Daily versus once-weekly growth hormone treatment and decision-making for children with growth hormone deficiency
Bethany Auble, MD, a pediatric endocrinologist at the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, discussed the different treatment options for pediatric patients with growth hormone deficiency.
Question:
Can you discuss the treatment options for pediatric growth hormone deficiency?
Bethany Auble, MD:
Our treatment options are usually in kind of 2 camps. We usually do a daily growth hormone injection that is typically given at night to kind of mimic the diurnal rhythm that we often see in growth hormone, that deepest in sleep kids will make growth hormone. We try to mimic that and so that’s our traditional, what we’ve done for 30 plus years is just like a nightly injection of growth hormone and there’s a variety of brands. Typically, insurance will guide which products that we are able to use. There’s usually several. As I’ve diagnosed a kid with growth hormone, I’ll often talk to my nursing colleagues and my growth hormone coordinator and they’ll say, these are the couple that are on the list. What do you want to do? We can kind of decide together, talk about what the pros and cons are.
What has recently come on the market in this last year or 2 is weekly growth hormone preparations, meaning they’re given just once a week, still by a subcutaneous injection, like a pen type device. Those, again, just once a week. In terms of your patients who are needle phobic, who are struggling, who just can’t keep a routine as well, this is helpful. We kind of have to decide with the family, especially if maybe they’ve already been on a daily growth hormone. Do you just want to stay on this? We’ve only got a year left of growing. Or do you want to change to a weekly formulation? Most families would prefer the weekly formulation because less injections, less stress at home, but there’s still something to like, oh no, I missed a dose and now I don’t have anything for 7 days kind of on board. There’s kind of the benefits and cons. Those are our 2 major ways of treating growth hormone deficiency.
Question:
How do you talk to families and patients about these treatment options and guide them in the selection process?
Bethany Auble, MD:
That is a great question, and to be honest, insurance truly drives our decision making. If I diagnose the growth hormone deficiency, I can often talk to a family about sometimes there’s daily and sometimes there’s weekly preparations. Do you have a sense of which you would prefer? Sometimes it is I just want to stay on a nightly routine and just do this because it makes sense for our family. Otherwise, I’m just going to forget.
Most families would choose a weekly formulation, but then once we apply for it, really the forms will say, these are the 2 options you have. I don’t have a menu list of all the options out there. I really am kind of stuck in those couple options. What does sometimes happen though is maybe a patient doesn’t tolerate the one that we’ve chosen. It burns, it stings, it’s really not going well. I could appeal and ask for a different product. Even if it’s not on the insurance preferred list, I can say, “I really need this one because of this reason. The patient has hives every time we give it.” That is like, there’s an allergy, there’s something going on. I can kind of decide, but usually it’s like, do you want this one or this one? Then that’s all. I kind of choose as I talk to a family, which one do you prefer? Or maybe I know that pen works better and is easier for families. I’ll choose that one based on our experience.
Question:
Can you talk more about once weekly versus daily growth hormone treatment dosing options for pediatric patients? What are important considerations when choosing a therapeutic?
Bethany Auble, MD:
The data that we have for the weekly formulations really does say it’s as effective, if not slightly more effective in terms of growth velocity and kind of height outcomes. Some of the weekly growth hormone preparations haven’t been around super long, so we can say full adult height outcomes just because they’re newer. That is important. When we think of speed of growth, you obviously are trying to speed up someone’s growth with growth hormones. Knowing that one is maybe slightly better, it could play a role into your decision making.
Then truly it comes down to a family’s preference and I would say 99 out of 100 would choose a weekly formulation if I could get it, if insurance would allow it. The weekly formulations tend to have a larger volume. They might be a different concentration, but it tends to be a little bit more in that injection because it has to last for an entire week. I have also heard that some of them maybe sting a little bit more because there’s proteins that the growth hormone is bound to in the solution that kind of keeps it hanging on for that entire week instead of just lasting for 24 hours. If a patient can tolerate how much the injection is, how much liquid they’re putting in and kind of a little bit of the stinging, then we’ll go with a weekly formulation. But kind of deciding that with the family is really important.
