Response to growth hormone therapy in Indian patients

An Observational Study on Response to Growth Hormone Therapy in Indian Patients of Short Stature with Special Emphasis on Biochemical Parameters and Bone Biomarkers

Introduction

There is a lack of Indian data on short stature treatment using recombinant human growth hormone (rhGH). We explored the effects of such treatment in eastern Indian patients, with emphasis on biochemical parameters and bone biomarkers in addition to basic anthropometry.

Methods

Our descriptive study covered 50 short stature patients of varied aetiology attending endocrine outpatient department (OPD) of a tertiary care teaching hospital. Patients were followed up for 1 year after the index visit, and prospective data were reconciled with past medical records. A dose of rhGH used was 0.18-0.375 mg/kg as standard, starting dose mostly being 0.2 mg/kg. Dosing was adjusted if the physician judged the clinical outcome to be less favourable than expected. Anthropometric parameters (height, weight, body mass index (BMI) and skeletal age) were recorded clinically, and various biochemical parameters and bone biomarkers were estimated from blood.

Results

Among 50 subjects, 60% had idiopathic growth hormone (GH) deficiency and 26% had Turner's syndrome. The median age at treatment start was 10 years, and the median treatment duration was 25.5 months. The height increased more in the first year of therapy. In the last 6 months, the height velocity was approximately 0.5 cm/month. Although the weight increased significantly, the increment slowed down in the last 6 months. Both remained less than age- and gender-matched references throughout. The skeletal age was on average 2 years behind chronological age (CA)-being 8.7, 9.6 and 11.3 years, respectively, at therapy start, after one year and at study end. Fasting blood glucose (FBG), total cholesterol and calcium level changes were not statistically significant. Serum cortisol and phosphate showed a modest but statistically significant rise, while thyroid-stimulating hormone (TSH) level declined. Insulin-like growth factor 1 (IGF-1) increase was relatively pronounced. Among bone biomarkers, a decrease in CTx and an increase in vitamin D were significant. Dual-energy X-ray absorptiometry (DEXA) data indicated that bone mineral density was less than that of age-matched controls despite treatment. The therapy was well tolerated.

Conclusions

rhGH treatment leads to significant improvement in anthropometry in Indian children comparable with Western data. Bone biomarker changes indicate decreased bone resorption and increased bone formation although bone mineral density still lags behind age-matched controls.

Management of Short Stature: Use of Growth Hormone in GH-Deficient and non-GH-Deficient Conditions

Growth hormone (GH) is an important driver for somatic growth and increase in height in children. The development of recombinant human GH has greatly increased its availability, and hence the potential for its use and abuse. GH therapy should only be offered to patients with established and approved indications. Common pediatric indications for treatment include growth hormone deficiency, Turner syndrome, Prader-Willi syndrome, small for gestational age, chronic renal insufficiency, and idiopathic short stature. Before initiating treatment, the family should be counseled about the treatment goals, costs, and possible adverse effects from the treatment. It is important for patients to have realistic expectations from the treatment. The dose of GH should be individualized for the indication and will require titration in each patient based on response to the treatment and the adverse effects. Overall, GH has a good safety record. However, GH treatment has many potential and real adverse effects that need to be considered and monitored during treatment. Recently, safety concerns regarding the long-term effect of GH therapy on cardiovascular morbidity have come under scrutiny.

Effects of Early Initiation of Growth Hormone Therapy on Different Auxological Parameters in Growth Hormone Deficient Children: Experience from an Indian Tertiary Care Center

OBJECTIVES

The aim of the study was to evaluate the efficacy of early initiation versus late growth hormone in improving the predicted adult height in growth hormone deficiency (GHD) children.

METHODS

A retrospective study of 550 GHD children with short stature, who had taken rGH for duration of minimum 12 months were included. They were divided into groups of less than 8 years and more than 8 years of age based on the initiation of growth hormone therapy. Their pretreatment and post-treatment auxological parameters were evaluated.

RESULTS

There were 148 children in less than 8 years group and 402 children in more than 8 years old group. In 8 years or younger age group, the pre-treatment mean height of -2.015 SDS improved to -0.7753 SDS after one year of treatment. There was an improvement in the mean height from -2.0447 SDS to -1.2658 SDS post-treatment in more than 8 years group. The pre- and post-treatment difference between the Z score of height, weight, and BMI were statistically significant (<0.001).

CONCLUSION

A significant height improvement occurred in both the groups' children after 1 year of GH treatment but the gain in final adult height was better when initiated less than 8 years of age. No significant side effects were noted during this period.

Long-term Response to Recombinant Human Growth Hormone Therapy in Indian Children with Growth Hormone Deficiency

BACKGROUND

Growth hormone deficiency (GHD) remains the most common indication for use of recombinant human growth hormone (rhGH) therapy in clinical practice. However, there is a paucity of studies focusing on long-term response to rhGH therapy in the Indian context.

AIM

To determine the response to rhGH therapy and its predictors in children with GHD followed up at a tertiary care center in North India.

MATERIALS AND METHODS

We performed a retrospective review of the records of children with GHD who received rhGH therapy for at least 1 year. The relevant anthropometric, biochemical and radiological data at baseline and follow-up were recorded.

RESULTS

A total of 99 children (64 boys, 35 girls; 61 isolated GHD, 38 multiple pituitary hormone deficiency) were studied. The mean (±SD) age and height SDS at treatment initiation were 12.4 (±3.0) years and -4.0 (±1.1) respectively, while median (IQR) serum insulin-like growth factor 1 (IGF-1) and peak growth hormone level on clonidine stimulation were 73 (25-167) ng/ml and 1.1 (0.4-3.6) ng/ml respectively. The height velocity was highest during the first year of treatment (10.6 ± 3.0 cm/year), declining to 8.7 ± 2.7 and 7.9 ± 2.2 cm/year during second and third year, respectively. Over the subsequent years, there was further graded fall in height velocity, declining to 4.8 ± 3.6 cm/year (n = 2) during the seventh year. The height gain during first year was negatively correlated with age at initiation of treatment, baseline height SDS, baseline serum IGF-1 and peak serum GH level on GH stimulation test, while it showed a positive correlation with bone age delay at baseline. Only baseline height SDS was found to have a significant negative correlation with height gain during the second year.

CONCLUSIONS

This study provides data on long-term response to rhGH therapy and its predictors in Indian children with GHD.

Challenges in the Diagnosis and Management of Growth Hormone Deficiency in India

In clinical practice, every year approximately 150,000 children are referred with short stature (SS) based on a cut-off of fifth percentile. The most important endocrine and treatable cause of SS is growth hormone deficiency (GHD). The lack of reliable data on the prevalence of GHD in India limits estimation of the magnitude of this problem. The diagnosis and treatment of GHD are hurdled with various challenges, restricting the availability of growth hormone (GH) therapy to only a very limited segment of the children in India. This review will firstly summarize the gaps and challenges in diagnosis and treatment of GHD based on literature analysis. Subsequently, it presents suggestions from the members at advisory board meetings to overcome these challenges. The advisory board suggested that early initiation of the therapy could better the chances of achieving final adult height within the normal range for the population. Education and awareness about growth disorders among parents, regular training for physicians, and more emphasis on using the Indian growth charts for growth monitoring would help improve the diagnosis and treatment of children with GHD. Availability of an easy-to-use therapy delivery system could also be beneficial in improving adherence and achieving satisfactory outcomes.

Clinical spectrum of hypopituitarism in India: A single center experience

OBJECTIVES

There is paucity of information regarding clinical profile of hypopituitarism from India. We report the clinical profile of hypopituitarism from a tertiary center in North India.

MATERIALS AND METHODS

This study was carried out in patients attending our endocrine center between January 2010 and December 2011. All new patients were studied prospectively and those registered before January 2010 retrospectively. Relevant clinical, hormonal, and imaging data were collected. Dynamic testing for pituitary functions was carried out as necessary. Hormonal deficiencies were defined as per prevailing recommendations.

RESULTS

This study included 113 subjects. The mean age was 38.6 ± 17.8 years (range, 4 - 76 years). There were 78 (69%) males and 35 females (31%). There were 22 subjects aged ≤18 years (childhood and adolescence) and 91 adults (>18 years). Visual disturbances were the most common presenting complaint (33%), though headache was the most common symptom (81%). Fifteen percent presented with pituitary apoplexy. Tumors comprised of 84% of cases. Hypogonadism (97%) was the most common abnormality seen followed by hypothyroidism (83.2%), hypoadrenalism (79.6%), growth hormone deficiency (88.1% of the 42 patients tested), and diabetes insipidus (13.3%). Panhypopituitarism was seen in 104 (92%) patients. There were no cases of hypopituitarism secondary to traumatic brain injury, subarachnoid hemorrhage, central nervous system infections, or cranial irradiation to extrasellar tumors.

CONCLUSION

The most common cause of hypopituitarism at tertiary care center is pituitary tumors and the commonest presenting complaint is visual symptoms. Panhypopituitarism is present in 92% cases.