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Question:

From Clarkston, Michigan, USA:

My 13-year-old son has had diabetes since he was two and is on a insulin pump. His A1c has been slightly above 7. His growth has slowed to almost nothing for the last three years. He falls below the 50th percentile. That is not consistent with his earlier growth. He has been tested for celiac and his thyroid has been checked. Both came back negative. His growth hormone level is low. He is not showing signs of puberty. His pediatric endocrinologist is very hesitant to start him on growth hormone. The doctor is concerned that my son will become insulin resistant. If my son takes the shots, is there a chance of him becoming insulin resistant? Does the resistance last forever? Should we get a second opinion?

Answer:

It is a little hard to offer solid advice here without confirming some more details. How was the diagnosis of growth hormone (GH) deficiency made in your son? What was the result of the bone age x-ray of the left hand? Did your doctor do any "stimulation" testing to assess puberty or was it all from clinical exam and maybe results from a one time blood stick? While perhaps not critical, did they scan your son's pituitary gland using MRI?

Given that I don't have the answers to the above, I will base the following on the assumption that your son has bona fide GH deficiency.

If that were the case, then I would think that while there are risks in regards to his diabetes management, GH replacement therapy would still be justified. After all, OTHER typical patients with diabetes produce GH; why should your son not get the benefit in terms of growth and the other metabolic effects on bone and muscle that GH provides? It is true that the effects of GH will antagonize the effects of insulin; i.e., he will become a bit insulin resistant. But, he should be able to overcome this degree of insulin resistance with a bit more insulin.

Furthermore, and on a similar note, puberty hormones (sex hormones) antagonize the effects of insulin, too. Virtually ALL teens with diabetes require more insulin with puberty, too. Puberty is associated with a growth spurt and that growth spurt has to be fueled by food (and, of course, the associated proper amount of insulin). And, unfortunately, commonly teens with diabetes undergo some regression in their degree of glycemic control during these years, unless they are aggressive and stay "on top" of matters.

The situation you describe with your son could possibly also represent a situation where there has been a delay in the onset of normal puberty, i.e., "a late bloomer." This diagnosis of a having a "constitutional delay in growth and puberty" is not formally made in a boy unless there are lacking signs of puberty by age 14. Is there a family history of late puberty in either parent's side of the family? A brief course of testosterone therapy might be helpful. It is important to note that the first REAL physical sign of puberty in a boy is some enlargement of the testicles. Only your pediatric endocrinologist's care exam could find this.

As for the permanence of any insulin resistance, the real and short answer is "yes, the resistance is permanent." As inferred above, ALL normal teens and adults, whether diabetics or not, get some degree of insulin resistance as they grow and begin to make the sex steroids and more GH. But, non-diabetics simply compensate and appropriately make more insulin. It is not a "big deal." If your son requires supplemental GH or testosterone, he, too, will get the expected physiologic resistance to insulin that comes with that. I do not think you have to fear that his insulin will never work again, but his requirements will likely increase and you and your son and the pediatric endocrinologist will need to stay vigilant that the degree of glycemic control does not get out of hand.

As for the second opinion, I think that it always a patient's prerogative to get a second opinion. In this case, your doctor seems to have appropriate caution. However, if you have concerns or there is uncertainty in the diagnosis of GH deficiency or late puberty, more information is typically good, so you should feel comfortable in asking for another opinion.

DS

DTQ-20081119204157
Original posting 22 Nov 2008
Posted to Other

  
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Last Updated: Tuesday April 06, 2010 15:10:18
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