0021-972X/98/$03.00/0 Journal of Clinical Endocrinology and Metabolism Copyright © 1998 by The Endocrine Society Vol. 83, No. 1 Printed in U.S.A. The Australian Multicenter Trial of Growth Hormone (GH) Treatment in GH-Deficient Adults* ROSS C. CUNEO, STEVE JUDD, JENNIFER D. WALLACE, DON PERRY-KEENE, HENRY BURGER†, SYLVIA LIM-TIO, BOYD STRAUSS, JAN STOCKIGT, DUNCAN TOPLISS, FRANK ALFORD, L. HEW, HANS BODE, ANN CONWAY, DAVID HANDELSMAN, STEWART DUNN, STEVE BOYAGES, N. WAH CHEUNG, AND DAVID HURLEY Endocrine Unit, Flinders Medical Centre (S.J.), Adelaide; Metabolic Research Unit, University of Queensland, Princess Alexandra Hospital (R.C.C., J.D.W.) Brisbane; Endocrine Unit, Royal Brisbane Hospital (D.P-K.), Brisbane; Prince Henry’s Institute of Medical Research, and Body Composition Laboratory, Monash Medical Centre (H.B., S.L-T., B.S.), Melbourne; Ewen Downie Metabolic Unit, Alfred Hospital (J.S., D.T.), Melbourne; Endocrine Unit, St. Vincent’s Hospital (F.A., L.H.), Melbourne; Paediatric Endocrine Unit, Sydney Children’s Hospital (H.B.), Sydney; Andrology Unit, Royal Prince Alfred Hospital (A.C., D.H.), Sydney; Medical Psychology Unit, University of Sydney (S.D.), Sydney; Endocrine Unit, Westmead Hospital (S.B., N.W.C.), Sydney; and Department of Diabetes and Endocrinology, Royal Perth Hospital (D.H.), Perth, Australia impedance (P , 0.001) or deuterium dilution (P 5 0.002). Fat mass measured by DEXA (P , 0.001), skinfold thicknesses (P , 0.001), and waist/hip ratio (P 5 0.001) decreased in the first 6 months. Most changes in body composition were complete by 3 months of treatment and maintained to 12 months. Whole-body bone mineral density (BMD) (by DEXA) was unaffected by GH treatment. Self-reported quality of life was considered good before treatment, and beneficial treatment effects were observed for energy, pain, and emotional reaction as assessed by the Nottingham Health Profile. In the initial 6 months, adverse effects were reported by 84% of patients in the GH and 75% in the placebo group, with more symptoms relating to fluid retention in the GH group (48% vs. 30%; P 5 0.016). Such symptoms were mild and resolved in 70% of patients despite continued treatment. Resting blood pressure did not change over the initial 6 months. In summary, GH treatment in adults with GH deficiency resulted in 1) prominent increases in serum IGF-I at the doses employed, in some cases to supraphysiological levels; 2) modest decreases in total- and low-density lipoprotein cholesterol, together with substantial reductions in totalbody and truncal fat mass consistent with an improved cardiovascular risk profile; 3) substantial increases in lean tissue mass; and 4) modest improvements in perceived quality of life. The excessive IGF-I response and side-effect profile suggest that lower doses of GH may be required for prolonged GH treatment in adults with severe GH deficiency. (J Clin Endocrinol Metab 83: 107–116, 1998) ABSTRACT GH treatment in adults with GH deficiency has numerous beneficial effects, but most studies have been small. We report the results of an Australian multicenter, randomized, double-blind, placebo-controlled trial of the effects of recombinant human GH treatment in adults with GH deficiency. GH deficiency was defined as a peak serum GH of ,5 mU/liter in response to insulin-induced hypoglycemia. Patients were randomly assigned to receive either GH (0.125 U/kg per week for 1 month and 0.25 U/kg per week for 5 months) or placebo. After 6 months, all patients received GH. The primary end points were biochemical responses, body composition, quality of life, and safety. One hundred sixty-six patients (72 females and 91 males) with a mean age of 40 6 1 yr (6SEM; range 17– 67 yr) were recruited. Serum insulin-like growth factor-I (IGF-I) increased from a standard deviation score of 22.64 6 0.27 (range 28.8 to 13.82; n 5 78) to 11.08 6 2.87 (range 27.21 to 16.42) at 6 months in the GH/GH group; 38% of the whole group were above the age-specific reference range following treatment [17.6% and 68.9% with subnormal (,2 SD) or normal (62 SD) pretreatment levels, respectively]. Fasting total cholesterol (P 5 0.042) and low-density lipoprotein cholesterol (P 5 0.006) decreased over the first 6 months. Fat-free mass increased in the first 6 months whether measured by bioelectrical impedance (P , 0.001) or dual energy x-ray absorptiometry (DEXA; P , 0.001). Total-body water increased in the first 6 months whether measured by bioelectrical T REATMENT of GH deficiency in adult humans became an option following the development of recombinant DNA-derived human GH and the early reports on the effect of GH therapy in such patients (1, 2). The syndrome of GH deficiency in adults principally comprises abnormalities in body composition, cardiovascular risk factors, and psychological well-being. In comparison to normal individuals, these patients have increased total-body fat mass (particularly visceral adiposity), reduced lean body (or fat-free) mass (FFM), reduced skeletal muscle mass, reduced muscle strength and exercise performance, and reduced bone mass (3– 6). Increased mortality rates, particularly relating to cardiovascular diseases, have been described in adults with hypopituitarism who received conventional hormone replacement with glucocorticoids, T4, and sex steroids (7). Whether these mortality rates are explained by elevated total and low-density lipoprotein (LDL) cholesterol and reduced high-density lipoprotein (HDL) cholesterol concentrations, central adiposity, or other factors remains unexplained (8). Received May 6, 1997. Revision received September 3, 1997. Accepted September 12, 1997. Address all correspondence and requests for reprints to: Ross C. Cuneo, University Department of Medicine, Princess Alexandra Hospital, Wooloongabba, Brisbane, 4102, Australia. E-mail: cuneo2@ gpo.pa.uq.edu.au. * This work was funded by Pharmacia (Australia) Pty Ltd. Portions of this data were reported at the Endocrine Society of Australia’s annual scientific meeting, Melbourne, September 1995. † Principal investigator. 107 108 JCE & M • 1998 Vol 83 • No 1 CUNEO ET AL. Reductions in muscle force generation and aerobic exercise performance may relate to reductions in skeletal muscle mass and altered myocardial function (9 –12). The psychological dysfunction comprises self-reported reductions in energy, mood, and sleep, along with objective reductions in marital and socioeconomic performance (13, 14). Treatment with GH has been reported to reverse many of these abnormalities (1, 2, 15, 16). Uncertainty remains regarding the definition of GH deficiency and the appropriate dose of GH for replacement. Differing studies have selected patients of markedly different degrees of GH deficiency, ranging from essentially no GH response to insulin-induced hypoglycemia to those with a peak GH of ,10 –20 mU/liter following oral clonidine (2). Recent data suggest that a peak GH of ,5 ng/mL in response to insulin-induced hypoglycemia is abnormal for all adults (17). Most early reports used high daily doses of GH (0.4 – 0.49 U/kg per week), resulting in side effects caused by fluid retention (18 –21). We undertook a large trial of GH treatment in adults with GH deficiency to assess the effects of a moderate dose of GH, in a group of patients selected on the basis of our current best definition of GH deficiency. The primary end points were assessment of biochemical responses, body composition, quality of life, and safety. Patients and Methods Study design Patients were randomly allocated without stratification to treatment either with GH (Genotropin, Pharmacia AB, Stockholm, Sweden) or identically presented placebo for the first 6 months in a double-blind fashion. Thereafter, all patients received GH in an open study for a further 6 months. The two groups were labeled GH/GH or placebo/GH. Randomization to either treatment involved a computer-generated listing, with equal numbers being entered per group at each of the 10 centers. The dose of GH (or placebo) was 0.125 U/kg per week (maximum 2 IU/day) for the first month, and 0.25 U/kg per week (or 0.55 mg/kg per week; maximum 4 IU/day) thereafter. Because the study remained blinded throughout, the dose for all subjects was lowered from month 6 until month 7, reverting to the full dose thereafter. The dose was reduced in response to the side effects of edema or arthralgia and remained at or was reduced to 0.125 IU/kg per week and increased only with resolution of the symptoms. Persistent side effects resulted in transient cessation of therapy, which was resumed with resolution of symptoms, with the dose remaining at 0.125 IU/kg per week thereafter. The dose was self-administered using the KabiPen (Pharmacia AB) from 16 IU/mL vials as sc injections 7 nights/week. The injection site was either the anterior thigh or abdomen, at the patient’s preference, but remained constant throughout the study. Compliance was checked by vial count and injection diary. Patients were assessed at months 0, 6, and 12 for all end points, at months 1 and 7 for safety checks, and at months 3 and 9 for selected end-point assessment. The study protocol was approved by the ethics committees of each participating unit. Center 1 participated only in the 6-month, doubleblind phase of the study. All patients received written information and gave written consent according to the Declaration of Helsinki (1964 and later revisions) and the National Health and Medical Research Council (Australia) Ethics in Medical Research (1983). The study was conducted according to the Australian Guidelines of Good Clinical Research Practice (1991). those ,19 yr; 2) GH deficiency was documented as peak GH of ,5 mU/liter following insulin-induced hypoglycemia (blood glucose ,2.2 mmol/liter or with symptoms); and 3) other pituitary hormone deficiencies were replaced, with stable replacement therapy for at least 6 months before entry. Daily glucocorticoid doses were not to exceed 30 mg hydrocortisone, 37.5 mg cortisone acetate, 7.5 mg prednisolone, or 0.5 mg dexamethasone. T4 replacement was to result in normal serumfree T4 (fT4) and/or free T3 (fT3) concentrations. Parenteral or oral testosterone administration was to be used in men and estrogen (with/or without progesterone) administration in women under age 50 yr. Women of child-bearing potential were to be using adequate contraception (oral contraceptives or intrauterine device) and were required to have a negative pregnancy test at entry. Preentry insulin-hypoglycemia testing was required within the last 5 yr after the age of 20 yr or after epiphysial closure unless: 1) the patient had had hypophysectomy with subsequent testing at any time; 2) the patient had radiotherapy. Testing was also specified to be 3) at least 6 months after normalization of serum PRL in a patient with prolactinoma; 4) at least 6 months after normalization of glucocorticoid status in a patient with Cushing’s disease; and 5) at least 12 months after cure of a TSH-secreting pituitary tumor. Patients were excluded if any of the following were present: 1) GH treatment in the last 12 months; 2) a history of acromegaly; 3) estrogen deficiency uncorrected in women below age 50 yr; 4) active Cushing’s syndrome; 5) any acute severe illness in the last 6 months; 6) pregnancy or lactation; 7) severe chronic liver disease (defined as persistent elevation of transaminases more than twice the upper limit of normal); 8) chronic renal impairment (defined as serum creatinine . 0.12 mmol/ liter or persistent hematuria or proteinuria); 9) diabetes mellitus; 10) history of malignancy other than cranial tumor or leukemia causing GH deficiency; 11) history of meningioma or currently active intracranial malignancy; 12) uncontrolled hypertension (diastolic blood pressure .90 mmHg); 13) overt cardiac dysfunction or ischemia on electrocardiogram; 14) severe chronic airway disease; 15) any medication thought to alter the response to treatment or the end points, especially high-dose glucocorticoids and diuretics (cholesterol-lowering agents were permitted, but doses of all medications were held as constant as possible); 16) history of noncompliance with medications, uncooperativity, or drug or alcohol abuse; and 17) known sensitivity to m-cresol. Screening of patients before entry included complete history and physical examination, resting electrocardiogram, routine biochemistry and hematology, and urinalysis. Biochemical responses Fasting serum concentrations of insulin-like growth factor I (IGF-I) and IGF-binding protein-3 (IGFBP-3) were measured at months 0, 6, and 12 in all centers. Samples were frozen and stored at 220 C and assayed in a central laboratory. IGF-I was measured by RIA after acid-ethanol extraction, using a truncated radiolabeled IGF as tracer (in- house assay, Pharmacia, Uppsala, Sweden). The detection limit was 20 ng/mL, and the intra- and interassay coefficients of variation (CVs) at 202 ng/mL were 3.1 and 10.0%, respectively. The concentration of IGF-I was also expressed as a standard deviation score (i.e. normal values range from 12 to 22), expressed in relation to normal age-adjusted adult values calculated as follows: IGF-I sds 5 (ln (IGF-I) 2 (5.95 2 0.0197 3 age))/0.282 Selection criteria The reference population was Swedish, comprised of 83 male and 73 female healthy blood donors, with mean body weights of 80.9 kg (range 60 –115 kg) and 66.1 kg (range 50 –95 kg) for males and females, respectively, and mean body mass indexes of 25 and 23.7 kg/m2, respectively (Pharmacia, unpublished data). IGFBP-3 was measured by RIA using 125 I-labeled recombinant human IGFBP-3 as tracer (in-house assay, Pharmacia). The assay’s detection limit was 0.9 ng/mL and the intra- and interassay CVs at 43.2 ng/mL were 4.9% and 7.2%, respectively. The assay had negligible cross-reactivity with IGFBP-1, -2, and -4 (,0.3%). The concentration of IGFBP-3 was also expressed as a standard deviation score from the same Swedish population data as IGF-I, calculated as follows: Patients were included if: 1) age was 18 – 65 yr and linear growth was completed as confirmed by epiphysial closure on wrist radiography for IGFBP-3 sds 5 (s IGFBP-3 2 exp (2.0466 2 (0.0099 3 age)))/ exp (0.6707 2 (0.0099 3 age)) GH TREATMENT IN ADULTS WITH GHD Fasting serum was collected for lipid estimation at months 0, 6, and 12 in all centers. Routine assays were performed at individual centers. Total cholesterol was measured by enzymatic and colorimetric methods (Boehringer Mannheim, Mannheim, Germany) in all centers except one, with interassay CVs of ,4.1%. HDL cholesterol was assayed following polyethylene glycol precipitation of other lipoproteins (phosphotungstic acid/Mg11 in one center), followed by identical analysis for cholesterol; CVs were ,6.4%. LDL cholesterol was calculated from the Friedwald formula. Serum triglyceride was measured by enzymatic and colorimetric methods (Boehringer Mannheim) in all centers except one, with interassay CVs , 4.8%. Body composition All centers measured anthropometric characteristics and bioelectrical impedance (BIA) at months 0, 3, 6, 9, and 12. Five centers (centers 2– 6) measured deuterium dilution (D2O) at the same intervals, plus the specialized body composition measurements at 0, 6, and 12 months [dual energy x-ray absorptiometry (DEXA) and total-body potassium scanning]. At centers 4 – 6, in vitro neutron activation analysis was also performed. Anthropometric measurements included height, weight, skinfold thicknesses, midarm circumference, and waist/hip circumference ratio (WHR). A Harpenden caliper was used at four standard sites (biceps, triceps, subscapular, suprailiac). Training was given to researchers at each center before the commencement of the study to minimize betweencenter variability, and where possible, one observer performed all measurements. Skinfold measurements are reported as peripheral (sum of biceps and triceps), truncal (sum of subscapular and suprailiac) and total (sum of four). Waist circumference was recorded at the narrowest point or at the umbilicus and hip circumference at the level of the greater trochanter. BIA was measured with the SEAC Bioimpedance Meter Model BIM 3.0 (Inderlec, Brisbane, Australia), except in center 4, where a BEI-101 Body Composition Analyzer (RJL Systems, Detroit, MI) was used. FFM and total-body water (TBW) were calculated according to formulae derived from healthy individuals (22, 23). TBW was derived from the D2O method, following oral administration of D2O and spectrophotometric analysis of venous plasma samples (24). The minimum intraassay CV of the assay was ,5.0% for a low standard and ,2.2% for a high standard, and interassay CV was ,2.9% over the duration of the study. DEXA measurements of the whole body and lumbar spine (results of the latter to be reported separately) were taken on two Lunar DPX System scanners (Lunar Corp., Madison, WI), one in both Brisbane and Melbourne. FFM, fat mass (FM), and total-body calcium were derived from the whole-body scans. Comparability of the two machines was assessed by scanning phantoms. Total-body potassium (TBK) was measured as 40K content using shadow shield counters in Brisbane and Melbourne. Subject measurements were calibrated against a phantom (25). Using the proportion of intracellular potassium as an index of FFM (64 – 68 mmol/kg) and the two compartment model of body composition, FFM and FM were derived. For the Melbourne scanner, the interassay CVs for measurements of the calibration and anthropometric phantoms were ,3.8%. Comparability of the two machines was assessed by swapping the phantoms of known potassium content. In vitro neutron activation analysis measured total-body nitrogen, and hence total-body protein (TBP) (24). The interassay CVs for day-day measurement of the calibration and anthropometric phantoms were ,3.8% (average 2.5%; within day) and ,10.5% (average 5.7%; within month) throughout the study period. The mean accuracy was 99.5% for the anthropometric phantom. Quality of life assessments Questionnaires were administered at months 0, 3, 6, 9, and 12. The Nottingham Health Profile (NHP) is a valid and reliable measure of perceived health, developed in the United Kingdom to assess physical, emotional, and social distress. It is regarded as valid for Australian populations (26, 27). Part I of the test was administered. Six subscales can be derived, including emotions, pain, physical mobility, sleep, energy, and social isolation. Analysis was based on the proportion of positive answers, with a score higher than 0 indicating a compromised state. A 109 summary score (SUM) was also derived, with a positive score indicating a favorable quality of life. The GH Deficiency Questionnaire (GHDQ) was developed for this trial. It was based on group discussions with adults with GH deficiency regarding their perceived major areas of disability, i.e. energy, mood, and sleep. The GHDQ consists of 30 questions relating to these three subscales or domains, each answered on a 10-cm visual analog scale, completed on an IBM portable computer, on which mean and range of responses was recorded. Mean responses are reported. A higher score represented a more positive status. The GHDQ has been validated in normal individuals and used as a trial in a small group of adults with GH deficiency (S. Dunn, unpublished data). Social history was also assessed at months 0, 6, and 12. Data was collected regarding marital status, number of children, living arrangements, education level, occupation/employment/retirement status, sick leave in the past 6 months, physical activity at leisure and work, social activity and satisfaction, and significant life events. Safety and adverse events monitoring Safety assessments included complete physical examination, routine biochemistry, fT4, glycosylated hemoglobin A1c, full blood examination, supine blood pressure recorded in triplicate after 5 min rest, and urinalysis at months 0, 6, and 12. All adverse events were recorded, quantitated according to the patient’s estimation of severity, and specific inquiry was made as to features of fluid retention and arthralgias. The adverse events were classified according to the WHO codes and preferred terms. Statistical analysis The study was analyzed on an intention-to-treat basis. Missing data points were not estimated. Comparisons of continuous and categorical baseline data were analyzed by ANOVA and contingency table analysis, respectively. Treatment effects for NHP data were assessed using the mean score test, a weighted analysis of covariance (ANCOVA) using baseline data as the covariate (28); variance was partitioned between treatment, withdrawal status, baseline data as covariate, month, and relevant interactions. Treatment effects for other continuous variables and the GHDQ were assessed using ANCOVA with baseline data as the covariate. Results of treatment and baseline data were therefore presented as means adjusted for baseline differences (mean 6 sem); sems for baseline data are presented uncorrected, whereas all posttreatment sems are adjusted for baseline covariance. For body composition data, variance was partitioned between treatment, center, gender, month, and withdrawal status. After ANCOVA, pairs of means were compared with the least significant difference, allowing comparison between groups at each time point. Maintenance of a treatment effect beyond the first 6 months was assigned if there was no significant change in the mean values in the GH/GH group from 6 –12 months and no significant difference between the GH/GH and placebo/GH group means at 12 months. Treatment effects for categorical data were assessed using contingency table analysis and a log linear model (29). Laboratory safety data were analyzed using Mann-Whitney U or Wilcoxon rank sum W tests. A P value of ,0.05 was considered significant. Results Patient population, study drug, and compliance One hundred sixty-six patients were entered. Three patients withdrew consent before initiation of treatment. The demographic characteristics of the patients are shown in Table 1. The two treatment groups were similar in all aspects except for the duration of GH deficiency, which was shorter in the GH/GH group (estimated from the time of abnormal insulin-hypoglycemia testing or pituitary surgery and/or radiotherapy; P 5 0.03). In addition to pituitary hormone replacement, 10% of patients received bromocryptine; 9% received antidepressants, anxiolytics, or hypnotic medica- 110 JCE & M • 1998 Vol 83 • No 1 CUNEO ET AL. tions; 6% anticonvulsants; 7% treatment for asthma; and 4% treatment for hypercholesterolemia. The most frequent changes in medication during the study were courses of antibiotics, increased bronchodilators or corticosteroids, and short increments in glucocorticoid replacement. There were no differences in medications between the two groups. The average maintenance dose of GH was 2.6 6 0.8 IU/day (0.03 6 0.01 U/kg per day or 0.22 6 0.05 IU/kg per week; n 5 74) at month 3 (2.6 6 0.6 IU/day for the placebo group; n 5 78) and 2.4 6 0.8 IU/day (0.22 6 0.06 IU/kg per week; n 5 117) at month 9. Twenty-four patients (29%) of the GH group had their GH dose reduced or interrupted because of symptoms of fluid retention or arthralgia, and 13 of these patients withdrew from the study. Two patients in the placebo group had their placebo dose reduced. High rates of compliance (.90%) were seen in 70% and 73% of patients who completed 6 and 12 months of treatment, respectively. Poor rates of compliance (,60%) were seen in 6.9% and 16.2% of patients who completed 6 and 12 months of treatment, respectively. TABLE 1. Patient characteristics at baseline Age (yr) Gender (F/M) Weight (kg) Height (cm) Body mass index (kg/m2) Duration of GH deficiency (yr) Pituitary hormone deficiency (%) ACTH TSH LH/FSH Antidiuretic hormone Previous GH treatment (%) Etiology of GH deficiency (%) Pituitary tumor Irradiation Craniopharyngioma Idiopathic Cushing’s disease Trauma Septooptic dysplasia Other GH/GH group Placebo/GH group 41.2 6 1.5 33:50 81.4 6 20.1 168.4 6 10.3 28.5 6 6.0 9.3 6 0.8 39.8 6 1.5 39:41 72.5 6 16.9 164.8 6 10.6 26.5 6 5.1 12.1 6 1.0a 67 71 75 28 28 76 78 83 26 35 48 13 6 8 6 5 1 12 39 19 15 13 3 1 0 11 Biochemical responses Serum IGF-I concentrations. At baseline, there was no difference between treatment groups (Table 2). The percentage of patients in the entire study group at baseline with IGF-I sds ,2 and 62 were 56.6% and 43.9%, respectively. There was a significant increase in serum IGF-I with GH treatment for months 0 – 6 and 0 –12, and a treatment 3 time interaction for months 0 –12 (all P , 0.001). The percentage of patients who developed supraphysiological serum IGF-I concentrations at 12 months (.2 sd) who had subnormal (,2 sd) or normal (62 sd) pretreatment levels was 17.6% (12/68) and 68.9% (31/45), respectively. Serum IGFBP-3 concentrations showed similar changes (Table 2). Serum lipids. At baseline, there were no differences between treatment groups or centers for fasting serum concentrations of total, LDL, and HDL cholesterol and triglycerides, except for HDL cholesterol, where there was a significant difference between treatment groups (GH 1.13 6 0.04 vs. placebo 1.28 6 0.06 mmol; P 5 0.050) (Table 3). There was a significant decrease in total cholesterol with GH treatment for months 0 – 6 (P 5 0.040) but not for months 0 –12 (P 5 0.103), with a significant difference in response between centers (P 5 0.03 and 0.014 for months 0 – 6 and 0 –12, respectively). There was a significant decrease in LDL cholesterol with GH treatment for months 0 – 6 and months 0 –12 (P 5 0.005 and 0.019, respectively), with no difference between centers. For serum HDL cholesterol concentration, there was no treatment effect or treatment 3 time interaction, but there was a significant difference between centers (P 5 0.001 and 0.008 for months 0 – 6 and 0 –12, respectively). For serum triglyceride concentration, there was no treatment effect, treatment 3 time interaction, or difference between centers. Body composition Results of body composition are shown in Table 4. Body weight remained unchanged (GH/GH group: 81.4 6 20.1, 80.0 6 19.4, and 79.7 6 18.2 kg at 0, 6, and 12 months, respectively; placebo/GH group: 72.5 6 16.9, 72.5 6 16.7, and 72.8 6 16.1 kg, respectively; mean 6 sd). Anthropometry. At baseline, the total sum of skinfold thicknesses was significantly different between males and females Data are presented as mean 6 SEM. , P , 0.05 comparing group means. a TABLE 2. Serum IGF-I and IGFBP-3 response Month Serum IGF-I (ng/mL) Serum IGF-I (SDS) Serum IGFBP-3 (ng/mL) Serum IGFBP-3 (SDS) 0 6 12 0 6 12 0 6 12 0 6 12 GH/GH group Placebo/GH group Mean (6SEM) n Mean (6SEM) n 100 280 6 203,a,b 291 6 243,b 22.46 1.08 6 0.343,a,b 1.17 6 0.373,b 2.97 3.93 6 0.252,a,b 4.08 6 0.251,b 21.66 20.91 6 0.202,a,b 20.84 6 0.193,b 78 71 57 78 71 57 78 71 47 78 71 47 98 90 6 6 255 6 20b,d 22.64 22.94 6 0.26 0.71 6 0.34b,d 2.61 2.66 6 0.18 4.29 6 0.32b,d 21.95 21.94 6 0.14 20.67 6 0.24b,d 79 74 60 79 74 60 79 74 54 79 74 54 Primary analysis for treatment effects was performed with ANCOVA (1, P 5 ,0.05; 2, P , 0.01; 3, P , 0.001; see text for details); secondary analyses performed with least significant difference analysis (a, difference between groups at each time point; b, c, d, and e, differences within one group between time point and month 0, 3, 6, and 9, respectively; all P , 0.05). GH TREATMENT IN ADULTS WITH GHD 111 TABLE 3. Lipid and safety data Month Total cholesterol (mmol/liter) LDL cholesterol (mmol/liter) HDL cholesterol (mmol/liter) Triglycerides (mmol/liter) Fasting serum glucose (mmol/liter) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) 0 6 12 0 6 12 0 6 12 0 6 12 0 6 12 0 3 6 9 12 0 3 6 9 12 GH/GH group Placebo/GH group Mean (6SEM) n Mean (6SEM) n 5.7 5.5 6 0.11,a,b 5.5 6 0.1b 3.8 3.3 6 0.12,a,b 3.3 6 0.11,b 1.2 1.3 6 0.1a,b 1.3 6 0.0b,d 1.8 1.9 6 0.1 1.8 6 0.1 4.5 4.7 6 0.13,a 4.7 6 0.11 120 118 6 1 118 6 1 115 6 2b 121 6 2e 78 76 6 1 75 6 1 74 6 1b 80 6 1c,d,e 70 67 51 41 36 29 52 48 41 70 67 51 67 64 47 72 72 69 53 53 72 72 69 53 53 5.8 5.7 6 0.1 5.7 6 0.1 3.9 3.8 6 0.1 3.6 6 0.1b 1.2 1.3 6 0.0 1.2 6 0.0 1.8 1.8 6 0.1 1.9 6 0.1 4.5 4.4 6 0.1 4.6 6 0.1 119 120 6 1 121 6 2 119 6 2 123 6 2b,e 76 78 6 1 78 6 1 76 6 1 77 6 1 78 72 60 45 36 35 57 49 47 78 72 60 74 66 52 79 77 77 65 61 79 77 77 65 61 Primary analysis for treatment effects was performed with ANCOVA (1, P 5 ,0.05; 2, P , 0.01; 3, P , 0.001; see text for details); secondary analyses performed with least significant difference analysis (a, difference between groups at each time point; b, c, d, and e, differences within one group between time point and month 0, 3, 6, and 9, respectively; all P , 0.05). (76.2 6 2.7 vs. 93.7 6 3.9 mm; P , 0.001) and between centers (P , 0.001) but not between treatment groups. There was a reduction in total sum of skinfold thicknesses with GH treatment for months 0 – 6 and 0 –12 (P , 0.001 and P 5 0.003, respectively). At baseline, the sum of truncal skinfold thicknesses was significantly different between males and females (44.7 6 1.6 vs. 50.5 6 2.1 mm; P , 0.001) between centers (P , 0.001) and between treatment groups (GH 49.3 6 1.9 vs. placebo 45.1 6 1.8 mm; P 5 0.015). There was a reduction in truncal skinfold thickness with GH treatment for months 0 – 6 and 0 –12 (P , 0.001 and P 5 0.001, respectively). At baseline, the sum of peripheral skinfold thicknesses was significantly different between males and females (31.1 6 1.4 vs. 44.6 6 2.2 mm; P , 0.001) and between centers (P , 0.001) but not between treatment groups. There was a reduction in peripheral skinfold thickness with GH treatment for months 0 – 6 and 0 –12 (P 5 0.021 and P 5 0.063, respectively). None of these treatment responses was influenced by gender. At baseline, WHR was different between centers (P 5 0.007), but not between treatment groups. There was a significant reduction in WHR with GH treatment for months 0 – 6 and 0 –12 (P 5 0.001 and P 5 0.015, respectively). Parallel reductions in total-body FM as measured by DEXA were also observed for months 0 – 6 and 0 –12 (both P , 0.001; data not shown). FFM derived from BIA. At baseline, there were significant differences between males and females (57.4 6 1.3 vs. 42.3 6 0.9 kg; P , 0.001) between centers (P 5 0.002) and between treatment groups (GH/GH group: 53.4 6 1.5 vs. placebo/GH group: 47.7 6 1.3 kg; P , 0.001). There was an increase in FFM with GH treatment for months 0 – 6 and 0 –12 (both P , 0.001) and a treatment 3 time interaction for months 0 –12 (P , 0.001). This response was influenced by gender (for the 0 – 6and 0 –12-month periods, treatment 3 gender interaction P 5 0.029 and 0.079, respectively) indicating a greater increment in FFM in males. FFM measured by DEXA, TBK, and TBP showed similar increments following GH treatment at both 6 and 12 months (P , 0.001 for all; data not shown). TBW derived from BIA. At baseline, there were significant differences between males and females (39.1 6 0.8 vs. 27.6 6 0.6 l; P , 0.001), between centers (P 5 0.001), and between treatment groups (GH/GH group: 35.9 6 1.0 vs. placebo/GH group: 31.8 6 0.9 l; P , 0.001). There was an increase in TBW with GH treatment for months 0 – 6 and 0 –12 (P , 0.001 and P 5 0.005, respectively) and a treatment 3 time interaction for months 0 –12 (P , 0.001). This response was not influenced by gender (for the 0 – 6- and 0 –12-month periods, treatment 3 gender interaction P 5 0.6 and 0.3, respectively). TBW derived from D2O showed a similar increment with GH treatment (P , 0.013; data not shown). Whole-body BMD. At baseline, there were significant differences between males and females (1.193 6 0.013 vs. 1.097 6 0.017 g/cm2; P , 0.001), between centers (P 5 0.024), but not between treatment groups (P 5 0.084). At baseline, the BMD represented 97.4 6 1.3% and 97.4 6 1.6% of young adult BMD, and 96.3 6 0.35% and 96.4 6 0.27% of age-matched BMD for the GH/GH and placebo/GH groups, respectively. There was no treatment effect (for the 0 – 6- and 0 –12-month periods, P 5 0.30 and 0.19, respectively) or treatment 3 time interaction. Secondary analysis (by least significant differ- 112 JCE & M • 1998 Vol 83 • No 1 CUNEO ET AL. TABLE 4. Body composition Month Total skinfold thicknesses (mm) Truncal skinfold thicknesses (mm) Peripheral skinfold thicknesses (mm) WHR FFM (kg) derived from BIA TBW (liters) derived from BIA Total-body BMD (g/cm2) Total-body BMD (% young adult; gender matched) 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 6 12 0 6 12 GH/GH group Placebo/GH group Mean (6SEM) n 84.3 6 3.4 74.0 6 1.6a,b 72.2 6 2.03,a,b 70.7 6 2.7b 69.2 6 3.02,b,c 47.4 6 1.9 40.6 6 1.0a,b 40.6 6 1.43,a,b 39.5 6 1.5b 40.3 6 1.83,b 37.5 6 2.0 34.3 6 1.0b 32.5 6 1.01,a,b 31.8 6 1.5b,c 29.6 6 1.6b,c,d,e 0.894 6 0.009 0.878 6 0.004a,b 0.877 6 0.0043,a,b 0.876 6 0.005b 0.870 6 0.0051,b 50.6 6 1.5 53.5 6 0.4a,b 53.6 6 0.43,a,b 54.1 6 0.5b 53.3 6 0.43,b 34.0 6 1.0 35.8 6 0.2a,b 35.7 6 0.33,a,b 36.1 6 0.3b 35.6 6 0.32,b 1.149 6 0.017 1.141 6 0.003 1.120 6 0.007b,d 97.3 6 1.3 96.9 6 0.4 95.3 6 0.5b,d 72 72 69 54 53 72 72 69 54 53 73 73 70 55 54 73 73 70 54 54 73 72 70 54 53 73 72 70 54 53 45 43 39 34 32 30 Mean (6SEM) 83.5 6 3.3 82.2 6 1.6 81.5 6 1.9 76.1 6 2.0b,c,d 72.7 6 2.4b,c,d,e 46.9 6 1.8 46.6 6 0.9 46.8 6 1.2 43.0 6 1.1b,c,d 42.5 6 1.5b,c,d 36.9 6 1.8 36.3 6 1.0 35.4 6 1.0 33.7 6 1.2b,c 30.8 6 1.2b,c,d,e 0.892 6 0.008 0.895 6 0.003 0.893 6 0.004 0.882 6 0.007b,c,d 0.880 6 0.005b,c,d 50.2 6 1.3 50.3 6 0.3 50.9 6 0.4 54.2 6 0.7b,c,d 53.1 6 0.4b,c,d 33.7 6 0.9 33.8 6 0.2 34.2 6 0.3 36.3 6 0.4c,d 35.5 6 0.3c,d,e 1.148 6 0.016 1.145 6 0.002 1.129 6 0.003b,d 97.3 6 1.6 96.4 6 0.3 95.3 6 0.3b,d n 79 78 77 63 60 79 78 77 63 60 79 78 77 64 60 79 78 77 65 61 77 75 74 61 58 77 75 74 61 58 43 42 36 35 35 30 Primary analysis for treatment effects was performed with ANCOVA (1, P 5 ,0.05; 2, P , 0.01; 3, P , 0.001; see text for details); secondary analyses performed with least significant difference analysis (a, difference between groups at each time point; b, c, d, and e, differences within one group between time point and month 0, 3, 6, and 9, respectively; all P , 0.05). ence) revealed a significant reduction in BMD in both groups by 12 months (see Table 4). Efficacy: quality of life assessment NHP. At baseline, analysis of the NHP revealed no difference between the GH/GH and placebo/GH groups with respect to energy, pain, sleep, and physical mobility (Table 5). The mean baseline scores were low (indicating little or no impairment). The proportion of patients with 0 scores (no impairment) was: energy 36.5%, pain 77%, emotional reaction 45.5%, sleep 43.5%, social isolation 70.5%, and physical mobility 59.5%. Improvement in quality of life in patients who score 0 at baseline cannot be measured with the NHP. Analysis of the data for efficacy by assessing only patients with positive scores at baseline revealed no differences from that presented (i.e. analyzing all data). For the energy subscale, there was an initial (months 0 – 6) improvement in the placebo/GH group vs. the GH/GH group (P 5 0.016); however, the GH/GH group improved progressively as shown by a treatment effect over months 0 –12 (P , 0.001) and a treatment 3 time interaction (P 5 0.046). For the pain subscale, there was no treatment effect, but there was a treatment 3 time interaction for months 0 – 6 (P 5 0.047), suggesting a lessening in perceived pain in the GH group. For the emotional reaction subscale, there was no treatment effect for months 0 – 6, but for months 0 –12 there was a beneficial effect (lessening of emotional reaction) seen in the GH/GH group vs. the placebo/GH group (P , 0.001). For the sleep subscale, there was no treatment effect for the months 0 – 6 or 0 –12, but a significant treatment 3 time interaction (P 5 0.011) indicated an improvement in the GH/GH group over the 0 –12-month interval. For the social isolation subscale, there was no treatment effect. For physical mobility subscale, there was no treatment effect, but there was a significant treatment 3 time interaction for the months 0 –12 (P 5 0.001), indicating an initial deterioration in mobility shortly after the introduction of GH treatment in both groups followed by improvement. There was no treatment effect for the SUM, but there was a treatment 3 time interaction from months 0 – 6 and 0 –12 (P 5 0.056 and 0.037, respectively), indicating an overall improvement in the GH/GH group. GHDQ. There were no differences between the groups at baseline, and there were no significant treatment effects for GH TREATMENT IN ADULTS WITH GHD 113 TABLE 5. NHP results Month Energy score Pain score Emotional reaction score Sleep score Social isolation score Physical mobility score SUM score 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 0 3 6 9 12 3 6 9 12 GH/GH group Placebo/GH group Mean (6SEM) n Mean (6SEM) n 1.03 6 0.06 0.69 6 0.06 0.55 6 0.051 0.15 6 0.03 0.23 6 0.043 0.77 6 0.10 0.84 6 0.10 0.34 6 0.041 0.28 6 0.05 0.45 6 0.09 1.38 6 0.12 0.87 6 0.09 0.65 6 0.07 0.32 6 0.05 0.31 6 0.063 1.14 6 0.07 0.93 6 0.07 0.85 6 0.07 0.58 6 0.07 0.70 6 0.081 0.48 6 0.06 0.26 6 0.03 0.27 6 0.04 0.13 6 0.03 0.18 6 0.04 0.54 6 0.07 0.84 6 0.07 0.61 6 0.06 0.39 6 0.05 0.58 6 0.073 4.43 6 0.06 4.67 6 0.11 5.24 6 0.09 5.09 6 0.121 73 73 70 52 54 73 73 70 51 54 72 72 70 52 54 73 73 70 52 54 73 72 70 52 54 73 73 70 52 54 70 69 50 53 1.17 6 0.05 0.50 6 0.04 0.56 6 0.04 0.60 6 0.05 0.36 6 0.04 0.23 6 0.06 0.19 6 0.04 0.28 6 0.05 0.44 6 0.06 0.49 6 0.09 0.70 6 0.07 0.43 6 0.05 0.58 6 0.05 0.68 6 0.06 0.55 6 0.06 0.99 6 0.06 0.52 6 0.05 0.55 6 0.05 1.14 6 0.06 0.78 6 0.07 0.24 6 0.03 0.19 6 0.03 0.31 6 0.04 0.10 6 0.02 0.29 6 0.04 0.38 6 0.03 0.26 6 0.04 0.37 6 0.05 0.73 6 0.05 0.54 6 0.06 5.02 6 0.05 4.43 6 0.12 4.78 6 0.12 4.88 6 0.13 76 79 76 64 61 79 76 75 65 60 78 76 76 65 61 79 78 76 65 61 79 78 76 65 61 78 78 76 65 61 69 71 62 57 Primary analysis for treatment effects was performed with mean score test, a weighted ANCOVA, with significant results for either a treatment effect or a treatment times time interaction being highlighted (1, P 5 ,0.05; 2, P , 0.01; 3, P , 0.001; see text for details). either mood, energy, or sleep scales throughout the study. For the sleep scale, there was a significant treatment 3 time interaction for months 0 –12 (P 5 0.011), indicating an improvement in sleep in the GH/GH group. Social history. Physical activity at work and at leisure, each quantitated into five categories, showed no change throughout the study. There was no change for the number of full sick days taken in the previous 6 months throughout the study, but the absolute numbers were small in each group (GH/GH group: 0.45 6 0.11 days sick/patient over 6 months vs. placebo/GH group: 0.41 6 0.09 by month 6). The frequency of meeting friends and satisfaction with life, quantitated into five categories or yes/no, respectively, showed no change. At baseline, 63% of the GH/GH and 73% of the placebo/GH groups were satisfied with their lives, rising to 85% and 83%, respectively, by 12 months. There was no change in the occurrence of significant life events between the groups. groups, and there was no change in with GH treatment for months 0 – 6 and 0 –12 (P 5 0.17 and P 5 0.093, respectively). At baseline, there was no difference in diastolic blood pressure between centers or treatment groups. There was no change in diastolic blood pressure with GH treatment for months 0 – 6 and 0 –12 (P 5 0.087 and P 5 0.23, respectively), but there was a significant treatment 3 month interaction (P 5 0.002) for the months 0 –12, indicating a progressive fall in the GH/GH group from 0 –9 months (with an increase at 12 months returning to pretreatment levels). Alkaline phosphatase and white cell count increased, and serum urea, potassium, alanine aminotransferase, aspartate aminotransferase, and g-glutamyltranspeptidase decreased in the GH/GH compared with the placebo/GH group (data not shown). The magnitude of such changes rendered these of doubtful clinical significance. There was no change in red cell count or glycosylated hemoglobin A1c. Safety monitoring Adverse events At baseline, there was no difference in fasting serum glucose between treatment groups, but serum glucose increased with GH treatment for months 0 – 6 and 0 –12 (P 5 0.001 and P 5 0.014, respectively; Table 3). At baseline, there was a no difference in systolic blood pressure between treatment Overall, the incidence of reported adverse events was high, partly relating to the method of documenting separate but related events. In months 0 – 6, 290 events in 70 of the 83 GH/GH patients (84%) and 219 events in 60 of the 80 placebo/GH patients (75%) were recorded. During the open 114 phase of GH treatment, 411 new events were reported in 99 patients. Events were considered either to relate to known GH actions or to be unexpected. Predictable side effects (Table 6) included edema (which included generalized, peripheral, or facial edema, carpal tunnel symptoms, and peripheral swelling or tightness; 48% of GH/GH patients vs. 30% placebo/ GH; P 5 0.016), arthralgias, and myalgias (which included arthritis, arthrosis, myalgia, muscle stiffness, tendonitis, and muscle weakness; 30% GH/GH vs. 13% placebo/GH; P 5 0.007), paresthesia and anesthesia (12% GH/GH vs. 4% placebo/GH; P 5 0.056), and increased sweating (3.6% GH/GH vs. 0% placebo/GH; P 5 0.078). Overall, 19 patients from the GH/GH group and 11 from the placebo/GH group withdrew. The primary reason for withdrawal was a GH-related adverse event in 40% of these patients. Events that were not predictably GH related included: 1) in months 0 – 6 reduced frequency of reported pain (0% GH/GH vs. 6.3% placebo/GH; P 5 0.02), aggressive reactions (0% GH/GH vs. 3.8% placebo/GH; P 5 0.075), and moniliasis (0% GH/GH vs. 3.8% placebo/GH; P 5 0.075); 2) five cases of adrenal insufficiency (all on GH/GH); 3) two cases of operation for pituitary tumors (one each on placebo/GH and GH/GH); 4) two episodes of collapse in a patient with similar past history (on GH/GH); 5) one episode each of amaurosis fugax and chest pain in one patient (on GH/GH); and 6) three abdominal surgical procedures. One patient with pulmonary fibrosis and chronic graft vs. host disease following childhood acute lymphatic leukemia died of respiratory failure, which was not considered to be related to the GH treatment. Withdrawn patients Analysis of completed vs. withdrawn patients revealed no difference with respect to baseline characteristics. Those who withdrew, compared with those completing the study, were characterized by 1) a tendency to have lower FFM for the 0 – 6- and 0 –12-month periods (P 5 0.089 and 0.025, respectively); 2) having a progressively worse NHP energy score TABLE 6. Predictable adverse events Phase 1 GH (n 5 83) Edema Incidence (%) Severity (% mild; moderate; severe) Duration (days) Unresolved (%) Myalgia/Arthralgia Incidence (%) Severity (% mild; moderate; severe) Duration (days) Unresolved (%) Paraestiesie Incidence (%) Severity (% mild; moderate; severe) Duration (days) Unresolved (%) JCE & M • 1998 Vol 83 • No 1 CUNEO ET AL. Phase 2 Placebo (n 5 80) Phase 2 GH (n 5 130) 48 57; 36; 7 30 67; 30; 2 43 58; 39; 3 36 6 58 30 37 6 57 28 26 6 38 33 30 44; 50; 6 13 64; 36; 0 25 57; 36; 7 101 6 201 36 23 6 49 14 33 6 40 2 12 77; 15; 8 4 80; 20; 0 15 67; 9; 4 43 6 44 39 22 6 36 20 36 6 26 46 for months 0 –12 (P 5 0.003); 3) having a worse NHP pain score for both the 0 – 6- and 0 –12-month periods (P 5 0.031 and 0.010, respectively); 4) those in the GH/GH group who withdrew having a worse NHP emotional reaction score than in the placebo/GH group for months 0 – 6 and 0 –12 (both P , 0.001); 6) those in the GH/GH group who withdrew having a worse NHP sleep score than in the placebo/GH group for months 0 – 6 (P 5 0.006) and 0 –12 (P , 0.001); 7) having a worse summary NHP score for months 0 – 6 and 0 –12 (P 5 0.037 and 0.005, respectively), and those in the GH/GH group who withdrew having a worse score than those in the placebo/GH group (P 5 0.004 and 0.002, respectively). Maintenance of treatment effects from 6 –12 months All biochemical end points remained stable (serum IGF-I, IGFBP-3, total cholesterol, and LDL cholesterol). Significant improvements in body composition end points were evident at 3 months (all three skinfold estimates, WHR, FFM by BIA, and TBW by BIA) and showed a gradual improvement (total and peripheral skinfolds) or stable course until 12 months. For FFM by DEXA, FM by DEXA, TBK, and TBN, improvements were evident at 6 months and were maintained to 12 months, with the placebo/GH group still below the GH/GH group values by 12 months for the last two end points. Discussion The definition of GH deficiency used in this study was a peak GH response to insulin-induced hypoglycemia of less than 5 mU/liter. Recent studies have shown that insulininduced hypoglycemia is one of the most reliable means of assessing GH secretion in adults, and that the threshold as defined in this study represents an optimal distinction between normal adults and patients with severe GH deficiency (17). The characteristics of the patients selected is representative of previous studies in GH deficiency in adults. The most frequent cause of the condition was previous pituitary adenomas and surgical and/or radiotherapy for such tumors treated during adult life. Three quarters of the group had panhypopituitarism. The presence of more than one pituitary hormone deficiency is strongly predictive of organic GH deficiency (28, 30). Approximately one third of the group received GH treatment for short stature during childhood. The GH dose during this study was approximately half that used in the original treatment trials (0.25 IU/kg per week vs. 0.49 IU/kg per week) (18 –21). Nevertheless, the incidence of GH-related adverse events was high. In comparing the results of treatment between this and other studies, it seems likely that GH-deficient adult patients with more profound degrees of GH deficiency (i.e. this study group) may be likely to have a greater response to GH treatment than those with lesser degrees of GH deficiency (i.e. studies using responses to clonidine or arginine) (31). Assuming IGF-I can act as a guide for optimizing GH dose, we found that the a substantial proportion of patients developed a supraphysiological serum IGF-I concentration following GH treatment, particularly in those with normal pretreatment serum IGF-I concentrations. This strongly suggests that the mean dose is still too high, and that certain subgroups may require even lower doses. Given the high rate of reported adverse events in GH TREATMENT IN ADULTS WITH GHD patients receiving placebo treatment, it was not possible to predict those at risk of GH-mediated adverse events. Adults with GH deficiency have increased risk factors for premature vascular disease, i.e. increased total and LDL cholesterol concentrations, reduced HDL concentrations, increased apolipoprotein B concentrations, increased number of small LDL particles, and increased WHRs, visceral adiposity, and varying degrees of insulin resistance (8, 32, 33). Such abnormalities may explain the increased mortality rates caused by vascular disease in adults with conventionally treated hypopituitarism (7, 34). With respect to vascular risk factors, GH treatment in our study induced small reductions in total (1.8%) and LDL cholesterol (7.0%) concentrations, and substantial reductions in truncal adiposity (9.2–14.1%; see below). The increase in serum glucose with GH treatment is well described, and appears to represent transient worsening of insulin resistance (35, 36). Previous studies have shown prominent reductions in intraabdominal or visceral fat following GH treatment (21), changes that would be expected to improve insulin resistance (37). There were no changes in other risk factors. Thus, whether continued GH treatment alters the long-term vascular mortality rate remains unknown. We were able to confirm the findings that GH treatment in adults with GH deficiency influenced body composition. In the 6-month controlled phase, FFM increased 4.5% as measured by BIA. In a subset of patients, other indices of lean tissue mass also increased: 4.4% by DEXA, 6.6% by TBK, and 8.6% by TBP. TBW measured by BIA in all patients increased by 3.2%. FM reflected in total skinfold thickness, truncal, or peripheral skinfold thicknesses declined 12.0%, 14.1%, and 9.3%, respectively, and when measured by DEXA declined 9.2%. WHR decreased by 2.0%. The different magnitudes of increase in lean tissue mass between the various methodologies may be partially explained by inaccuracies induced by concomitant shifts in other body compartments (38), differing specificities of the tools, and that some measurements were performed on subsets of patients. Our data confirm the prominent lipolytic action of GH in adults with GH deficiency, and that more subcutaneous fat was lost from the trunk than the periphery. Overall, the magnitude of such changes was slightly less than reported in the early trials, reflecting the lower dose of GH used in the current trial (18, 19, 21). Additionally, we have shown that the GH-induced changes in body composition were sustained to 12 months. Males showed greater increments in FFM measured by BIA than females; the physiological explanation may relate to interactions between testosterone and GH in stimulating growth and protein anabolism (39), or in stimulating greater IGF-I responses (40). Mean whole-body BMD declined 2.5% in the GH/GH group and 1.7% in the placebo/GH group over 12 months, with no GH treatment effect. Such findings are consistent with an early GH-mediated increase in bone remodeling (41). Adults with GH deficiency perceive their own quality of life to be worse than that of normal subjects (5, 42), and have poor social performances in employment and marriage (43, 44). The NHP questionnaire used in this study has been validated for a variety of diseased populations and in different cultures. Although we did not assess a control pop- 115 ulation under similar circumstances, between one third and two thirds of our patients before treatment felt little or no impairment in their quality of life. Hypothetically, the longterm presence of GH deficiency may have habituated them to accept their condition. Despite this favorable pretreatment quality of life, GH treatment still resulted in measurable beneficial effects for energy, emotional reaction, the overall score, and possibly pain and sleep. Detrimental effects were recorded for physical mobility in the 3 months following initiation of GH treatment, most likely relating to the high prevalence of adverse effects of peripheral edema or arthralgias. The perceived beneficial effects of GH treatment, the high compliance rate, and the percent of patients completing the study is encouraging given the high incidence of adverse events. The nature of the adverse events correspond with previous reports, and can be summarized as those caused by sodium retention (resulting in edema or carpal tunnel symptoms) or arthralgias/myalgias (which may relate to articular cartilage swelling and skeletal muscle growth or edema). Although a variety of disorders were reported under the heading of edema, carpal tunnel syndrome was the least common, with an incidence of 4.8% in the GH/GH group, 1.3% in the placebo/GH group, and 3.4% during the open phase of treatment. Such effects are clearly dose dependent and in many individuals self-limiting. One adverse event not previously reported was glucocorticoid deficiency. Such events were infrequent (five events in approximately 180 patient years of treatment), making causality difficult to ascribe to GH. Increased glucocorticoid catabolism has been reported following GH treatment, with reduced 24-h serum cortisol profile of hypopituitary patients on stable glucocorticoid replacement therapy (45), and induction of cytochrome P-450 enzymes (29). Adults with GH deficiency treated with GH at a dose of 0.25 IU/kg per week (0.55 mg/kg per week) for 6 –12 months benefit by means of 1) a doubling in serum IGF-I concentration; 2) substantial benefits in body composition such as increased FFM and reduced FM; 3) modest reductions in cardiovascular risk factors with as yet unproven biological consequences; and 4) improvements in self-perceived quality of life. Whether these changes translate into improved cardiovascular morbidity and mortality rates and enhanced physical and psychological function in the long term requires careful ongoing study. Optimization of the dose, with attendant reductions in adverse events that relate predominantly to sodium and fluid retention, remains an important objective for the future development of this therapy. Acknowledgments We gratefully acknowledge the assistance of Ms. Phillipa Smith and Mr. George Papadopoulos of Pharmacia (Australia). 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