Feeling misguided: a comment on the US guidelines on growth hormone and insulin-like growth factor-I treatment in children and adolescents

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The growth hormone (GH) treatment Guidelines by Grimberg et al. [1] on behalf of the Drug and Therapeutics Committee and Ethics Committee of the US Pediatric Endocrine Society (PES) were long overdue and comprehensive. Unfortunately, there are several aspects of this work that raise concern in the Pediatric Endocrine communities. First, it only puts forth North American views. In the age of globalization, input from sister societies (ESPE, SLEP, JPES and so on) would have timely and welcome as noted in a recent commentary by Ranke and Wit [2]. Second, it approaches the topic with the rigor typically used in fields such as hypertension and hypercholesterolemia, where dozens of very-large, long-term randomized trials are regularly being conducted; ignoring the fact that in pediatric short stature, randomized trials are infrequent, small and rarely conducted till adult height, and smaller studies must be considered. In fact, the relatively long interval that has elapsed since the previous PES 2003 guidelines is a result of the paucity of new research in the field. Third, these treatment guidelines blurred the lines between practice and ethics, and represent the views of a legitimate but not unanimous component of the US Pediatric Endocrine community. The group that crafted these guidelines was selected not for its expertise in the growth field but with an ‘ideological’ litmus test [3] whereby only individuals who did not report honoraria or grant support from GH manufacturers were allowed to participate, representing a departure from the commonly accepted practice of allowing experts to participate in such activities as long as they fully list their conflicts. Moreover, several members of the PES Drugs and Therapeutics Committee have indicated that they had no input into the document and had not necessarily agreed with all of its contents. Furthermore, while PES policy requires a period of public comment on a draft of such guidelines, scores of comments, including lengthy and thoughtful comments from the two authors of this commentary and multiple other highly regarded experts, were simply brushed off and ignored. During this public comment period preceding the publication of the Guidelines, two issues sparked the most interest and commentary. These two issues were: benefits of insulin like growth factor-1 (IGF-1)-based GH dosing and sex steroid priming in the evaluation of GH deficiency. These two issues will be addressed in this invited, brief commentary.
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