Evaluation and Treatment of Adult Growth Hormone Deficiency: An Endocrine Society Clinical Practice Guideline

Abstract

GHD can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. GH therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.

Dutch National Registry of GH Treatment in Adults: patient characteristics and diagnostic test procedures

“…For ITT, a peak GH response of !3 mg/l (!9 mU/l) was used to diagnose severe GHD (11,14,23). For the GHRH-arginine test, a peak GH response of !9 mg/l (!27 mU/l) was used as cut-off value (24).…”

“…Severe GHD is defined according to the consensus guidelines of the GH Research Society for the diagnosis and treatment of adults with GHD, published in 1997 (11). Thereafter, these guidelines have been reviewed and updated a number of times (2,(12)(13)(14)(15). The insulin tolerance test (ITT) is considered to be the 'gold standard' to diagnose severe GHD in adults.…”

“…The insulin tolerance test (ITT) is considered to be the 'gold standard' to diagnose severe GHD in adults. The combined GHRH-arginine test is a good alternative if ITT is contraindicated, although the latter may be misleading in an early stage in patients with GHD of hypothalamic origin (11,14,16). When two or more pituitary deficiencies are present and insulin-like growth factor 1 (IGF1) level is below the lower reference range for age and gender, GHD can be assumed, since the probability of severe GHD increases with an increasing number of pituitary hormone deficits (11,(17)(18)(19).…”

Exercise-induced GH secretion in the assessment of GH deficiency in adult individuals

“…The study population encompassed 14 patients with severe GHD and 20 control individuals (CI). Severe GHD was defined according to the current guidelines either based on an increase of GH to !5.1 ng/ml during an insulin tolerance test (ITT) with a nadir plasma glucose of !2.2 mmol/l and hypoglycaemic symptoms, or an insufficient GH releasing hormone (GHRH)/arginine test with body mass index (BMI)-dependent cut offs (11.5, 8.0 and 4.2 ng/ml for BMI !25, 25-30 and O30 kg/m 2 respectively), or insufficiency of at least three pituitary axes in addition to a low value for insulin-like growth factor 1 (IGF1) (11)(12)(13). Owing to a potential interference of oral oestrogens with IGF1 levels the diagnosis of GHD in female patients was based on stimulation testing, exclusively.…”

“…The diagnostic value in predicting GHD was calculated for each time point of GH assessment during exercise by performing receiver operating characteristics (ROC) analysis. In a ROC analysis, the diagnostic test under investigation (for the present analysis: exercise-induced GH concentrations) is compared with an accepted gold standard (for the present analysis: GHD assessed according to guidelines (11)(12)(13)). First, ROC analysis was performed including all GHD patients and all CI.…”