This pilot study utilizing 6 boys and 4 girls was designed to determine whether rhGH could overcome some of the catabolic effects of chronic glucocorticoid (CG) treatment (24 months) of IBD.  Subcutaneous rhGH (0.05 mg/kg/d) was given for a minimum of 6 months.  Seven patients continued for 12 months.  Body composition changed favorably with increased fat free mass and decreased fat mass.  Linear growth velocity increased from 3.5 ± 0.4 cm/yr pre-rhGH to 7.7 ± 0.9 cm/yr after 6 months.  The GV persisted for the next 6 months in all 7 treated.  Bone calcium accretion increased as did alkaline phosphate specific for bone [(a measure of bone formation) p = .03].  Fasting and 2 hour post prandial glucose levels, fasting insulin levels, and HbAlC remained in the normal range.  The authors concluded that treatment with rhGH at the doses used has beneficial effects in prednisone-dependent growing children, on body composition without detrimental effects in carbohydrate metabolism or the intermediate metabolism of substrates.  Larger studies will be needed to assess long term safety and efficacy.

Editor’s Comment: This well designed study provides encouraging data that rhGH can overcome the anti-anabolic effects of prednisone, enhance the growth rate, and do so without measurable toxicity over 6-12 months.  Of particular interest was the disappointing observation that there was no change in the disease activity as determined by the Crohn’s Disease Activity Scale adapted for pediatric subjects.  There were significant increases in serum levels of IGF-1 and IGF.BP3.  The authors suggest that a state of “functional” GH deficiency caused by chronic steroids may be overcome with rhGH administration.  It is important to remember that rhGH has not been effective in treating patients with IBD who are not on glucocorticoid treatment.  Also of importance is to recall the reports of Rivkees et al and Allen et al who reported the acceleration of growth in glucocorticoid treated children with significant growth retardation who were treated with rhGH.  Allen et al reviewed the data of the Genentech National Growth Study in which 83 children with extreme glucocorticoid induced short stature were treated for at least 12 months with rhGH.  The authors concluded: (1) growth suppressing effects of chronic GC are counter-balanced by GH therapy; the mean response being a doubling of baseline growth rate, (2) responsiveness to GH is negatively correlated with GC doses, and (3) glycolysated hemoglobin levels increased slightly, but glucose and insulin levels were not altered by GH therapy.  These authors summarized: “In a cohort of 83 poorly growing GC-dependent children, we suggest that the growth suppressing effects of GC can be variably overcome by GH.  The short term risks of combined GH and GC treatment appear low; potential long term effects require further surveillance and study.  Treatment of GC-dependent children with GH remains experimental; children considered for such treatment should be enrolled in studies that facilitate careful monitoring and data analysis.”  Dr. Mauras and her co-investigators have heeded the suggestion and extended the data.  Rivkees et al, Allen et al, and Mauras et al are to be commended for clinical investigation that significantly enhances patient care.

	Rivkees SA, et al. J Pediatr 1994;125:322-325.
	Allen DB, et al. J Clin Endocrinol Metab 1998;83:2824-29.

Robert M. Blizzard, MD