A monocentric experience of growth hormone replacement therapy in adult patients

Stable bone density in adolescents with severe growth hormone deficiency after six months off rhGH

OBJECTIVE

Severe growth hormone deficiency causes lean body mass loss in male adolescents and increased fat mass in both sexes. The changes appear after a 6 month GH pause.

AIM

The aim was to examine bone density and structure changes in adolescents with severe GHD during a 6-month rhGH treatment interruption.

PATIENTS AND METHODS

In total, 113 adolescents (20 females) paused rhGH treatment for 6 months at near-final height, and they were retested with arginine-GHRH challenge and basal IGF-1. Severe GHD was diagnosed in 19 individuals (5 females, GH peak <16 ng/ml and IGF-1 < -1.9 SDS) and excluded in 94 (15 females). Bone density and structure were measured by pQCT of the forearm and DXA of the total body at cessation of rhGH and 6 months later.

RESULTS

In severe adolescent GHD (sGHD) patients, trabecular density (mg/cm³) decreased from 214 to 202 (p < 0.01); changes in the adolescents with normal test results (tGHD) were from 221 to 214 (p < 0.05). Cortical density (mg/cm³) increased from 1077 to 1099 (p < 0.01) in sGHD patients and from 1060 to 1082 in tGHD patients (p < 0.001). The strength strain index (mm³) showed no significant changes in sGHD patients (306 to 307) but changed from 302 to 315 in tGHD patients (p < 0.05). Total bone area (mm²) shifted from 145.1 to 145.2 in sGHD patients and from 153 to 156 in tGHD patients. Total body aBMD (g/cm²) increased in both groups: from 1.10 to 1.12 in sGHD patients and from 1.11 to 1.14 in tGHD patients (p < 0.01). All bone measurements remained within the reference ranges, and there were no differences between sGHD and tGHD patients.

CONCLUSION

During a 6-month pause of rhGH treatment, the bone structure and density of adolescents with sGHD did not show changes implying harm. Routine retesting of adolescents, including 6 months without GH, is unlikely to be detrimental to the bone.

Physician' attitudes to growth hormone replacement therapy in adults following pituitary surgery: Results of an online survey

OBJECTIVE

The aim of this study was to evaluate physician attitudes and practices in the management of adult growth hormone deficiency (GHD) following pituitary surgery.

MATERIALS AND METHODS

An online questionnaire survey was sent to a sample group of physicians.

RESULTS

A total of 131 respondents provided usable responses. More than three quarters were senior physicians, with most practicing in tertiary care centers (73%). Four-fifths of the respondents see at least 1 to 5 patients with GHD following pituitary surgery per year. Seventy-four percent acknowledge the benefit in principle of growth hormone replacement therapy (GHRT) for patients with GHD after pituitary surgery. Most respondents (84%) would only consider GHRT for symptomatic patients. However, 16% stated that patients with GHD after pituitary surgery generally suffer from the side effects of GHRT. Forty-four percent said that the serum insulin-like growth factor-1 (IGF-1) level is the best screening test for assessing GHD after pituitary surgery but 57% of the respondents would use IGF-I levels, and 29% the insulin tolerance test (ITT), in patients with a documented deficiency in three pituitary axes. The main barriers to long-term GHRT use were that it requires injections (67%), and is costly with limited supply (61%). Other reasons not to use GHRT include an absence of GHD symptoms and apparent GHT ineffectiveness (44%), physician lack of familiarity with the medication (40%), and lack of adherence to available guidelines (38%).

CONCLUSION

This survey addressed physician attitudes and practices in recognizing and treating GHD in adult's post-pituitary surgery. Regional guidelines must be developed to help address/tackle these issues and assist physicians in understanding and treating this condition.

Adult growth hormone deficiency: clinical advances and approaches to improve adherence

Introduction: There have been significant clinical advances in the understanding of the diagnosis and benefits of long-term recombinant human growth hormone (rhGH) replacement in adults with GH deficiency (GHD) since its approval in 1996 by the United States Food and Drug Administration.Areas covered: We searched PubMed, Medline, CINAHL, EMBASE and PsychInfo databases between January 2000 and June 2019 for published studies evaluating adults with GHD. We reviewed the data of the oral macimorelin test compared to the GHRH plus arginine and the insulin tolerance tests that led to its approval by the United States FDA and European Medicines Agency for adult diagnostic testing. We summarize the clinical advances of long-term benefits of rhGH therapy and the potential effects of GH receptor polymorphisms on individual treatment responsiveness. We identify that non-adherence and discontinuation rates are high and recommend strategies to support patients to improve adherence. We also provide an overview of several long-acting GH (LAGH) preparations currently under development and their potential role in improving treatment adherence.Expert opinion: This article summarizes recent clinical advances in rhGH replacement therapy, the biological and molecular aspects that may influence rhGH action, and offers practical strategies to enhance adherence in adults with GHD.

Adherence, Attitudes and Beliefs of Growth Hormone Deficient Patients - A Questionnaire-based Cohort Study

INTRODUCTION

GHD is a chronic and systemic disease requiring daily replacement of growth hormone (GHRT). Adherence and attitudes of adult GHD patients are not well known. We sought to assess patients' knowledge of growth hormone deficiency (GHD) in association with treatment adherence and attitudes regarding available and upcoming treatment options.

METHODS

We performed a cross-sectional survey with a custom-made questionnaire at a single centre assessing data on demographics, knowledge of GHD, adherence and attitudes towards GHRT.

RESULTS

Of 106 eligible patients actively followed for GHD 70 returned the completed survey (return-rate 66%, 34 m/36 f; age 56±14 years). 46 patients were actively treated, but almost one third (n=24) refused GHRT. 12 patients had participated in clinical trials with LAGH (long-acting growth hormone). Overall, patients with GHRT showed good adherence. Patients refusing GHRT mostly feared side effects and/or had a lack of information/perceived effect. Disease knowledge and level of education were higher in treated than untreated patients (p=0.023/0.017). Only 36% of respondents would initiate treatment with LAGH. Patients with prior LAGH experience and patients with childhood-onset GHD were more likely to adopt LAGH (p=0.048/0.031).

DISCUSSION

Most often, misinformation causes patients to refuse GHRT. Possibly the understanding of their condition and consequences of non-treatment is limited. To improve adherence more focused educational and behavioural strategies may be needed. Willingness to begin a therapy with LAGH was lower than expected (36%). The reasons for reluctance against LAGH need to be elucidated.

Is insulin-like growth factor-I a good marker for treatment adherence in growth hormone deficiency in adulthood?

OBJECTIVE

There is a paucity of studies on adherence to growth hormone treatment in growth hormone deficient (GHD) adults. Therefore, this study reports on adherence to GH-replacement therapy in adults with GHD, with a special focus on the course and potential predictors of nonadherence.

DESIGN

Retrospective single-centre cohort study.

PATIENTS

From the local patient database, 179 suitable patients with GHD were identified.

MEASUREMENTS

The primary outcome was adherence assessed by calculating the percentage of available prescription data in comparison with recommended GH dosages over a mean follow-up period of 92·4 months. Patients were categorized into five adherence categories ranging from <20% to >80%.

RESULTS

Mean overall adherence was 74·0%, with 52·9% of patients falling into the adherence group of >80% and 8·8% of <20%. There was a significant drop in adherence (9·8%) between the first and second years of treatment (P < 0·001). Patients with childhood-onset GHD were significantly less adherent to GH treatment than patients with adult-onset GHD (62·0% vs 77·0%, P = 0·012); however, this finding was no longer significant after including age as a covariate. Frequency of IGF-1 levels lying outside the age- and sex-specific reference range was not a good indicator for adherence.

CONCLUSION

Although overall adherence was relatively high in our study sample, there is a significant amount of patients who should be regarded as nonadherent. This applies in particular to younger patients. Treating physicians should be aware of the fact that IGF-1 levels do not seem to be a good indicator for adherence.