From Pediatric to Adult Care: Growth Hormone Deficiency and Treatment
Robert Rapaport, MD, professor of pediatrics and a pediatric endocrinologist at the Mount Sinai at the Icahn School of Medicine and the Children’s Hospital, talks about the challenges of transitioning a pediatric patient with growth hormone deficiency into the adult care setting.
Question:
What are some of the challenges children with growth hormone deficiency face when transitioning from pediatric to adult endocrinology care?
Robert Rapaport, MD:
The vast majority of children who are treated for growth hormone deficiency are children who have idiopathic isolated growth hormone deficiency, which means they’re only deficient growth hormone and not any other pituitary hormones.
The standard that we use for these children is that once they’ve achieved their growth, when their bone age is more than 16, when they grow less than 2 cm per year, we stop the growth hormone, and we test initially an IGF-1 level. If that’s slow, then we possibly do a 3-hour growth hormone stimulation test. The vast majority were foreign to this category.
We have several of those where they’re deficient not only in growth hormone but multiple other pituitary hormones because of an organic lesion, because of whatever other developmental or acquired reason, those are the children who will benefit from being transitioned and being treated as, quote, “adults.” We call adult treatment if it’s not really for growth, but it’s really for growth hormone’s metabolic benefits. Then the concern is how do we transition them? The reality is most pediatric endocrinologists will continue to see some of these children when they become young adults, but the idea would be at some point to transition them to an adult endocrinologist.
Many of the adult endocrinologists are not familiar with growth hormone treatment, so you need to find a group or at least an individual who is both familiar with and comfortable with seeing young people who take growth hormone.
Multiple other challenges exist because they need to have replacement of multiple hormones, and the testing and the definition and “adult growth hormone deficiency” is somewhat fuzzier. There are some studies that have looked at this adult growth hormone deficiency, and the difference is whether it’s childhood-onset adult growth hormone deficiency or adult-onset. I think we are talking about childhood-onset that needs to be transitioned. For those, it’s more than likely, although on occasion there’s sufficient with a single orbital deficiency, but more than likely it will be multiple hormones related to some kind of developmental or organic problem.
Question:
Do you find that adherence remains a challenge in adult patients requiring therapy for growth hormone deficiency?
Robert Rapaport, MD:
Yeah, there is multiple challenges. Some of them come from the people to whom you transition them to. Some of them come from the insurance company that says, “Oh no, they’ve reached a good height forget growth hormone.” Of course, we need to educate both groups to say that in fact, these young children who are now transitioning to young adulthood do in fact have an ongoing need for growth hormone hormone.
Question:
What current and emerging treatment options are available for adult patients with growth hormone deficiency?
Robert Rapaport, MD:
From my colleagues who deal with mostly adults, there’s always a bit of a reluctance to go on injectable treatment, especially if there’s a history they’ve been reasonably well. I think the long-acting growth hormone I think should be a terrific benefit for adults who perhaps have never had injectable treatment, and now they will be on treatment with a medication that perhaps could be given weekly. I think in the future, it may be once every 2 weeks, perhaps once a month, perhaps alternate forms of treatment. But I think those would be the challenges for the adult population who haven’t been used.
