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While growth hormone (GH) may have some direct growth-promoting effects, it is thought to mediate skeletal growth principally through production of insulin-like growth factor-I (IGF-I) at the epiphyseal plate, which acts mainly in an autocrine/paracrine manner. IGF-I may also promote statural growth through endocrine mechanisms. The findings of small testes and a microphallus in this patient suggest a diagnosis of hypogonadism, likely as a consequence of gonadotropin deficiency. This patient is at risk for multiple hypothalamic/pituitary deficiencies. He may already have or may subsequently develop ACTH/ cortisol and TSH/thyroid hormone deficiencies and thus may require supplementation with hydrocortisone and levothyroxine, in addition to supplementation with GH and testosterone. He should also be evaluated for the pres-ence of central diabetes insipidus and, if present, treated with desmopressin, a V2 vasopressin receptor–selective analog.
Betty J. Dong, PharmD, FASHP, FCCP, FAPHA
JP is a 33-year-old woman who presents with complaints of fatigue requiring daytime naps, weight gain, cold intoler-ance, and muscle weakness for the last few months. These complaints are new since she used to always feel “hot,” noted difficulty sleeping, and could eat anything that she wanted without gaining weight. She also would like to become preg-nant in the near future. Because of poor medication adherence to methimazole and propranolol, she received radioactive iodine (RAI) therapy, developed hypothyroidism, and was started on levothyroxine 100 mcg daily. Other medications include calcium carbonate three times daily to “protect her bones” and omeprazole for “heartburn.” On physical exami-nation, her blood pressure is 130/89 mm Hg with a pulse of 50 bpm. Her weight is 136 lb (61.8 kg), an increase of 10 lb (4.5 kg) in the last year. Her thyroid gland is not palpable and her reflexes are delayed. Laboratory findings include a thyroid-stimulating hormone (TSH) level of 24.9 μIU/mL (normal 0.45–4.12 μIU/mL) and a free thyroxine level of 8 pmol/L (normal 10–18 pmol/L). Evaluate the management of her past history of hyperthyroidism and assess her current thyroid status. Identify your treatment recommendations to maximize control of her current thyroid status.