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Yuen KCJ, Blevins LS, Clemmons DR, Faurby M, Hoffman AR, Kelepouris N, Kerr JM, Tarp JM, Fleseriu M. Medical Costs Associated with High/Moderate/Low Likelihood of Adult Growth Hormone Deficiency: A Healthcare Claims Database Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:133-147. [PMID: 38476578 PMCID: PMC10929649 DOI: 10.2147/ceor.s445495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Purpose Adult growth hormone deficiency (AGHD) is often underdiagnosed and undertreated, leading to costly comorbidities. Previously, we developed an algorithm to identify individuals in a commercially insured US population with high, moderate, or low likelihood of having AGHD. Here, we estimate and compare direct medical costs by likelihood level. Patients and Methods Retrospective, observational analysis using the Truven Health MarketScan database to analyze direct medical costs relating to inpatient and outpatient claims, outpatient prescription claims, medication usage, clinical utilization records, and healthcare expenditures. Patients were categorized into groups based on algorithmically determined likelihoods of AGHD. Likelihood groups were further stratified by age and sex. Trajectories of annual costs (USD) by likelihood level were also investigated. Results The study cohort comprised 135 million US adults (aged ≥18 years). Individuals ranked as high-likelihood AGHD had a greater burden of comorbid illness, including cardiovascular disease and diabetes, than those ranked moderate- or low-likelihood. Those in the high-likelihood group had greater mean total direct medical monthly costs ($1844.51 [95% confidence interval (CI): 1841.24;1847.78]) than those in the moderate- ($945.65 [95% CI: 945.26;946.04]) and low-likelihood groups ($459.10 [95% CI: 458.95;459.25]). Outpatient visits accounted for the majority of costs overall, although cost per visit was substantially lower than for inpatient services. Costs tended to increase with age and peaked around the time that individuals were assigned a level of AGHD likelihood. Total direct medical costs in individuals with a high likelihood of AGHD exceeded those for individuals with moderate or low likelihood. Conclusion Understanding the trajectory of healthcare costs in AGHD may help rationalize allocation of healthcare resources.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
| | - Lewis S Blevins
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - David R Clemmons
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mads Faurby
- Global Evidence, Pricing and Access, Novo Nordisk A/S, Søborg, Denmark
| | | | - Nicky Kelepouris
- Department of Medical Affairs BioPharm, CMR, Novo Nordisk Inc., Plainsboro, NJ, USA
| | - Janice M Kerr
- Department of Endocrinology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | | | - Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
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Ratku B, Sebestyén V, Erdei A, Nagy EV, Szabó Z, Somodi S. Effects of adult growth hormone deficiency and replacement therapy on the cardiometabolic risk profile. Pituitary 2022; 25:211-228. [PMID: 35106704 PMCID: PMC8894188 DOI: 10.1007/s11102-022-01207-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 12/12/2022]
Abstract
Adult growth hormone deficiency (AGHD) is considered a rare endocrine disorder involving patients with childhood-onset and adult-onset growth hormone deficiency (AoGHD) and characterized by adverse cardiometabolic risk profile. Besides traditional cardiovascular risk factors, endothelial dysfunction, low-grade inflammation, impaired adipokine profile, oxidative stress and hypovitaminosis D may also contribute to the development of premature atherosclerosis and higher cardiovascular risk in patients with AGHD. Growth hormone replacement has been proved to exert beneficial effects on several cardiovascular risk factors, but it is also apparent that hormone substitution in itself does not eliminate all cardiometabolic abnormalities associated with the disease. Novel biomarkers and diagnostic techniques discussed in this review may help to evaluate individual cardiovascular risk and identify patients with adverse cardiometabolic risk profile. In the absence of disease-specific guidelines detailing how to assess the cardiovascular status of these patients, we generally recommend close follow-up of the cardiovascular status as well as low threshold for a more detailed evaluation.
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Affiliation(s)
- Balázs Ratku
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, Egyetem tér 1, Debrecen, 4032, Hungary
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary
- Department of Emergency and Oxyology, Faculty of Health, University of Debrecen, Debrecen, Hungary
| | - Veronika Sebestyén
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, Egyetem tér 1, Debrecen, 4032, Hungary
- Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Annamária Erdei
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Endre V Nagy
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szabó
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, Egyetem tér 1, Debrecen, 4032, Hungary
| | - Sándor Somodi
- Department of Emergency Medicine, Faculty of Medicine, University of Debrecen, Egyetem tér 1, Debrecen, 4032, Hungary.
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Heaney A, de Oliveira RWR, Bizzi M, Correa RA, Corso Pereira M, Simao Mol S, Santana Soares B, McKenna SP, Ribeiro-Oliveira A. Assessment of the performance of the Brazilian Portuguese Nottingham Health Profile in adult growth hormone deficiency and pulmonary hypertension. F1000Res 2021; 9:1399. [PMID: 34621522 PMCID: PMC8447051 DOI: 10.12688/f1000research.27748.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The Nottingham Health Profile (NHP) is a generic measure of perceived distress that has been used widely as an outcome measure in clinical practice and trials. The availability of two Brazilian datasets provided the opportunity to assess the psychometric performance of the NHP in different populations - adult growth hormone deficiency (GHD) and pulmonary hypertension (PH). The purpose of the study was to see how valuable the NHP could be in assessing outcomes in diseases where no disease-specific measures are available. Methods: Secondary analyses were performed with NHP data. Patients diagnosed with adult GHD or PH were administered the NHP during clinic visits on two occasions, two weeks apart. A disease-specific measure of quality of life (QoL) was also administered to the relevant sample of patients on each occasion. Results: The psychometric properties of the NHP were good for both disease groups. As expected, both samples reported high scores on energy level, the PH sample scored high on physical functioning and the GHD sample on emotional reactions. For both samples, most of the NHP sections were able to distinguish between groups of respondents with different ratings of perceived general health. While most sections of the NHP were relatively highly correlated with the QoL measures, pain and sleep did not seem to be important predictors of QoL in either of the samples. Conclusions: The use of the NHP in adult GHD and PH populations in Brazil is not recommended as there are high-quality disease-specific measures available for each disease. However, where no disease-specific measures are available, the NHP can provide good descriptive information of the impact of disease on different patient populations.
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Affiliation(s)
| | - Rafael W R de Oliveira
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Mariana Bizzi
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Ricardo Amorim Correa
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Monica Corso Pereira
- Department of Internal Medicine, State University of Campinas, Campinas, Sao Paulo, Brazil
| | - Suelem Simao Mol
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Beatriz Santana Soares
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Stephen P McKenna
- Galen Research Ltd, Manchester, UK.,School of Health Sciences, University of Manchester, Manchester, UK
| | - Antonio Ribeiro-Oliveira
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Ricci Bitti S, Franco M, Albertelli M, Gatto F, Vera L, Ferone D, Boschetti M. GH Replacement in the Elderly: Is It Worth It? Front Endocrinol (Lausanne) 2021; 12:680579. [PMID: 34211437 PMCID: PMC8239420 DOI: 10.3389/fendo.2021.680579] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022] Open
Abstract
Growth hormone (GH), once the age of linear growth is completed, continues to play a fundamental role for the human body. In adulthood, GH contributes to regulate muscle, cardiovascular and bone metabolism. The same happens in old age, although there is less data on the effect of GH in the elderly. Regardless the age of onset, a reduced quality of life (QoL), an increased cardiovascular risk and an accelerated age-related decline in physical strength have been demonstrated in the elderly with GH deficiency (EGHD). In adults with GH deficiency (AGHD), recent studies suggest a role of GH replacement therapy (GHrt) in improving lean/fat mass ratio, blood pressure, lipid profile, bone metabolism and QoL. Despite these recent studies, there is still a lack of randomized controlled trials proving these positive effects in EGHD. Moreover, the lack of a long-term positive outcome on mortality, and the cost of GHrt could often impact on treatment decision-making and lead to postpone or avoid the prescription. The aim of this mini-review is to summarize the available data on GHrt in EGHD, in order to highlight its weaknesses and strengths and to provide directions to clinicians that will help in the management of this specific set of patients.
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Affiliation(s)
- Silvia Ricci Bitti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Marta Franco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Manuela Albertelli
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | - Federico Gatto
- Endocrinology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | - Lara Vera
- Endocrinology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Endocrinology Unit, IRCCS Policlinico San Martino, Genova, Italy
- *Correspondence: Mara Boschetti,
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Bensalah M, Donaldson M, Labassen M, Cherfi L, Nebbal M, Haffaf EM, Abdennebi B, Guenane K, Kemali Z, Ould Kablia S. Prevalence of hypopituitarism and quality of life in survivors of post-traumatic brain injury. Endocrinol Diabetes Metab 2020; 3:e00146. [PMID: 32704567 PMCID: PMC7375098 DOI: 10.1002/edm2.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 04/08/2020] [Accepted: 04/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hypopituitarism is a recognized sequela of traumatic brain injury (TBI) and may worsen the quality of life (QoL) in survivors. AIMS To assess the prevalence of post-traumatic hypopituitarism (PTHP) and growth hormone deficiency (GHD), and determine their correlation with QoL. METHODS Survivors of moderate to severe TBI were recruited from two Algerian centres. At 3 and 12 months, pituitary function was evaluated using insulin tolerance test (ITT), QoL by growth hormone deficiency in adults' questionnaire (QoL-AGHDA), and 36-item short-form (SF-36) health survey. RESULTS Of 133 (M: 128; F: 5) patients aged 18-65 years, PTHP and GHD were present at 3 and 12 months in 59 (44.4%) and 23 (17.29%), 41/116 (35.3%) and 18 (15.5%). Thirteen patients with GHD at 3 months tested normally at 12 months, while 9 had become GHD at 12 months. At 3 and 12 months, peak cortisol was < 500 nmol/L) in 39 (29.3%) and 29 (25%) patients, but <300 nmol/L in only five and seven. Prevalence for gonadotrophin deficiency was 6.8/8.6%, hypo- and hyperprolactinaemia 6.8/3.8% and 5.2/8.6%, and thyrotrophin deficiency 1.5/0.9%. Mean scores for QoL-AGHDA were higher in patients with PTHP at 3 and 12 months: 7.07 vs 3.62 (P = .001) and in patients with GHD at 12 months: 8.72 vs 4.09 (P = .015). Mean SF-36 scores were significantly lower for PTHP at 3 months. CONCLUSION Prevalence of PTHP and GHD changes with time. AGHDA measures QoL in GHD more specifically than SF-36. Full pituitary evaluation and QoL-AGHDA 12 months after TBI are recommended.
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Affiliation(s)
| | | | - Malek Labassen
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
| | - Lyes Cherfi
- Critical Care UnitCentral Hospital of ArmyAlgiersAlgeria
| | | | | | | | - Kamel Guenane
- Critical care UnitSalim Zemirli HospitalAlgiersAlgeria
| | - Zahra Kemali
- Endocrinology UnitCentral Hospital of ArmyAlgiersAlgeria
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Webb SM, Santos A, Aulinas A, Resmini E, Martel L, Martínez-Momblán MA, Valassi E. Patient-Centered Outcomes with Pituitary and Parasellar Disease. Neuroendocrinology 2020; 110:882-888. [PMID: 32101858 DOI: 10.1159/000506809] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Abstract
Over the last 2 decades, advances in the diagnosis and management of pituitary diseases have made it possible to attain an endocrine "cure" in a large proportion of patients. In other words, tumors can be excised or controlled with drugs, mass effects of the lesion on surrounding structures can be solved, and pituitary deficiencies can be substituted with all relevant hormones. While this is considered a satisfactory outcome for health care providers, patients often suffer from an aftermath of prior endocrine dysfunction exposure, with irreversible effects, both physically and psychologically, which have a great impact on their everyday life. Diagnostic delay, often of several years, adds a negative impact on health perception. This affects their social, professional, and family domains and determines their future life. Understanding that this may occur is important, and health care providers should offer information to prepare the patient for this difficult journey, especially in the case of acromegaly, Cushing disease, or hypopituitarism. In order to maintain a good quality of life (QoL) in the long-term, patients need to adapt to this new situation, something that may be difficult, since they often cannot continue with all the activities and rhythm they used to do. Depression is often the consequence of maladaptation to the new situation, leading to impaired QoL.
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Affiliation(s)
- Susan M Webb
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain,
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain,
| | - Alicia Santos
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Aulinas
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Eugenia Resmini
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Luciana Martel
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain
| | - María-Antonia Martínez-Momblán
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Department of Fundamental and Medico-Surgical Nursing, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Elena Valassi
- Department of Medicine/Endocrinology, IIB-Sant Pau, Hospital Sant Pau, Research Center for Pituitary Diseases, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Loftus J, Camacho-Hubner C, Hey-Hadavi J, Goodrich K. Targeted literature review of the humanistic and economic burden of adult growth hormone deficiency. Curr Med Res Opin 2019; 35:963-973. [PMID: 30411985 DOI: 10.1080/03007995.2018.1546682] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Quality of life (QoL) and health economic data are becoming increasingly important factors in healthcare decision making. While there is a wealth of information establishing the benefit of growth hormone (GH) replacement therapy in adults with growth hormone deficiency (aGHD), recent reviews on the QoL and health economic impact of aGHD and the effect of treatment on these factors is limited. OBJECTIVE The aim of this article is to summarize the impact of early and sustained treatment on the QoL and economic burden of aGHD by conducting a targeted literature review. METHODS Standard electronic databases, including PubMed and the Cochrane collaboration website, were searched for publications between January 2006 and July 2016 for evidence of the humanistic and economic burden of aGHD. Search terms included growth hormone deficiency, health-related quality of life, HRQoL, patient-reported outcomes, outcome assessment, well-being and adherence. RESULTS The literature search identified 732 initial hits and a final 14 publications were included. The analysis showed that the economic burden of aGHD is largely driven by the productivity losses associated with the disease. This is because most patients with aGHD are of working age and the QoL domains (memory & concentration and energy & vitality) most commonly affected by aGHD severely impair a person's ability to work and may limit their contribution to society. CONCLUSION Untreated aGHD can seriously affect patients' functioning. Early and continued treatment with GH replacement therapy could potentially improve the QoL and reduce the economic burden associated with aGHD. This review has limitations: only English language articles published since January 2006 were included and many of the studies were conducted in the Nordic countries; it is unclear how representative these studies are of the population as a whole. This was a literature review and not a systematic review, as it was thought to be unlikely that, in this rare disease, any additional publications would have been identified. Overall, this review reveals a paucity of data in this underserved population and points to research gaps which could be addressed with new studies.
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Webb SM. Clinical outcomes of childhood craniopharyngioma: can we do better? Endocrine 2018; 62:1-2. [PMID: 29934877 DOI: 10.1007/s12020-018-1654-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/12/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Susan M Webb
- Department of Endocrinology/Medicine, CIBERER U747, ISCIII, Research Center for Pituitary Diseases, Hospital S Pau, IIB-SPau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Abstract
Over the last three decades, short- and long-term observational studies, clinical trials, systematic reviews, and meta-analyses have provided relevant information on the efficacy and safety of growth hormone (GH) replacement therapy in adults with GH deficiency (AGHD). The knowledge acquired during this time has been compiled into different guidelines that offer clinicians an evidence-based, practical approach for the management of AGHD. There are, however, still open questions in some key areas in which recommendations are supported by only moderate or weak evidence. In the last recent years, the development of long-acting GH preparations has created new therapeutic possibilities by decreasing injection frequency, improving adherence and thereby potentially maximizing clinical outcomes. The aims of this review are to advance our understanding on the diagnosis and treatment of AGHD and to present an update and future perspectives on the use of long-acting GH preparations.
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Affiliation(s)
- Cesar Luiz Boguszewski
- Endocrine Division (SEMPR), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
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Webb SM, Crespo I, Santos A, Resmini E, Aulinas A, Valassi E. MANAGEMENT OF ENDOCRINE DISEASE: Quality of life tools for the management of pituitary disease. Eur J Endocrinol 2017; 177:R13-R26. [PMID: 28351913 DOI: 10.1530/eje-17-0041] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/07/2017] [Accepted: 03/28/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND In the last few years, quality of life (QoL) has become an outcome measure in patients with pituitary diseases. OBJECTIVE To describe the available data on QoL impairment evaluated with questionnaires in patients with pituitary diseases. DESIGN Critical review of the pertinent literature and pragmatic discussion of available information. METHODS Selection of relevant literature from PubMed and WOK, especially from the last 5 years and comprehensive analysis. RESULTS QoL is impaired in all pituitary diseases, mostly in acromegaly and Cushing's disease (similar to other causes of Cushing's syndrome), but also in non-functioning pituitary adenomas and prolactinomas, especially in the active phase of the disease. Nevertheless, even after endocrine 'cure', scores tend to be below normative values, indicative of residual morbidity after hormonal control. The presence of hypopituitarism worsens subjective QoL perception, which can improve after optimal substitution therapy, including recombinant human growth hormone, when indicated. CONCLUSIONS To improve the long-term outcome of pituitary patients, helping them to attain the best possible health, it appears desirable to include subjective aspects captured when evaluating QoL, so that the affected dimensions are identified and if relevant treated. Additionally, being aware that treatment outcome may not always mean complete normalisation of physical and mental issues related to QoL can be a first step to adaptation and conforming to this new status.
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Affiliation(s)
- Susan M Webb
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Iris Crespo
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Alicia Santos
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Eugenia Resmini
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Aulinas
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Elena Valassi
- Hospital Sant PauIIB-Sant Pau, Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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11
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Elbornsson M, Horvath A, Götherström G, Bengtsson BÅ, Johannsson G, Svensson J. Seven years of growth hormone (GH) replacement improves quality of life in hypopituitary patients with adult-onset GH deficiency. Eur J Endocrinol 2017; 176:99-109. [PMID: 27803031 DOI: 10.1530/eje-16-0875] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 11/01/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Few studies have determined the effects of long-term growth hormone (GH) replacement on quality of life (QoL). This study investigated the effects of 7 years of GH replacement on QoL. DESIGN A prospective, single-center, open-label study of 95 adults (mean age 52.8 years; 46 men) with adult-onset GH deficiency (GHD). METHODS QoL was measured using Quality of Life-Assessment for Growth Hormone Deficiency in Adults (QoL-AGHDA) and Psychological General Well-Being (PGWB) scores. RESULTS The GH dose was gradually increased from 0.13 mg/day to 0.42 mg/day. IGF-I SD score increased from -1.49 at baseline to 0.35 at study end. The GH replacement induced sustained improvements in total QoL-AGHDA and PGWB scores. GHD women had a more marked improvement in total QoL-AGHDA score than GHD men after 5 and 7 years. Most of the improvement in QoL was seen during the first year, but there was a small further improvement also after one year as measured using QoL-AGHDA. All QoL-AGHDA dimensions improved, but the improvement in memory and concentration as well as tenseness occurred later than that of other dimensions. Correlation analysis demonstrated that the patients with the lowest baseline QoL had the greatest improvement in QoL. CONCLUSIONS Seven years of GH replacement improved QoL with the most marked improvements in GHD women and in patients with low baseline QoL. Most, but not all, of the improvement in QoL was seen during the first year. Some QoL-AGHDA dimensions (memory and concentration, tenseness) responded at a slower rate than other dimensions.
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Affiliation(s)
- Mariam Elbornsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Alexandra Horvath
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Galina Götherström
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Bengt-Åke Bengtsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Gudmundur Johannsson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Johan Svensson
- Department of EndocrinologyInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Allo Miguel G, Serraclara Plá A, Partida Muñoz ML, Martínez Díaz-Guerra G, Hawkins F. Seven years of follow up of trabecular bone score, bone mineral density, body composition and quality of life in adults with growth hormone deficiency treated with rhGH replacement in a single center. Ther Adv Endocrinol Metab 2016; 7:93-100. [PMID: 27293538 PMCID: PMC4892402 DOI: 10.1177/2042018816643908] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Adult growth hormone deficiency (AGHD) is characterized by impaired physical activity, diminished quality of life (QoL), weight and fat mass gain, decreased muscle mass and decreased bone mineral density (BMD). The aim of this study was to evaluate the effects of long-term treatment (7 years) with recombinant human growth hormone (rhGH) on metabolic parameters, body composition (BC), BMD, bone microarchitecture and QoL. PATIENTS AND METHODS In this prospective study, BMD and BC were assessed by dual-energy X-ray absorptiometry (DXA). Bone microarchitecture was assessed with the trabecular bone score (TBS). The QoL-AGHDA test was used to assess QoL. RESULTS A total of 18 AGHD patients (mean age, 37.39 ± 12.42) were included. Body weight and body mass index (BMI) showed a significant increase after 7 years (p = 0.03 and p = 0.001, respectively). There was a significant tendency of body fat mass (BFM) (p = 0.028) and lean body mass (LBM) (p = 0.005) to increase during the 7 years of rhGH treatment. There was a significant increase in lumbar spine (LS) BMD (p = 0.01). TBS showed a nonsignificant decrease after 7 years of treatment, with a change of -0.86% ± 1.95. QoL showed a large and significant improvement (p = 0.02). CONCLUSION Long-term rhGH treatment in AGHD patients induces a large and sustained improvement in QoL. Metabolic effects are variable with an increase in LBM as well as in BMI and BFM. There is a positive effect on BMD based on the increase in LS BMD, which stabilizes during long-term therapy and is not associated with a similar increase in bone microarchitecture.
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Affiliation(s)
| | - Alicia Serraclara Plá
- Endocrinology Service, 12 de Octubre University Hospital, University Complutense, Madrid, Spain
| | | | | | - Federico Hawkins
- Endocrinology Service, 12 de Octubre University Hospital, University Complutense, Madrid, Spain
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13
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Yuen KCJ, Heaney AP, Popovic V. Considering GH replacement for GH-deficient adults with a previous history of cancer: a conundrum for the clinician. Endocrine 2016; 52:194-205. [PMID: 26732039 DOI: 10.1007/s12020-015-0840-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/18/2015] [Indexed: 11/30/2022]
Abstract
Previous studies have shown that GH and IGF-I may enhance tumorigenesis, metastasis, and cell proliferation in humans and animals. Evidence supporting this notion is derived from animal model studies, epidemiological studies, experience from patients with acromegaly, molecular therapeutic manipulation of GH and IGF-I actions, and individuals with GH receptor and congenital IGF-I deficiencies. Prior exposure to radiation therapy, aging, family history of cancer, and individual susceptibility may also contribute to increase this risk. Therefore, the use of GH replacement in patients with a history of cancer raises hypothetical safety concerns for patients, caregivers, and providers. Studies of GH therapy in GH-deficient adults with hypopituitarism and childhood cancer survivors have not convincingly demonstrated an increased cancer risk. Conversely, the risk of occurrence of a second neoplasm (SN) in childhood cancer survivors may be increased, with meningiomas being the most common tumor; however, this risk appears to decline over time. In light of these findings, if GH replacement is to be considered in patients with a previous history of cancer, we propose this consideration to be based on each individual circumstance and that such therapy should only be initiated at least 2 years after cancer remission is achieved with the understanding that in some patients (particularly those with childhood cancers), GH may potentially increase the risk of SNs. In addition, close surveillance should be undertaken working closely with the patient's oncologist. More long-term data are thus needed to determine if GH replacement in GH-deficient adults with a history of cancer is associated with the development of de novo tumors and tumor recurrence.
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Affiliation(s)
- Kevin C J Yuen
- Department of Neurosurgery and Neurology, Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA, 98122, USA.
| | - Anthony P Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90073, USA
| | - Vera Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disease, University Clinical Center Belgrade, Faculty of Medicine, University of Belgrade, Dr Subotica 13, 11000, Belgrade, Serbia
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Mesa J, del Pozo C. Two decades of growth hormone treatment in adulthood. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2016; 63:55-57. [PMID: 26522974 DOI: 10.1016/j.endonu.2015.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 08/24/2015] [Accepted: 08/26/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Jordi Mesa
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d́Hebron, Barcelona, España.
| | - Carlos del Pozo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, España
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15
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Yuen KC, Popovic V. Growth hormone replacement in patients with a history of malignancy: a review of the literature and best practice for offering treatment. Expert Rev Endocrinol Metab 2015; 10:319-326. [PMID: 30298774 DOI: 10.1586/17446651.2015.996130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Previous studies have implicated the growth hormone (GH)/IGF-I axis as an important mediator of cancer risk in humans and animals. Evidence supporting this notion is derived from animal studies, epidemiological observations, patients with acromegaly and from therapeutic manipulation of GH and IGF-I actions. Therefore, the use of GH therapy in patients with a history of malignancy raises hypothetical safety concerns. Reassuringly, GH therapy in childhood cancer survivors has not been confirmed to increase the cancer risk. Conversely, the risk of occurrence of a second neoplasm may be increased, with meningiomas being the most common tumor. In light of these findings, we propose considering GH therapy to be based on each individual's circumstance and commenced at least 2 years after cancer remission is achieved with close monitoring during therapy. More long-term data are needed on the safety of GH replacement therapy in GH-deficient adults with a history of malignancy.
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Affiliation(s)
- Kevin Cj Yuen
- a 1 Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA 98122, USA
| | - Vera Popovic
- b 2 Faculty of Medicine, University of Belgrade and Clinic for Endocrinology, Diabetes and Metabolic Disease, University Clinical Center Belgrade, Dr Subotica 13, 11000 Belgrade, Serbia
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16
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Abstract
This article presents an overview of adult growth hormone deficiency (AGHD) and corticotropin deficiency (central adrenal failure, CAI). Both conditions can result from various ailments affecting the hypothalamus or pituitary gland (most frequently a tumor in the area or its treatment). Clinical manifestations are subtle in AGHD but potentially life-threatening in CAI. The diagnosis needs dynamic testing in most cases. Treatment of AGHD is recommended in patients with documented severe deficiency, and treatment of CAI is mandatory in all cases. Despite significant progress in replacement hormonal therapy, more physiologic treatments and more reliable indicators of treatment adequacy are still needed.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-36 Aviatorilor Boulevard, Bucharest 011863, Romania; Department of Pituitary and Neuroendocrine Diseases, C.I. Parhon National Institute of Endocrinology, 34-36 Aviatorilor Boulevard, Bucharest 011863, Romania
| | - John A H Wass
- Discipline of Endocrinology and Diabetes, University of Oxford, Old Road, Headington, Oxford OX3 7LE, UK; Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK.
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17
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Crespo I, Valassi E, Santos A, Webb SM. Health-related quality of life in pituitary diseases. Endocrinol Metab Clin North Am 2015; 44:161-70. [PMID: 25732652 DOI: 10.1016/j.ecl.2014.10.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the last 15 years, worse health-related quality of life (QoL) has been reported in patients with pituitary diseases compared with healthy individuals. Different QoL questionnaires have shown incomplete physical and psychological recovery after therapy. Residual impairments often affect QoL even long-term after successful treatment of pituitary adenomas. In this article, knowledge of factors that affect QoL in pituitary diseases is reviewed. The focus is on 5 pituitary diseases: Cushing syndrome, acromegaly, prolactinomas, nonfunctioning pituitary adenomas, and hypopituitarism.
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Affiliation(s)
- Iris Crespo
- Department of Endocrinology, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain
| | - Elena Valassi
- Department of Endocrinology, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain
| | - Alicia Santos
- Department of Endocrinology, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain
| | - Susan M Webb
- Department of Endocrinology, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret, n. 167, Barcelona 08025, Spain.
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18
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Mailhot Vega R, Kim J, Hollander A, Hattangadi-Gluth J, Michalski J, Tarbell NJ, Yock TI, Bussiere M, MacDonald SM. Cost effectiveness of proton versus photon radiation therapy with respect to the risk of growth hormone deficiency in children. Cancer 2015; 121:1694-702. [PMID: 25641407 DOI: 10.1002/cncr.29209] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/04/2014] [Accepted: 11/18/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proton therapy in pediatrics may improve the risk/benefit profile of radiotherapy at a greater upfront financial cost, but it may prove to be cost effective if chronic medical complications can be avoided. Tools to assist with decision making are needed to aid in selecting pediatric patients for protons, and cost-effectiveness models can provide an objective method for this. METHODS A Markov cohort-simulation model was developed to assess the expected costs and effectiveness for specific radiation doses to the hypothalamus with protons versus photons in pediatric patients. Costing data included cost of investment and the diagnosis and management of growth hormone deficiency. Longitudinal outcomes data were used to inform risk parameters for the model. With costs in 2012 US dollars and effectiveness measured in quality-adjusted life years, incremental cost-effectiveness ratios were used to measure outcomes. RESULTS Proton therapy was cost effective for some scenarios based on the difference in hypothalamic sparing. Although some scenarios were not cost effective, others were not only cost effective for proton therapy but also demonstrated that protons were cost saving compared with photons. CONCLUSIONS The current results provide the first evidence-based guide for identifying children with brain tumors who may benefit the most from proton therapy with respect to endocrine dysfunction. Proton therapy may be more cost effective for scenarios in which radiation dose to the hypothalamus can be spared, but protons may not be cost effective when tumors are involving or directly adjacent to the hypothalamus if there is a high dose to this structure.
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Affiliation(s)
- Raymond Mailhot Vega
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
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19
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Shimatsu A, Iwamoto N, Tanaka T, Teramoto A, Taketsuna M, Ihara K, Funai J, Irie M, Chihara K. Possible predictors for QOL improvement following GH replacement therapy in adult GHD. Endocr J 2015; 62:749-56. [PMID: 26073867 DOI: 10.1507/endocrj.ej14-0616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In addition to impaired physical activity, adult GH deficiency (GHD) can decrease quality of life (QOL). Hence, assessment of QOL is important to evaluate the efficacy of GH replacement therapy. This study aimed to identify factors that may be predictive of long-term improvement in QOL among clinical/laboratory variables during GH replacement therapy. The analysis included 83 Japanese adults with GHD who participated in the Hypopituitary Control and Complications Study (HypoCCS). Correlations between the change from baseline in clinical/laboratory variables at 6 months and the change from baseline in Quality of life (Short-Form 36 [SF-36] component scores) at 12 months were examined. Unexpectedly, all component scores were negatively correlated with the change in fasting plasma glucose concentration (FPG) (physical component summary [PCS], r = -0.456; mental component summary [MCS], r = -0.523; role/social component summary [RCS], r = -0.433). The change in MCS was positively correlated with the change in insulin-like growth factor-1 standard deviation score (IGF-1 SDS) (r = 0.417). The change in PCS was positively correlated with the change in body fat (r = 0.551). The change in RCS was positively correlated with the change in waist circumference (r = 0.528). Short-term changes in several clinical/laboratory variables, most notably FPG and IGF-1 SDS, were correlated with long-term changes in QOL. The clinical importance of these correlations for predicting GH replacement treatment efficacy warrants further investigation.
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Affiliation(s)
- Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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20
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Díez JJ, Cordido F. [Benefits and risks of growth hormone in adults with growth hormone deficiency]. Med Clin (Barc) 2014; 143:354-9. [PMID: 24485161 DOI: 10.1016/j.medcli.2013.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/31/2013] [Accepted: 11/14/2013] [Indexed: 11/17/2022]
Abstract
Adult growth hormone (GH) deficiency is a well-recognized clinical syndrome with adverse health consequences. Many of these may improve after replacement therapy with recombinant GH. This treatment induces an increase in lean body mass and a decrease in fat mass. In long-term studies, bone mineral density increases and muscle strength improves. Health-related quality of life tends to increase after treatment with GH. Lipid profile and markers of cardiovascular risk also improve with therapy. Nevertheless, GH replacement therapy is not without risk. According to some studies, GH increases blood glucose, body mass index and waist circumference and may promote long-term development of diabetes and metabolic syndrome. Risk of neoplasia does not appear to be increased in adults treated with GH, but there are some high-risk subgroups. Methodological shortcomings and difficulties inherent to long-term studies prevent definitive conclusions about the relationship between GH and survival. Therefore, research in this field should remain active.
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Affiliation(s)
- Juan J Díez
- Servicio de Endocrinología, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España.
| | - Fernando Cordido
- Servicio de Endocrinología, Complejo Hospitalario Universitario de A Coruña, Departamento de Medicina, Universidad de A Coruña, A Coruña, España
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21
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Yuen KCJ, Koltowska-Häggström M, Cook DM, Fox JL, Jönsson PJ, Geffner ME, Abs R. Clinical characteristics and effects of GH replacement therapy in adults with childhood-onset craniopharyngioma compared with those in adults with other causes of childhood-onset hypothalamic-pituitary dysfunction. Eur J Endocrinol 2013; 169:511-9. [PMID: 23904277 DOI: 10.1530/eje-13-0280] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Adults with childhood-onset (CO) craniopharyngioma (COCP) have poor quality of life (QoL) and clinical outcomes, but few studies have compared these patients with adults with other causes of CO hypothalamic-pituitary dysfunction. In this study, we compared baseline clinical characteristics and patient-reported outcomes before starting GH replacement therapy in adults with GH deficiency (GHD) due to COCP with those of adults either with CO idiopathic/congenital hypopituitarism (COH) or with CO extrasellar (COE) tumours, and evaluated the 1- and 5-year effects of GH replacement therapy. SUBJECTS AND METHODS Retrospective analysis of the data recorded in KIMS (Pfizer International Metabolic Database) was carried out. Patients with COCP, COH and COE tumours were evaluated at baseline, and after 1 and 5 years of therapy. RESULTS Compared with COH and COE patients, more COCP patients underwent surgery, had greater abnormalities of body composition and higher prevalence of pituitary hormone deficits (all P<0.001), but comparable fasting glucose, HbA1c, total cholesterol and LDL-cholesterol levels, marital status, parenthood, living arrangements, education, employment and annual sick-leave days. After 1 and 5 years of GH replacement therapy, similar changes were evident with regard to body composition, fasting glucose and HbA1c levels, QoL, and the level of and satisfaction with physical activity across the three groups. CONCLUSIONS Adults with untreated COCP with GHD at baseline demonstrated more co-morbidities including greater abnormalities of body composition, pituitary hormone deficits and visual field defects. Overall, adults with COCP, COH and COE tumours responded comparably to short- and long-term GH replacement therapy, suggesting that patients with GHD due to COCP benefited from GH replacement therapy to a similar degree as those with other causes of CO hypothalamic-pituitary dysfunction did.
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Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode: L607, Portland, Oregon 97239-3098, USA
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22
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Mailhot Vega RB, Kim J, Bussière M, Hattangadi J, Hollander A, Michalski J, Tarbell NJ, Yock T, MacDonald SM. Cost effectiveness of proton therapy compared with photon therapy in the management of pediatric medulloblastoma. Cancer 2013; 119:4299-307. [PMID: 24105630 DOI: 10.1002/cncr.28322] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/07/2013] [Accepted: 07/11/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Proton therapy has been a hotly contested issue in both scientific publications and lay media. Proponents cite the modality's ability to spare healthy tissue, but critics claim the benefit gained from its use does not validate its cost compared with photon therapy. The objective of this study was to evaluate the cost effectiveness of proton therapy versus photon therapy in the management of pediatric medulloblastoma. METHODS A cost-effective analysis was performed from the societal perspective using a Monte Carlo simulation model. A population of pediatric medulloblastoma survivors aged 18 years was studied who had received treatment at age 5 years and who were at risk of developing 10 adverse events, such as growth hormone deficiency, coronary artery disease, ototoxicity, secondary malignant neoplasm, and death. Costing data included the cost of investment and the costs of diagnosis and management of adverse health states from institutional and Medicare data. Longitudinal outcomes data and recent modeling studies informed risk parameters for the model. Incremental cost-effectiveness ratios were used to measure outcomes. RESULTS Results from the base case demonstrated that proton therapy was associated with higher quality-adjusted life years and lower costs; therefore, it dominated photon therapy. In 1-way sensitivity analyses, proton therapy remained the more attractive strategy, either dominating photon therapy or having a very low cost per quality-adjust life year gained. Probabilistic sensitivity analysis illustrated the domination of proton therapy over photon therapy in 96.4% of simulations. CONCLUSIONS By using current risk estimates and data on required capital investments, the current study indicated that proton therapy is a cost-effective strategy for the management of pediatric patients with medulloblastoma compared with standard of care photon therapy.
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Affiliation(s)
- Raymond B Mailhot Vega
- Department of Radiation Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Reed ML, Merriam GR, Kargi AY. Adult growth hormone deficiency - benefits, side effects, and risks of growth hormone replacement. Front Endocrinol (Lausanne) 2013; 4:64. [PMID: 23761782 PMCID: PMC3671347 DOI: 10.3389/fendo.2013.00064] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 05/18/2013] [Indexed: 11/26/2022] Open
Abstract
Deficiency of growth hormone (GH) in adults results in a syndrome characterized by decreased muscle mass and exercise capacity, increased visceral fat, impaired quality of life, unfavorable alterations in lipid profile and markers of cardiovascular risk, decrease in bone mass and integrity, and increased mortality. When dosed appropriately, GH replacement therapy (GHRT) is well tolerated, with a low incidence of side effects, and improves most of the alterations observed in GH deficiency (GHD); beneficial effects on mortality, cardiovascular events, and fracture rates, however, remain to be conclusively demonstrated. The potential of GH to act as a mitogen has resulted in concern over the possibility of increased de novo tumors or recurrence of pre-existing malignancies in individuals treated with GH. Though studies of adults who received GHRT in childhood have produced conflicting reports in this regard, long-term surveillance of adult GHRT has not demonstrated increased cancer risk or mortality.
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Affiliation(s)
- Mary L. Reed
- Geriatrics and Extended Care, VA Puget Sound Health Care System, Madigan Health Care System, Tacoma, WA, USA
| | - George R. Merriam
- Division of Metabolism, Endocrinology, and Nutrition, VA Puget Sound Health Care System, University of Washington School of Medicine, Tacoma, WA, USA
| | - Atil Y. Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
The availability of synthetic recombinant human growth hormone (GH) in potentially unlimited quantities since the 1980s has improved understanding of the many nonstatural effects of GH on metabolism, body composition, physical and psychological function, as well as the consequences of GH deficiency in adult life. Adult GH deficiency is now recognized as a distinct if nonspecific syndrome with considerable adverse health consequences. GH replacement therapy in lower doses than those used in children can reverse many of these abnormalities and restore functional capacities toward or even to normal; if dosed appropriately, GH therapy has few adverse effects. Although some doubts remain about possible long-term risks of childhood GH therapy, most registries of adult GH replacement therapy, albeit limited in study size and duration, have not shown an increased incidence of cancers or of cardiovascular morbidity or mortality.
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Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 North West 10th Avenue, Suite 807, Miami, FL 33136, USA
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25
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Gasco V, Prodam F, Grottoli S, Marzullo P, Longobardi S, Ghigo E, Aimaretti G. GH therapy in adult GH deficiency: a review of treatment schedules and the evidence for low starting doses. Eur J Endocrinol 2013; 168:R55-66. [PMID: 23152440 DOI: 10.1530/eje-12-0563] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recombinant human GH has been licensed for use in adult patients with GH deficiency (GHD) for over 15 years. Early weight- and surface area-based dosing regimens were effective but resulted in supraphysiological levels of IGF1 and increased incidence of side effects. Current practice has moved towards individualised regimens, starting with low GH doses and gradually titrating the dose according to the level of serum IGF1 to achieve an optimal dose. Here we present the evidence supporting the dosing recommendations of current guidelines and consider factors affecting dose responsiveness and parameters of treatment response. The published data discussed here lend support for the use of low GH dosing regimens in adult GHD. The range of doses defined as 'low dose' in the studies discussed here (∼1-4 mg/week) is in accordance with those recommended in current guidelines and encompasses the dose range recommended by product labels.
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Affiliation(s)
- Valentina Gasco
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, c.so Dogliotti 14, 10126 Turin, Italy
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26
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Crespo I, Santos A, Resmini E, Valassi E, Martínez-Momblán MA, Webb SM. Improving Quality of Life in Patients with Pituitary Tumours. EUROPEAN ENDOCRINOLOGY 2013; 9:32-36. [PMID: 30349608 PMCID: PMC6193521 DOI: 10.17925/ee.2013.09.01.32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/29/2013] [Indexed: 11/24/2022]
Abstract
Evaluation of health-related quality of life (QoL) in people with pituitary tumours has received much attention over the last 10-15 years. Most of them show impaired QoL, but little is known about how to prevent impairment or how to improve QoL. Our aim is to review what is known about QoL in pituitary tumours patients and to highlight the areas worth improving, for the patient's well being. The article has four sections: acromegaly, Cushing's syndrome, prolactinomas and non-functioning adenomas. Control of comorbidities is usually an important factor to prevent QoL impairment; however, each disease has specific characteristics that should be properly addressed in order to obtain full patient recovery after successful therapy.
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Affiliation(s)
- Iris Crespo
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
| | - Alicia Santos
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
| | - Eugenia Resmini
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
| | - Elena Valassi
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
| | - Maria Antonia Martínez-Momblán
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
- Escola Universitària d’Infermeria, Hospital Sant Pau, Universitat Autonoma de Barcelona, Barcelona, España
| | - Susan M Webb
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autonoma de Barcelona
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Shimatsu A, Tai S, Imori M, Ihara K, Taketsuna M, Funai J, Tanaka T, Teramoto A, Irie M, Chihara K. Efficacy and safety of growth hormone replacement therapy in Japanese adults with growth hormone deficiency: a post-marketing observational study. Endocr J 2013; 60:1131-44. [PMID: 23823978 DOI: 10.1507/endocrj.ej13-0083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This large-scale observational study examined the long-term effectiveness and safety of growth hormone (GH) replacement therapy for adult GH deficiency (GHD) in Japanese clinical practice using the Hypopituitary Control and Complications Study database. The study included 402 GHD patients for safety analyses and a subset of 209 patients (149 adult-onset and 60 childhood-onset GHD patients) who had not previously received GH replacement therapy for the efficacy analyses. Data on clinical, metabolic, quality of life (QoL) characteristics, and all adverse events (AEs) were collected at baseline (start of GH treatment), 6 months, 1 year and 2 years. Over the observation period, there were improvements from baseline in insulin-like growth factor-I standard deviation scores (P<0.001), although the changes in metabolic parameters were minimal. QoL (Short Form-36) Z-scores significantly increased from baseline in both onset-type groups for several subscale domains (P<0.05). A total of 145 (36.1%) patients experienced ≥1 AE. Common AEs were hyperlipidaemia (2.7%) and hyperinsulinaemia (2.2%). Some patients experienced recurrent hypothalamic/pituitary tumour (events per 1000 patient-years: 2.78), new benign (0.93), malignant tumour (10.28) or other new tumour (0.93), new diabetes mellitus (7.45), and new stroke (3.71). Seven patients died during the observation period. Our safety findings are inconclusive about the associations between GH replacement and AEs, although the incidence of diabetes mellitus and cardiovascular events are similar to those reported in the Japanese general population. In conclusion, the key beneficial effects of GH replacement therapy for GHD are observed in routine clinical practice in Japan.
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Affiliation(s)
- Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Valassi E, Brick DJ, Johnson JC, Biller BMK, Klibanski A, Miller KK. Effect of growth hormone replacement therapy on the quality of life in women with growth hormone deficiency who have a history of acromegaly versus other disorders. Endocr Pract 2012; 18:209-18. [PMID: 22440981 DOI: 10.4158/ep11134.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the response in quality of life (QoL) to growth hormone (GH) replacement in women with GH deficiency (GHD) and a history of acromegaly with that in women with GHD of other causes. METHODS Fifty-five women with GHD were studied: 17 with prior acromegaly and 38 with other causes of GHD. We compared two 6-month, randomized, placebo-controlled studies of GH therapy in women with hypopituitarism conducted with use of the same design-one in women with a history of acromegaly and one in women with no prior acromegaly. QoL was assessed with the following questionnaires: the QoL-Assessment of Growth Hormone Deficiency in Adults (AGHDA), the Symptom Questionnaire, and the 36-Item Short-Form Health Survey (SF-36). RESULTS The 2 groups had comparable mean pretreatment age, body mass index, and QoL scores and comparable mean GH dose at 6 months (0.61 ± 0.30 versus 0.67 ± 0.27 mg daily). After 6 months of GH replacement therapy, women with GHD and prior acromegaly demonstrated a greater improvement in AGHDA score, four SF-36 sub-scales (Role Limitations due to Physical Health, Energy or Fatigue, Emotional Well-Being, and Social Functioning), and the Somatic Symptoms subscale of the Symptom Questionnaire than did women with GHD of other causes. Poorer pretreatment QoL was associated with a greater improvement in QoL after administration of GH. CONCLUSION In this study, GH replacement therapy improved QoL in women with GHD and a history of acromegaly but not in women with GHD due to other hypothalamic and pituitary disorders. Further studies are needed to determine the long-term risks versus benefits of GH replacement in patients who develop GHD after definitive treatment for acromegaly.
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Affiliation(s)
- Elena Valassi
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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29
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Phelan N, Conway SH, Llahana S, Conway GS. Quantification of the adverse effect of ethinylestradiol containing oral contraceptive pills when used in conjunction with growth hormone replacement in routine practice. Clin Endocrinol (Oxf) 2012; 76:729-33. [PMID: 22098528 DOI: 10.1111/j.1365-2265.2011.04277.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Oestrogen antagonizes the action of growth hormone (GH). For women with combined GH and oestrogen deficiency, transdermal oestradiol is more favourable in this regard compared to oral oestradiol. Oral contraceptive pills containing ethinylestradiol (EE) are commonly used in young women with GHD and there is little information on the impact of this form of oestrogen. DESIGN A case note review of women with growth hormone deficiency (GHD) attending a tertiary endocrine clinic comparing the dose of GH and serum insulin-like growth factor 1 concentrations and the type of exogenous oestrogen. METHODS All women with GHD between the ages of 18 and 47 attending University College London Hospitals (UCLH) were included and grouped according to type of oestrogen replacement. Weight, GH dose and serum IGF-I concentrations were recorded at 121 visits in 88 women. RESULTS The daily dose of GH was significantly higher and the GH responsivity was significantly lower in the EE group compared to those taking no oestrogen and transdermal oestrogen. The additional cost of GH for women using EE compared to transdermal oestradiol was £6016 per patient per year. Effectiveness of GH improved in all women changing from EE to another form of oestrogen. CONCLUSION Use of oral contraceptive pills containing EE should be avoided in women receiving treatment with GH. Alternative options include oral or transdermal hormone replacement therapy (HRT) preparations for those that require oestrogen replacement or a progesterone-based regimen for contraceptive purposes.
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MESH Headings
- Adolescent
- Adult
- Body Weight/drug effects
- Contraceptives, Oral/administration & dosage
- Contraceptives, Oral/therapeutic use
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/therapeutic use
- Dose-Response Relationship, Drug
- Drug Therapy, Combination
- Estrogens/adverse effects
- Estrogens/deficiency
- Estrogens/therapeutic use
- Ethinyl Estradiol/administration & dosage
- Ethinyl Estradiol/adverse effects
- Ethinyl Estradiol/therapeutic use
- Female
- Hormone Replacement Therapy/economics
- Hormone Replacement Therapy/methods
- Human Growth Hormone/antagonists & inhibitors
- Human Growth Hormone/deficiency
- Human Growth Hormone/therapeutic use
- Humans
- Injections, Intradermal
- Insulin-Like Growth Factor I/metabolism
- Middle Aged
- Outcome Assessment, Health Care/economics
- Outcome Assessment, Health Care/methods
- Retrospective Studies
- Young Adult
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Affiliation(s)
- Niamh Phelan
- Department of Endocrinology, University College London Hospitals, London, UK
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Kokshoorn NE, Biermasz NR, Roelfsema F, Smit JWA, Pereira AM, Romijn JA. GH replacement therapy in elderly GH-deficient patients: a systematic review. Eur J Endocrinol 2011; 164:657-65. [PMID: 21339335 DOI: 10.1530/eje-10-1170] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Context Recombinant human GH (rhGH) is prescribed for the treatment of adults with GH deficiency (GHD). However, conflicting data are available on the efficacy of rhGH treatment in elderly GHD patients. Objective To assess the efficacy of rhGH treatment in elderly GHD subjects. Methods We searched the available literature in PubMed, Cochrane Library, Web of Science and EMBASE. Study selection Studies on GHD patients, aged >60 years, treated with rhGH were eligible for inclusion. Data extraction was performed by two reviewers independently. Results We found 11 eligible studies with a total of 534 patients. Only two studies had prospective, randomized, placebo-controlled study designs of rhGH treatment with a duration of 6 (n=15) and 12 months (n=62), respectively. Treatment with rhGH decreased total and low density lipoprotein (LDL) cholesterol levels by 4-8 and 11-16%, respectively, but did not alter high density lipoprotein or triglyceride levels. RhGH did not affect body mass index, but decreased waist circumference (by ∼3 cm) and waist/hip ratio. RhGh did not consistently affect blood pressure or bone mineral density. RhGH increased lean body mass by 2-5% and decreased total fat mass by 7-10% in four studies, but did not affect body composition in two other studies. RhGH consistently improved quality of life (QoL) parameters reflected in AGHDA-scores. There were no explicit data on elderly GHD patients aged >80 years. Conclusion RhGH replacement in elderly subjects with GHD decreases LDL cholesterol levels and improves QoL, but the effects on other parameters are not unequivocal. There were no data on the efficacy and safety of rhGH treatment in octogenarians with GHD.
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Affiliation(s)
- Nieke E Kokshoorn
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, 2300 RC Leiden, The Netherlands.
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Affiliation(s)
- M E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine Chicago, 645 N. Michigan Avenue, Suite 530 Chicago, IL 60611, USA.
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32
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2011; 18:83-98. [PMID: 21178692 DOI: 10.1097/med.0b013e3283432fa7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Shimatsu A, Tai S, Tanaka T, Fujieda K, Teramoto A, Chihara K. Clinical characteristics of Japanese adults with growth hormone deficiency: a HypoCCS database study. Endocr J 2011; 58:325-33. [PMID: 21467694 DOI: 10.1507/endocrj.k10e-363] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The clinical characteristics of Caucasian adults with growth hormone (GH) deficiency (GHD) have been well defined. However, no large-scale clinical practice study has examined the clinical characteristics of Japanese adults with GHD. The aim of our study was to describe the clinical characteristics of Japanese adults with GHD by reviewing the records of participants who were GH-naive at the time of enrollment in the Hypopituitary Control and Complications Study (N = 349). The majority of participants (280 of 349; 80.2%) had adult-onset rather than childhood-onset GHD. Hypothalamo-pituitary tumors were the most common cause of GHD in Japanese adults (247 of 349; 70.8%); these tumors were primarily pituitary adenomas in participants with adult-onset GHD (156 of 243; 64.2%), and germ cell tumors (19 of 40; 47.5%) and craniopharyngiomas (18 of 40; 45.0%) in participants with childhood-onset GHD. Most participants (310 of 349; 88.8%) had multiple pituitary hormone deficiencies. Dyslipidemia (195 of 349; 55.9%), visual field loss (67 of 349; 19.2%), hypertension (59 of 349; 16.9%), and liver disease (54 of 349; 15.5%) were the most common pre-existing conditions in Japanese adults with GHD. Quality of life was decreased in seven of the eight short form-36 domains in participants with GHD compared with age- and sex-matched healthy Japanese individuals. Our findings confirm that the clinical characteristics of Japanese adults with GHD are similar to those of Caucasian adults with GHD. Confirmation of these clinical characteristics will enhance the ability of clinicians to identify and treat Japanese adults with GHD.
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Affiliation(s)
- Akira Shimatsu
- Clinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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