Side Effects of Growth Hormone Therapy in Pediatric Patients
Growth hormone therapy in pediatric patients is generally safe with no significant association between GH therapy and serious adverse events such as malignancy, slipped capital femoral epiphysis, avascular necrosis, glucose intolerance, pancreatitis, rapid progression of chronic kidney disease, acute allograft rejection, or fluid retention. 1
Common Side Effects
Intracranial hypertension: Rare but documented in registry data. Baseline fundoscopy is recommended before starting GH therapy, and immediate evaluation including fundoscopy should be performed if persistent headache or vomiting occurs 1
Lipoatrophy at injection sites: Can be prevented by rotating injection sites daily 1
Glucose metabolism alterations:
- Insulin secretion increases during the first year of treatment
- Hyperinsulinemia may persist during long-term therapy
- Evidence suggests GH treatment for ≤5 years typically does not have adverse effects on glucose tolerance
- Close monitoring of glucose metabolism is advised, especially in patients with obesity or risk factors 1
Secondary hyperparathyroidism:
- Occasionally reported as a complication of GH therapy
- GH may directly stimulate the parathyroid gland or affect calcium and phosphate homeostasis
- Pre-existing renal osteodystrophy may be unmasked by increased longitudinal bone growth 1
Monitoring Recommendations
- Regular clinic visits: Every 3-6 months (more frequently for young patients and those with advanced CKD) to monitor 1:
- Growth parameters (stature, height velocity)
- Pubertal development
- Skeletal maturation (wrist radiography)
- Renal function
- Thyroid hormone levels (TSH and free T3)
- Serum glucose
- Calcium, phosphate, bicarbonate
- Parathyroid hormone levels
Contraindications and Special Considerations
Absolute contraindications 1:
- Known hypersensitivity to GH or its constituents
- Active malignancy
- Uncontrolled diabetes mellitus
- Pre-existing papilledema
Special populations requiring careful monitoring 1:
- Patients with obesity - increased risk of impaired glucose tolerance
- Patients with nephropathic cystinosis - increased risk of diabetes mellitus
- Patients with severe secondary hyperparathyroidism (PTH >500 pg/ml) - GH should be withheld until PTH levels return to target range
When to Stop GH Treatment
GH treatment should be discontinued in the following situations 1:
- When epiphyseal closure is demonstrated
- At the time of renal transplantation
- In patients with persistent severe secondary hyperparathyroidism (PTH >500 pg/ml)
Long-term Safety Considerations
- Short-term RCTs have shown similar adverse effects between GH-treated patients and control populations 1
- Long-term registry data supports the overall safety profile of GH therapy 1
- Both reference GH products and biosimilars appear to have comparable safety profiles based on pharmacovigilance data over the past decade 1
Administration Considerations
- Recommended dosage: 0.045-0.05 mg/kg body weight per day 1
- Administration: Daily subcutaneous injections in the evening to mimic physiological circadian rhythm 1
- Injection technique: Change injection site daily to avoid lipoatrophy 1
- Self-administration: Children from 8-10 years of age can be encouraged to self-administer with proper training and adherence monitoring 1
By following these monitoring guidelines and being vigilant for potential side effects, the benefits of GH therapy in improving growth outcomes can be maximized while minimizing risks in pediatric patients.