Pediatric growth hormone treatment in Italy: A systematic review of epidemiology, quality of life, treatment adherence, and economic impact

Objectives

This systematic review aims to describe 1) the epidemiology of the diseases indicated for treatment with growth hormone (GH) in Italy; 2) the adherence to the GH treatment in Italy and factors associated with non-adherence; 3) the economic impact of GH treatment in Italy; 4) the quality of life of patients treated with GH and their caregivers in Italy.

Methods

Systematic literature searches were performed in PubMed, Embase and Web of Science from January 2010 to March 2021. Literature selection process, data extraction and quality assessment were performed by two independent reviewers. Study protocol has been registered in PROSPERO (CRD42021240455).

Results

We included 25 studies in the qualitative synthesis. The estimated prevalence of growth hormone deficiency (GHD) was 1/4,000–10,000 in the general population of children; the prevalence of Short Stature HOmeoboX Containing gene deficiency (SHOX-D) was 1/1,000–2,000 in the general population of children; the birth prevalence of Turner syndrome was 1/2,500; the birth prevalence of Prader-Willi syndrome (PWS) was 1/15,000. Treatment adherence was suboptimal, with a range of non-adherent patients of 10–30%. The main reasons for suboptimal adherence were forgetfulness, being away from home, pain/discomfort caused by the injection. Economic studies reported a total cost for a complete multi-year course of GH treatment of almost 100,000 euros. A study showed that drug wastage can amount up to 15% of consumption, and that in some Italian regions there could be a considerable over- or under-prescribing. In general, patients and caregivers considered the GH treatment acceptable. There was a general satisfaction among patients with regard to social and school life and GH treatment outcomes, while there was a certain level of intolerance to GH treatment among adolescents. Studies on PWS patients and their caregivers showed a lower quality of life compared to the general population, and that social stigma persists.

Conclusion

Growth failure conditions with approved GH treatment in Italy constitute a significant burden of disease in clinical, social, and economic terms. GH treatment is generally considered acceptable by patients and caregivers. The total cost of the GH treatment is considerable; there are margins for improving efficiency, by increasing adherence, reducing drug wastage and promoting prescriptive appropriateness.

The quality of life of Turner women in comparison with grown-up GH-deficient women

Various aspects of the way of life in 20 adult patients (mean age: 25.7 +/- 6.0) with Turner syndrome were studied for their quality of life (QOL). The study found that many more Turner women went on to university (P < 0.01) than the general population, whereas GH-deficient women did not. The employment status of both Turner and GH-deficient women does not differ from that of the general population. Only 7 of the 12 Turner and 5 of the 15 GH-deficient employees are satisfied with their present jobs, but 10 of the former and 7 of the latter women think that their jobs are worthwhile. The total annual income of 3 of 19 Turner women exceeded 3 million yen, but not that of any of 10 GH-deficient women who answered the question on their income. Half of the Turner and GH-deficient women complained of shoulder stiffness and one fourth of the Turner and one fifth of the GH-deficient women have a sense of despair and irritability. Seven Turner and 9 GH-deficient women have anxiety about their body, and 6 of the former and 8 of the latter have anxiety about marriage. Only 4 Turner and 3 GH-deficient women are married. Three of the former marriages were arranged by their parents, but all 3 GH-deficient women got married after falling in love. These marriage rates are significantly lower (P < 0.005) than that of the age-matched general population. Most of the unmarried women in both groups live with their parents, and half of the Turner and one third of the GH-deficient women have difficulty in getting clothes and shoes to fit them. Otherwise, they have no particular problem in their daily life. In conclusion, Turner women are well educated and work as normal women, but they, as well as GH-deficient women, appear to be anxious about their body and marriage.