Growth Hormone Deficiency in Adults Workup
- Author: Mohsen S Eledrisi, MD, FACP, FACE; Chief Editor: George T Griffing, MD more...
Evaluation for GH deficiency is recommended in patients with hypothalamic-pituitary disease, surgery or irradiation in these areas, head trauma, or the presence of other pituitary hormone deficiencies. For patients with childhood-onset GH deficiency, retesting for GH deficiency is indicated after achievement of adult height to determine the need to continue therapy. In these patients, discontinuing GH therapy for at least 1 month is recommended before retesting. Patients with congenital or irreversible hypothalamic-pituitary structural abnormalities do not require retesting for GH deficiency.
Random serum growth hormone levels are of little value because of the pulsatile nature of GH secretion.
GH deficiency is diagnosed by a low level of serum insulinlike growth factor-1 (IGF-1) in the presence of deficiency of 3 or more pituitary hormones.
Patients who have deficiency of 2 or fewer pituitary hormones or pituitary/hypothalamic disease with low IGF-I levels require stimulation tests to establish the diagnosis of GH deficiency. The two most commonly used tests are the insulin tolerance test (ITT) and the combination of growth hormone-releasing hormone (GHRH) and arginine (GHRH-arginine test). The glucagon stimulation test is a third option.
Patients should have adequate replacement of other deficient pituitary hormones before testing for GH secretion.
All stimulation tests are done after an overnight fast and involve measuring serum growth hormone levels. In the ITT, insulin is administered intravenously at a dose of 0.1 unit/kg (time 0) to produce a lowering in plasma glucose level to less than 40 mg/dL (2.2 mmol/L). Glucose levels can be monitored by capillary samples every 15 minutes and once symptoms of hypoglycemia develop. A repeated dose of insulin can be administered if hypoglycemia does not develop by 30-60 minutes. Serum glucose and serum growth hormone levels are measured at 0, 15, 30, 60, 90, and 120 minutes after administering insulin. GH deficiency is diagnosed if peak growth hormone level is less than 5.1 mcg/L.
The test should be undertaken by an experienced staff under the direct supervision of a physician. It should be avoided in patients with cardiovascular disease, cerebrovascular disease, or seizure disorders.
The GHRH-arginine can be used as an alternative to the ITT. GHRH is administered intravenously at a dose of 1 mcg/kg body weight (time 0) followed by an intravenous infusion of 0.5 g/kg body weight (maximum 30 g) of arginine over 30 minutes. Serum growth hormone is measured at -30, 0, 30, 60, 90, and 120 minutes.
Because body mass index (BMI) can influence the GH response, the following criteria are used to establish the diagnosis of GH deficiency when using the GHRH-arginine test:
Peak GH level is less than 11.1 mcg/L in patients with BMI <25
Peak GH level is less than 8.1 mcg/L in patients with BMI³ 25 and <30
Peak GH level is less than 4.1 mcg/L in patients with BMI³ 30
In patients with GH deficiency of hypothalamic origin (such as irradiation), GHRH can stimulate the pituitary and therefore yields falsely normal results. In such cases using alternative stimulation tests is recommended.
The glucagon test can be used if GHRH is not available or the GHRH-arginine test is normal in the context of a high suspicion for GH deficiency and using ITT is contraindicated.
Glucagon is administered intramuscularly at a dose of 1 mg (1.5 mg for patients who weigh >90 kg); GH levels are measured just before the injection and every 30 minutes for 4 hours. GH deficiency is diagnosed if the peak GH level is <3.1 mcg/L.
MRI of the hypothalamic-pituitary region may be used to define the anatomy of this region for the presence of tumors or structural abnormalities.
Dual-energy x-ray absorptiometry (DXA) may be used to assess bone mineral density.
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