Growth hormone deficiency testing and treatment following mild traumatic brain injury

Leah J Mercier, Natalia Kruger, Quynk B Le, Tak S Fung, Gregory A Kline, Chantel T Debert, Leah J Mercier, Natalia Kruger, Quynk B Le, Tak S Fung, Gregory A Kline, Chantel T Debert

Abstract

Pituitary dysfunction, specifically growth hormone (GH) deficiency, can occur following traumatic brain injury. Our objective was to characterize the prevalence of GH deficiency (GHD) testing and response to recombinant human GH (rhGH) treatment in adults with persistent symptoms following mild traumatic brain injury (mTBI) referred for assessment of pituitary dysfunction. A retrospective chart review was conducted of patients seen at an outpatient brain injury clinic with a diagnosis of mTBI and persistent post-concussive symptoms who were referred to endocrinology. Clinical assessments of symptoms were collected. Investigations and results of GHD were collected, including initiation of rhGH treatment and treatment response. Of the 253 patients seen in both brain injury and endocrinology clinics, 97 with mTBI were referred for investigation of pituitary dysfunction and 73 (75%) had dynamic testing for assessment of GHD. Of the 26 individuals diagnosed with GHD, 23 (88%) started rhGH. GH therapy was inconsistently offered based on interpretation of GH dynamic testing results. Of those who started rhGH, 18 (78%) had a useful treatment response. This study suggests that clinical management of these patients is varied, highlighting a need for clear guidelines for the diagnosis and management of GHD following mTBI.

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
Flowchart of referral to endocrinology, GH testing and rhGH therapy. CBIP Calgary Brain Injury Program (outpatient brain injury clinic), GH growth hormone, GHD growth hormone deficiency, GHI growth hormone insufficiency, mTBI mild traumatic brain injury, OECs outpatient endocrinology clinics, rhGH recombinant human growth hormone, TBI traumatic brain injury.
Figure 2
Figure 2
GHD prevalence using alternative diagnostic cut-offs based on peak GH during dynamic testing. Numbers of patients meeting differential diagnostic cut-offs with percentages calculated out of total number of individuals tested (n = 73). GH growth hormone, GHD growth hormone deficiency.
Figure 3
Figure 3
Clinical outcomes and response to dynamic testing. Participants dichotomized as severe GHD (peak GH a–c) Symptom burden (RPQ) (n = 48), depression (PHQ-9) (n = 60) and quality of life (QoL-AGHDA) (n = 28) scores were higher in individuals with severe GHD, however this was not statistically significant. Higher Qol-AGHDA scores indicate worse quality of life. (d) Cognition (MoCA) (n = 57) scores were lower in individuals with severe GHD, however this was not statistically significant. GH growth hormone, GHD growth hormone deficiency, MoCA Montreal Cognitive Assessment, PHQ-9 Patient Health Questionnaire-9, RPQ Rivermead Post Concussion Symptoms Questionnaire, QoL-AGHDA Quality of Life Assessment of Growth Hormone Deficiency in Adults.
Figure 4
Figure 4
Quality of life assessment and dynamic testing results. Qol-AGHDA scores (n = 28) were correlated with peak GH during dynamic testing, r(26) = − 0.454, p = 0.015. GH growth hormone, GHD growth hormone deficiency, GHI growth hormone insufficiency, QoL-AGHDA Quality of Life Assessment of Growth Hormone Deficiency in Adults.
Figure 5
Figure 5
Whether rhGH therapy was offered and corresponding peak GH results. GH growth hormone, GHD growth hormone deficiency, GHI growth hormone insufficiency, rhGH recombinant human growth hormone.

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