| name | ata-gh-titration |
| description | Titrates GH replacement dose to keep IGF-1 below the upper limit of normal and reduces dose when side effects appear. Use when monitoring GH replacement therapy; triggers include patient on GH replacement needing dose adjustment. |
Titrate GH replacement dose based on IGF-1 and side effects
STEP 1 — Gather Information
Collect current GH dose (mg/d), age-adjusted IGF-1 level and its upper limit of normal (ULN), and assess for GH-related side effects (fluid retention, arthralgia, myalgia, paresthesia, carpal tunnel syndrome, sleep apnea, etc.). Record IGF-1 as % above/below ULN and side-effect presence/severity.
STEP 2 — Rule In / Rule Out
Is the IGF-1 level above the age-adjusted ULN? If yes, proceed to dose-reduction evaluation; if no, assess for side effects to determine if dose reduction is warranted.
STEP 3 — Classify or Stratify
Classify IGF-1 elevation: mild (1–25% above ULN), moderate (26–50% above), severe (>50% above). If IGF-1 ≤ ULN, classify side-effect severity: none, mild, moderate/severe.
STEP 4 — Decide
If IGF-1 > ULN, reduce GH dose by 0.1–0.2 mg/d for mild, 0.2–0.3 mg/d for moderate, ≥0.3 mg/d for severe; if side effects present, reduce dose by 0.1–0.2 mg/d for mild, 0.2–0.4 mg/d for moderate/severe; recheck IGF-1 and side effects in 6 weeks. If IGF-1 ≤ ULN and no side effects, consider maintaining dose or increasing by 0.1 mg/d if clinically indicated and IGF-1 remains below ULN.
Clinical Guardrails / Mimics / Pitfalls
Do not titrate GH dose based solely on IGF-1 without assessing side effects; avoid exceeding dose that causes adverse effects such as significant fluid retention or hyperglycemia; do not use GH in patients with active malignancy or uncontrolled diabetes; do not ignore age-adjusted IGF-1 reference ranges; do not increase dose when IGF-1 is already at or above ULN; do not forget to assess for pituitary tumor recurrence in long-term therapy.
Concrete Clinical Example
A 45-year-old woman on GH replacement 0.3 mg/d has IGF-1 at 130% of age-adjusted ULN and mild ankle swelling. Dose reduced by 0.2 mg/d to 0.1 mg/d; after 6 weeks IGF-1 falls to 110% ULN and swelling resolves; dose held.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, doi:10.1210/jc.2016-2118
TODO: consider adding scripts/calc.py for the ata-gh-titration calculator
