Es Ghd Retest Indication

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name: es-ghd-retest-indication
description: This skill identifies adult childhood cancer survivors with isolated growth hormone deficiency and prior hypothalamic‑pituitary axis radiation exposure who require retesting to confirm persistence of GHD. Triggers include clinician questions such as “Should I retest for GHD in this adult survivor with childhood GHD and radiation history?” or “Is repeat GHD evaluation indicated in this patient?”
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# Determine GHD retest need in adult survivors

## STEP 1 — Gather Information
Collect patient’s age, cancer treatment history (specifically hypothalamic‑pituitary axis radiation exposure), childhood diagnosis of isolated GHD (confirm no other anterior pituitary hormone deficits), current GH therapy status, and timing since last GHD assessment.

## STEP 2 — Rule In / Rule Out
If the patient is an adult survivor of childhood cancer, received hypothalamic‑pituitary axis radiation, and had a diagnosis of isolated GHD in childhood → proceed to retest; otherwise, retesting is not indicated per guideline.

## STEP 3 — Classify or Stratify
No further stratification needed; all patients meeting the criteria above are candidates for retesting regardless of radiation dose or time since exposure.

## STEP 4 — Decide
Order provocative GHD testing (e.g., insulin tolerance test, glucagon stimulation test, or GHRH‑arginine if available) per guideline 2.3, ensuring appropriate pretest precautions (e.g., discontinuation of GH therapy, consideration of obesity‑related cut‑offs).

## Clinical Guardrails / Mimics / Pitfalls
Do not rely solely on serum IGF‑I levels; avoid GHRH‑alone or GHRH‑plus‑arginine testing; avoid spontaneous GH sampling; be aware that obesity, estrogen exposure, or hypothyroidism can blunt GH response and require lower cut‑off values; do not retest if three or more other pituitary hormone deficiencies are present (per 2.6); ensure GH therapy has been discontinued for adequate washout before testing.

## Concrete Clinical Example
A 23‑year‑old male survivor of childhood acute lymphoblastic leukemia who received 18 Gy cranial radiation at age 4, was diagnosed with isolated GHD at age 10 based on a subnormal ITT, and has been off GH therapy for 18 months. He presents for routine endocrine follow‑up. The clinician gathers history of isolated GHD and HP axis radiation, confirms no other pituitary deficits, and orders an insulin tolerance test to retest for GHD persistence.

**Source:** Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-01175