Replacement therapy should be offered to adults with severe growth hormone deficiency

Editor-In 1996 adult growth hormone deficiency became a licensed indication for growth hormone replacement therapy. Under most circumstances it is not difficult to identify patients likely to have severe growth hormone deficiency. We screen this cohort and assess their need for replacement therapy. Because of current health economic policies we are unable to provide a supply of growth hormone from the hospital and therefore ask the patient's general practitioner to do this. We provide a shared care protocol and justification for the therapeutic decision and emphasise that we are happy to supervise the patient's management while he or she is taking growth hormone replacement.

Currently only a fifth to a quarter of our requests for a prescription for growth hormone are met. Some of the general practitioners do not reply or refuse a prescription on medicolegal grounds. In addition, many general practitioners refer the request to their local health adviser, who often misquotes or is ill informed about the evidence on the benefits and side effects of growth hormone replacement therapy. Some of these advisers quote an efficacy review, available on the Internet, that is inaccurate, having been prepared 18 months ago, before growth hormone was licensed for adult use and before many data on efficacy were available.

Last August I wrote an editorial on this topic for the BMJ.1 My aim was to present a balanced case to cover the available evidence. I tried to develop a therapeutic strategy that would apply to the patients who are most in need. At the same time I was keen to avoid financial waste, being aware that, by endocrine standards, growth hormone is expensive. In the editorial I concluded that a substantial proportion of patients with severe growth hormone deficiency benefit from growth hormone replacement therapy.

Thus it is with great regret that I have learnt that a number of health authorities have misconstrued the tenor of my editorial and are using it as an argument against prescribing adult growth hormone replacement. To avoid any misunderstanding I wish to make my position clear: in my view a trial of growth hormone replacement therapy should be offered to patients with severe growth hormone deficiency and considerably impaired quality of life or severe osteopenia; such therapy should be continued in those patients in whom the trial shows benefit.