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ACTH, adrenocorticotrophic hormone; IHT, insulin-hypoglycemia test; TSH, thyroid-stimulating hormone; GH, growth hormone; FSH, follicle-stimulating hormone; LH, leutinizing hormone; ADH, anti-diuretic hormone; U & E, urea and electrolytes.

ACTH, adrenocorticotrophic hormone; IHT, insulin-hypoglycemia test; TSH, thyroid-stimulating hormone; GH, growth hormone; FSH, follicle-stimulating hormone; LH, leutinizing hormone; ADH, anti-diuretic hormone; U & E, urea and electrolytes.

health. The first dose should be at or just before rising, and the latest in the late afternoon or early evening. The dose should be doubled during any intercurrent pyrexial illness, and an emergency pack of intramuscular hydrocortisone 100 mg can be available for use during severe vomiting or diarrhea. As noted, a "steroid card" should be held by the patient and, ideally, a Medic-Alert bracelet worn in countries where this is available. Recent data suggest that previous dose regimens were too high, and generally 15-20 mg daily should be adequate.

Thyroid hormone replacement is relatively straightforward, with a usual daily dose of 0.1 mg levothyroxine being sufficient. TSH monitoring is unhelpful in this situation.

For the sex steroids, there is no consensus as to the optimal form of estrogen and progesterone, and this should be given as standard hormone replacement therapy. For the younger patient, the oral contraceptive preparations are slightly unorthodox, but we can see no reason why they should not be used, especially because they may allow the patient to feel more "normal" in relation to her peers. For men, there are several testosterone treatments, attesting to the belief that none is perfect. The cheapest and most popular form is injectable testosterone enanthate, 100 mg weekly, 250 two or three weekly, or 500 mg three or four weekly; however, the injections may be uncomfortable, and the pharmacokinetics are far from ideal, especially with the larger doses. In some UK centers, implants are favored and may last for up to 6 mo. Of the patches, currently the only one still available in the UK has a high incidence of skin sensitivity problems. The oral preparation, testosterone undecanoate, must be given two or three times daily, and dosing is difficult because blood levels of testosterone are unreliable indicators of its efficacy (it is mainly metabolized to dihydrotestosterone). A "buccal" slow-release

Table 2

Clinical Features of Growth Hormone Deficiency in Adults

Background

Known pituitary pathology ± previous treatment Full conventional pituitary hormone replacement Need for growth hormone (GH) treatment as a child Symptoms

Abnormal body composition Reduced lean body mass Increased abdominal adiposity Reduced strength and exercise capacity Impaired psychological well-being Depressed mood Reduced vitality and energy Emotional lability

Signs

Overweight, with predominantly central (abdominal) adiposity Thin, dry skin; cool peripheries; poor venous access Reduced muscle strength Reduction exercise performance Depressed affect, labile emotions Investigations

Low or low-normal serum insulin-like growth factor (IGF)-I

Elevated serum lipids, particularly low-density lipoprotein cholesterol

Reduced lean body mass/increased fat mass

Reduced bone mineral density preparation may become available with in the next year or two, while in the United States a gel formulation looks promising and will soon be available in Europe. In the end, the choice of replacement sex steroid should be decided upon after discussion between patient and physician.

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