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Growth Hormone Endocrinology Handbook Imperial Centre for Endocrinology Imperial College Healthcare NHS Trust Charing Cross, Hammersmith and St. Mary’s Hospitals Updated: April 2016 First published: 1988 Available as a .pdf file since 1999 on: http://imperialendo.co.uk http://meeran.info 1 INTRODUCTION Diagnosis and appropriate treatment in clinical endocrinology rely heavily on the accurate use and interpretation of diagnostic tests. This handbook was devised as a means of guiding new junior staff (and refreshing the memories of their seniors!) when confronted by clinical problems and their investigation. This bible is meant to be brief and didactic with the inevitable costs as well as benefits of such an approach. It is envisaged that it will be reprinted at 6 monthly intervals incorporating corrections and additions, any suggestions and comments from readers are welcome. Grateful acknowledgements are due to: Professor Sir Stephen Bloom, Dr Simon Wallis, Professor Graham Joplin, Professor Kaye Ibbertson, Dr James Jackson, Dr Jacky Burrin, Mrs Veronica Ferguson, Mr Stuart Lavery, Mr Paul Bains, Dr Emma Walker, Dr Alexander Comninos and all our colleagues for their help and encouragement. We are delighted to note that this handbook is forming the basis of many endocrine protocols on various website around the country. The first version of this was written by the registrars and consultants in the Endocrine Unit in 1988 and used as a handbook for the junior doctors ever since. It has been available on the web since 1999 and it has since been widely used as the central source of endocrine protocols ever since. Please feel free to use this information to educate your own staff, and please simply acknowledge the Imperial Centre for Endocrinology. IMPORTANT NOTE: Any reference ranges provided apply specifically to Imperial College Healthcare NHS Trust (ICHNT). If using this resource at a difference centre, please check your local lab's reference ranges. 2 AUTHORS Sarah Ali Ben Jones Matthew Allum Bernard Khoo Maha Barakat Carl Le Roux Maria Barnard Niamh Martin Sophie Barnes Karim Meeran Duncan Bassett Elaine Murphy Rachel Batterham Nick Oliver Preeshila Behary Fausto Palazzo Nicola Bridges Arshia Panahloo Jaimini Cegla Debbie Peters Harvinder Chahal Michela Rossi Alexander Comninos Amir Sam Gerry Conway Leighton Seal Jaideep Dhariwal Mano Sira Waljit Dhillo Sarah Stanley Agnieska Falinszka Tricia Tan John Frank George Tharakan Stephen Gilbey Jeannie Todd Tony Goldstone Emma Walker Saira Hameed Julian Waung Peter Hammond Florian Wernig Emma Hatfield John Wilding Andrew Hattersley Matt Williams Chioma Izzi-Engbeaya Zarni Win Sheba Jarvis Sagen Zac-Varghese Channa Jayasena 3 CONTENTS INTRODUCTION ..................................................................................................................................... 2 AUTHORS ............................................................................................................................................... 3 ANTERIOR PITUITARY .......................................................................................................................... 9 ANTERIOR PITUITARY FUNCTION .................................................................................................. 9 INSULIN TOLERANCE TEST (ITT) ................................................................................................. 9 GLUCAGON TEST ........................................................................................................................ 13 METYRAPONE SUPPRESSION TEST ........................................................................................ 15 THYROTROPHIN RELEASING HORMONE (TRH) TEST ........................................................... 17 GONADOTROPHIN RELEASING HORMONE GNRH/LHRH TEST ............................................ 18 COMBINED PITUITARY FUNCTION TESTS (CPT) ..................................................................... 19 VISUAL FIELD TESTING (GOLDMANN AND HUMPHREYS PERIMETRY) ............................... 22 SUSPECTED CUSHING‟S DISEASE ................................................................................................... 24 LOW DOSE DEXAMETHASONE SUPPRESSION TEST (LDDST) ................................................. 24 BILATERAL SIMULTANEOUS INFERIOR PETROSAL SINUS SAMPLING (IPSS) WITH CRH .... 26 HIGH DOSE DEXAMETHASONE SUPPRESSION TEST ............................................................... 28 PRE-OPERATIVE PREPARATION OF PATIENTS WITH CONFIRMED CUSHING‟S DISEASE/SYNDROME ..................................................................................................................... 30 PERIPHERAL VENOUS SAMPLING FOR SOURCES OF ECTOPIC ACTH .................................. 30 OVERNIGHT DEXAMETHASONE SUPPRESSION TEST .............................................................. 30 CRH TESTING (WITHOUT DEXAMETHASONE ............................................................................. 31 PROLACTINOMAS AND NON-FUNCTIONING PITUITARY ADENOMAS ......................................... 34 ASSAY PROBLEMS TO BE AWARE OF WITH PROLACTIN ......................................................... 34 DISTINGUISHING PITUITARY MACROADENOMAS SECRETING PROLACTIN FROM NON- FUNCTIONING TUMOURS .............................................................................................................. 34 PROTOCOL FOR CABERGOLINE SUPPRESSION ....................................................................... 35 PREGNANCY AND THE PITUITARY ............................................................................................... 35 DOPAMINE AGONIST TREATMENT OF HYPERPROLACTINAEMIA ........................................... 36 PITUITARY TUMOURS ........................................................................................................................ 37 OPERATIVE MANAGEMENT OF PITUITARY TUMOURS .............................................................. 37 HYDROCORTISONE REPLACEMENT PRE- AND POST- PITUITARY SURGERY ....................... 38 POST-OPERATIVE MANAGEMENT OF DIABETES INSIPIDUS (DI) ............................................. 39 POST-OPERATIVE ASSESSMENT OF GH BURDEN IN ACROMEGALY ..................................... 40 4 IMMEDIATE POST-OPERATIVE ASSESSMENT OF EARLY REMISSION IN CUSHING‟S DISEASE ........................................................................................................................................... 42 CUSHING‟S DAY CURVE FOR ASSESSMENT OF EARLY REMISSION FOLLOWING TRANS- SPHENOIDAL SURGERY FOR CUSHING‟S DISEASE .................................................................. 45 FOLLOW UP OF PATIENTS WITH CUSHING‟S DISEASE FOLLOWING BILATERAL ADRENALECTOMY .......................................................................................................................... 46 HYDROCORTISONE DAY CURVE .................................................................................................. 47 GROWTH HORMONE .......................................................................................................................... 48 A WORD ON UNITS .......................................................................................................................... 48 HUMAN GROWTH HORMONE (HGH) PRESCRIBING FOR ADULT ONSET GROWTH HORMONE DEFICIENCY (AOGHD) ................................................................................................ 48 EXERCISE TEST .............................................................................................................................. 50 GHRH-ARGININE STIMULATION TEST .......................................................................................... 51 ARGININE STIMULATION TEST ...................................................................................................... 53 ORAL GLUCOSE TOLERANCE TEST FOR ACROMEGALY .......................................................... 54 FOLLOW UP POST PITUITARY SURGERY AND RADIOTHERAPY ............................................. 55 SCREENING COLONOSCOPY IN ACROMEGALY ......................................................................... 55 HISTORICAL METHODS OF ASSESSING EXCESS GROWTH HORMONE ................................. 56 PITUITARY RADIOTHERAPY .......................................................................................................... 58 POLICY ON SPERM STORAGE PRIOR TO PITUITARY RADIOTHERAPY ............................... 58 ASSESSMENT OF HYPOPITUITARISM FOLLOWING CRANIAL IRRADIATION ...................... 58 POSTERIOR PITUITARY ..................................................................................................................... 60 DIABETES INSIPIDUS ...................................................................................................................... 60 WATER DEPRIVATION TEST ...................................................................................................... 60 PROLONGED WATER DEPRIVATION TEST (MILLER AND MOSES) ....................................... 63 THERAPEUTIC TRIAL OF DDAVP ............................................................................................... 65 ADRENAL INVESTIGATIONS .............................................................................................................. 66 SHORT SYNACTHEN TEST (SST) .................................................................................................. 66 LONG SYNACTHEN TEST ..............................................................................................................
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