MONITORING GROWTH-HORMONE TREATMENT - SAFETY CONSIDERATIONS

The use of growth hormone (GH) has expanded from the treatment of shor t stature due to GH deficiency (GHD) in children with open epiphyses t o include growth failure due to chronic renal in sufficiency (CRI) and Turner's syndrome (TS) as well as adults with GHD. The safety conside rations in using GH differ somewhat in these diagnostic groups, and th e physician caring for these patients will need to keep this in mind w hen monitoring patients receiving GH. Peripheral edema and carpal tunn el syndrome have been reported as side effects more frequently in adul ts than in children treated with GH. Idiopathic intracranial hypertens ion has been reported most frequently in children with CRI (31.1 cases per 1000 patient years [pt-yrs]), although children with GHD and TS a lso have an increased incidence (1.6 and 3.7 cases per 1000 pt-yrs, re spectively). The greatest risk is at the beginning of treatment, and c omplaints of headache or visual disturbance at this time should prompt careful neurologic and ophthalmologic examination. The risk of leukem ia and nonleukemic extracranial neoplasms in children treated with GH seems to be confined to those with identifiable risk factors, Although numerous studies have failed to show an increased risk of brain tumor recurrence associated with GH treatment, children with a history of s uch tumors should have completed tumor therapy and have brain imaging studies before beginning GH. Children with CRI, GHD, and TS have an in creased risk of developing slipped capital femoral epiphysis. Complain ts of limping or hip or knee pain need to be evaluated with radiograph ic studies if there is limited hip movement. Although there is no evid ence that treatment with GH causes scoliosis, children with pre-existi ng scoliosis should be observed for rapid progression after starting G H treatment. Most studies of the effect of GH on carbohydrate metaboli sm show only transient changes insulin sensitivity. Nevertheless, pati ents with an increased risk of diabetes should be encouraged to modify their diet and exercise habits. Gynecomastia is a common side effect in adults receiving GH, and self limited gynecomastia has been reporte d in prepubertal boys during GH treatment. Older preparations of pitui tary GH contained GH oligomers and were frequently associated with hig h titers of GH antibodies and growth deceleration. Except for patients with GH gene deletions, antibodies are rarely a cause of poor respons e to GH, Other causes of poor growth should be investigated in a child who fails to respond to prescribed GH as expected. Specific recommend ations for managing patients in different diagnostic categories who ar e treated with GH are reviewed.