherence to paediatric GH therapy have used either issued/encashed GH prescriptions or questionnaires. Estimates of prevalence of non-adherence vary from 5-82%, depending on the methods and definitions used. Different studies have variously demonstrated an association (or lack thereof) between adherence and age, socioeconomic status, treatment duration, injection device used and injection-giver. A number of interventions have been proposed to improve adherence, including offering a choice of injection device, but none are supported by trials. Poor adherence is associated with reduced height velocity and likely increased economic costs; evidence for other effects is circumstantial. CONCLUSION Adherence to paediatric GH therapy is suboptimal, which may partially explain why the mean final height attained is below that of the general population. Analysis of the causes of non-adherence is complicated by conflicting evidence from different studies. Multifactorial interventions are most likely to be successful in improving adherence. We make recommendations for further research.
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Affiliation(s)
- Roberto Lanes
- Pediatric Endocrine Unit, Hospital de Clinicas Caracas, Caracas, Venezuela.
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Lanes R, Boguszewski CL, Calzada R, Cassorla F, Fideleff H, Boquete H. Growth hormone deficiency: transition from adolescence to adulthood. Highlights from a Latin-American Serono Symposia International Foundation Conference. J Pediatr Endocrinol Metab 2010; 23:225-33. [PMID: 20480720 DOI: 10.1515/jpem.2010.23.3.225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Roberto Lanes
- Pediatric Endocrine Unit, Hospital de Clinicas Caracas, Caracas, Venezuela.
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Festen DAM, de Lind van Wijngaarden R, van Eekelen M, Otten BJ, Wit JM, Duivenvoorden HJ, Hokken-Koelega ACS. Randomized controlled GH trial: effects on anthropometry, body composition and body proportions in a large group of children with Prader-Willi syndrome. Clin Endocrinol (Oxf) 2008; 69:443-51. [PMID: 18363884 DOI: 10.1111/j.1365-2265.2008.03228.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prader-Willi syndrome (PWS) children have impaired growth, and abnormal body composition. Previous 1-year controlled studies showed improvement of height and body composition during GH-treatment. OBJECTIVE To evaluate growth, body composition and body proportions during GH-treatment in a large group of PWS children. DESIGN/PATIENTS We performed a randomized controlled GH trial in 91 prepubertal PWS children (42 infants, 49 children, aged 3-14 years). After stratification for age, infants were randomized to GH-treatment (GH-group; 1 mg/m(2)/day; n = 20), or no treatment (control group; n = 22) for 1 year. In the second year all infants were treated with GH. After stratification for BMI, children > 3 years of age were randomized to GH-treatment (GH-group; 1 mg/m(2)/day; n = 27) or no treatment (control group; n = 22) for 2 years. Anthropometric parameters were assessed once in every 3 months. Body composition was measured by Dual Energy X-ray Absorptiometry. RESULTS Median (interquartile range, iqr) height SDS increased during 2 years of GH in infants from -2.3 (-2.8 to -0.7) to -0.4 (-1.1-0.0) and in prepubertal children from -2.0 (-3.1 to -1.7) to -0.6 (-1.1 to -0.1). In non-GH-treated children height SDS did not increase. Head circumference completely normalized during 1 and 2 years of GH in infants and children, respectively. Body fat percentage and body proportions improved in GH-treated children, but did not completely normalize. Lean body mass SDS improved compared to the control group. Serum IGF-I increased to levels above the normal range in most GH-treated children. CONCLUSIONS Our randomized study shows that GH-treatment in PWS children significantly improves height, BMI, head circumference, body composition and body proportions. PWS children are highly sensitive to GH, suggesting that monitoring of serum IGF-I is indicated.
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Fintini D, Alba M, Salvatori R. Influence of estrogen administration on the growth response to growth hormone (GH) in GH-deficient mice. Exp Biol Med (Maywood) 2005; 230:715-20. [PMID: 16246898 DOI: 10.1177/153537020523001004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In women who are growth hormone (GH) deficient, exogenous estrogens increase the dosage of GH that is needed to normalize circulating levels of insulin-like growth factor (IGF-1). Serum IGF-1 derives mostly from the liver, and it is unknown whether the peripheral effects of GH are also impaired by estrogens. Because the ultimate effect of GH is longitudinal growth, we have investigated the influence of estrogen administration on the growth response to recombinant mouse GH therapy in prepubertal GH-deficient (GHD) GHRH knockout (GHRHKO) female mice. Twenty-four GHRHKO female mice (4 animals/group) were treated for 4 weeks (from the second to sixth week of age) with the following schedules: Group I, GH only (25 microg/day); Group II, subcutaneous (sc) ethynil estradiol (EE) (0.035 ES01247g/day); Group III, GH + scEE; Group IV, oral (po) EE (0.035 microg/day); Group V, GH + poEE; Group VI, placebo. At the end of the treatment period, we measured uterine weight, total body weight (TBW), body length (nose-anus, N-A), and femur length. In addition, serum IGF-1 levels were measured. Uteri of mice treated with oral or scEE showed similar increases in weight. There was no difference in the increase in longitudinal growth parameters between mice treated with GH alone or with GH in association with oral or scEE. Serum IGF-1 decreased in animals treated with GH + scEE, compared with GH group, but no group was significantly different from placebo. These results show that subcutaneous or oral EE does not reduce the growth response to GH in female GHD mice.
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Affiliation(s)
- Danilo Fintini
- Department of Medicine, Division of Endocrinology, Ilyssa Center for Molecular and Cellular Endocrinology, Johns Hopkins University, Baltimore, MD 21287, USA
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Abstract
For almost two decades, recombinant growth hormone (GH) has been in abundant supply to treat GH-deficient subjects to final height, yet the results continue to be suboptimal. Although there are numerous potential causes for this underachievement, the issues of poor compliance, ineffective dosing and lack of efficacy monitoring have been frequently promulgated to explain the phenomenon. Compliance is tied to knowledge, which is best promoted at the time of diagnosis by hospital-based personnel. GH pens have improved acceptability, but data on improvement in compliance are lacking. No GH device or delivery system has yet been shown to increase final height. Daily (or six times per week) dosing is clearly more effective, but increasing GH dose, especially during puberty, has a tendency to advance bone age and pubertal progression, which mitigates many of the effects. Finally, titration of dose to the insulin-like growth factor (IGF)-I level may prove to be useful in promoting final height; however, the converse is not true, i.e. increments in IGF-I level have not been shown to correlate with increments in height velocity. Thus, these issues with respect to achievement of final height are far from solved.
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Affiliation(s)
- Robert H Lustig
- Division of Endocrinology, Department of Pediatrics, University of California, San Francisco, CA 94143-0434, USA.
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Pandian R, Nakamoto JM. Rational use of the laboratory for childhood and adult growth hormone deficiency. Clin Lab Med 2004; 24:141-74. [PMID: 15157561 DOI: 10.1016/j.cll.2004.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
No laboratory test has sufficient diagnostic sensitivity and specificity to serve as a gold standard for the diagnosis for GHD: therefore, test results must be interpreted after assessment of risk for GHD is determined on clinical grounds. Growth data are particularly crucial for diagnosis of childhood GHD;history of known pituitary damage and presence or absence of other pituitary hormone deficiencies are the critical elements for the diagnosis of adult GHD. New reference preparations are available for GH and IGF-I and should greatly aid interassay comparisons when the preparations are universally adopted.GH stimulation testing remains a key part of the diagnosis of adult GHD, but is currently being de-emphasized for the diagnosis of pediatric GHD. Better interassay comparative data and organized clinical collaboration between clinicians and test manufacturers/laboratories to set rational clinical diagnostic cutoffs would improve greatly the clinical usefulness of GH stimulation testing. The availability of statistically sound age- and sex-related normative data for IGF-I and IGFBP3 make these key tests for the diagnosis of childhood GHD. Although IGF-I may not be a perfect test for the diagnosis of adult GHD, it may be sufficiently informative in many cases to warrant using it ona routine basis. IGF-I also has a role in monitoring the safety of adult patients who are on GH treatment; studies are underway to determine if IGF-I may be useful in the future for optimization of GH dosaging.
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Affiliation(s)
- Raj Pandian
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA 92690, USA.
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Bercu BB. Titration of growth hormone dose using insulin-like growth factor-1 measurements: is it feasible in children? J Pediatr 2002; 141:601-5. [PMID: 12410184 DOI: 10.1067/mpd.2002.129480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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