GH Stim test results

[Kovash]

I have asked you a question before about my 6 year old son.  He is 41 inches and 34 pounds and is only averaging 2 cm of growth per year.  He had growth hormone stim test a few weeks back and we got the results yesterday.
His levels from the blood draws were:
0.8
4.6
11
12
7.1
6.9
3.8
Because insurance requires all numbers to be below 10 to be accepted we are going down a different route.  His IGF-1 is low, his level is 32.  I was told that it shouldn't be a problem getting insurance to accept that and we can treat him for the IGFD.  
Are you in agreement that we should go that route?  I know that those GH numbers are a tad low but in your opinion are they low enough to fight for the GH therapy or are we better off just treating the IGFD?  Because from my understanding that the IGFD therapy is not going to work if he is GHD.  Is that correct?  
I guess I just want to make the best medical decision for our son and not have any thoughts of "we should have done it this way" later.  
Thank you.

[Deanna L Aftab Guy, MD]

ok, hard to tell you how I would treat as I tend to have to see each child overtime to convince me of their individual treatment plan but most of my patients who are young like 6 with mixed gh stim test results I will watch another 4-6 months to document growth velocity. If the growth is less than 1.5 inches a year in rate at next visit or the one after that then I have more evidence to make my case with the insurance companies. I tend to use growth hormone first and in certain cases use igf-1.
He will grow with both!

[Kovash]

One more question...  Is a IGF-1 level of 32 in a just turned 6 year old boy considered a severe deficiency or just a little low?  I was told that the normal was like 60-228 but I'm not sure if that 32 is considered very low or just a little low?  I've heard of the Primary IGFD and severe Primary IGFD.
Thanks again.

[Kovash]

We used two stimulants for his GH test, clonidine and arginine.  You say you have used the med to treat IGFD not to much because IGFD is hard to diagnose.  With his level at 32 and being 6 years old would you consider that to be deficient?  (Also considering his growth is very slow.  I could list all his hight and weights here from birth but they were average as an infant but started to decline at about 10 months of age.)  If our son were your patient would you be recommending the same thing, that we treat the IGFD?  What are the medical risks of not treating IGFD and just letting him be?  I know they say his peak height will be 5'3", so we know that he will be short but are there any medical risks by not treating this?
Thank you for your time to answer our questions.

[Deanna L Aftab Guy, MD]

peak gh was 12, did they use more than one stimulant?? So it is not classically gh deficiency on paper based on this test. So as I say to my patients I have to line my ducks in a row and this test is merely a part, we have to demonstrate the patients height velocity, height standard deviation score(how far are they from the mean), bone age, other labs and yes, igf-1 which is the hormone that gh from the pitutiary stimulates in the liver and the two stimulate elongation of bones at the growth plate. When a child passes the gh test it is not really ruling out gh treatment, I tend to describe it as gh insufficiency rather than gh deficiency, meaning you make gh but not enough to growth in a healthy fashion. So treatment with gh is still possible, diagnosis is different and we tend to fight a little harder to get it approved, there are brands that are easier than others to get help from. IGF deficiency is really becoming something to be considered, the product that is available is an igf-1 analog, medication that copies igf-1, given also as an injection it acts at the igf-1 receptor to help with growth and yes, kids grow. The bummer is that it is usually given twice a day instead of once a day, also as an injection. there can be a side effect in some of a low sugar but this is rarely a problem if the medication is given at the time of a meal according to the company. I have used it, not as much as gh since igf-deficiency is less common or perhaps more common but harder to diagnose.
There are many other factors that we cannot test for directly that also stimulate growth beyond the gh receptor and gh still helps as does igf-1 analogs.
He will grow either way.
I would find out first, can you get gh approved for what is termed idiopathic short stature indication, ask your docs office to work with the company that has helped the most.
And then sit down with them and discuss both products and weigh each one.
You should be fine either way, you just need to understand each one to make your decision.