Treatment of children with GH: an audit of adherence to NICE guidelines
R El Khairi, M Urs & V Nanduri
Background: The National Institute of Clinical Excellence (NICE) published guidelines in May 2002 on the use of GH in children, recommending GH in 4 conditions: GH deficiency (GHD), Turner Syndrome, Prader-Willi Syndrome and chronic renal insufficiency.
Aim: To audit whether GH prescribing at our hospital adheres to NICE guidelines.
Methods: A retrospective audit was performed of children commenced on GH treatment between May 2002 and July 2008 in a district general hospital.
Results: Thirty patients (14 M:16 F) on GH were identified. Indications included GHD (15 patients) and TS (six patients). Nine patients were prescribed GH outside NICE guidelines (1 SGA, 5 skeletal dysplasias, 1 Noonan syndrome, 1 Kabuki syndrome, 1 short stature).
In 100% of patients treatment was initiated and monitored by a paediatrician with a special expertise in endocrinology. A shared care agreement with the GP to provide treatment was in place for 29 of 30 (97%) patients.
About 8 of 15 (53%) children had isolated GHD and seven had multiple pituitary hormone deficiency (MPHD) and/or defined CNS pathology. In 100% of patients with GHD, the diagnosis was supported by auxological measurements and bone age. About 100% of children with GHD had 1 pituitary stimulation test, IGF-1 and IGFBP-3. About 14 of 15 (93%) patients had a peak GH <20 mU/l. About 9 of 15 (60%) patients with GHD had an MRI brain. About 100% of patients with MPHD and CNS pathology had an MRI.
Treatment response was re-evaluated within 1 year in 30 of 30 patients. Good compliance was noted in all patients. Four patients reported minor side-effects. Of 15 patients with GHD, 12 (80%) showed an increase in growth velocity (HV) of >50%. GH was discontinued in 1 patient at 15.93 years at final height 174.5 cm (Ht SDS=0.22). Age at diagnosis of TS ranged from birth to 11.13yrs. About 3 of 4 patients had an increase in HV >50%.
Conclusion and recommendations: About 9 of 30 patients were prescribed GH for conditions outside NICE guidelines. Guidelines were adhered to with respect to monitoring and shared care. Areas to be addressed: 1) Two stimulation tests to diagnose isolated GHD; 2) MRI for all children with GHD; 3) Use of GH in other conditions needs to be discussed.