IAGS 39:839-841, 1991
LETTERS TO THE EDITOR
Growth Hormone in Youth and Old Age (The Old and New Deja Vu) To the Editor:-As a pediatric endocrinologist, I was struck by the similarity of a recent, highly publicized study to one published by the same senior author almost a decade ago.' Rudman et alz have just reported on the favorable effects of administering human growth hormone to 12 healthy elderly men. During treatment, the men gained muscle mass and skin thickness and lost fat; plasma IGF-1 levels rose to the "youthful range." In 1981, Rudman et al' also described short children without growth hormone deficiency as having 'normal-variant short stature." Like the elderly men in the current report, the children were treated with growth hormone for 6 months, the number of subjects was small (five children in each of four subgroups), changes in plasma IGF-1 (somatomedin C) levels were an important measure of treatment success, and the results were impressive; in two of the four subgroups, growth rate accelerated five-fold. Rudman et a1 concluded that their study had identified normal short children who would benefit from long-term administration of growth hormone, but after almost 10 years we have had no follow-up on these children to support this claim. Human growth hormone is still approved by the FDA only for children with demonstrated growth hormone deficiency. Before using growth hormone treatment in the elderly on the basis of enthusiastic preliminary results, the possible dangers of therapy should be considered. The most extensive use of growth hormone has been in children, and there is recent concern about ethical and medical risks in treating normal short children including possible increased incidence of leukemia and diabetes and basic changes in metaboli~m.~ In,old ~ ' age, ~ the potential deleterious effects of growth hormone treatment, including diabetes, hypertension, arthritis, congestive heart failure, and cancer warrant more emphasis because these are all conditions to which the elderly are more susceptible. To paraphrase George Santayana and a quote attributed to Yogi Berra: those who cannot remember the past are condemned to suffer from dkja vu-all over again. Currently it costs $10,000-$20,000 yearly to treat a short child or elderly adult with growth hormone. The American health care system could spend many billions of dollars vainly pursuing increased height for the young and youth for the old. Before considering this, we deserve better scientific evidence of the effectiveness and safety of growth hormone treatment. EDGARJ. SCHOEN,MD Department of Pediatrics Kaiser Permanente Medical Center Oakland, CA
REFERENCES Rudman D, Kutner MH, Blackston RD et al. Children with normal-variant short stature: treatment with human growth hormone for six months. N Engl J Med 1981;305:123-131. Rudman D, Feller AG, Hoskote SN et al. Effects of human growth hormone in men over 60 years old. N Engl J Med 1990; 323:l-6. Fisher DA, Job J-C, Preece M, Underwood LE. Leukaernia in patients treated with growth hormone [letter]. Lancet 1988;1:1159-1160. Lantos J, Siegler M, Cuttler L. Ethical issues in growth hormone therapy. JAMA 1989;46 1 :1020-1 024.
Co 1991 by fhe American Geriafrics Society
5. Walker JM, Bond SA, Voss LD et al. Treatment of short normal children with growth hormone: a cautionary tale? Lancet 1990;336:1331-1334.
Coffee as Therapy for Hypotension To the Editor:-In their double-blind randomized clinical trial, Heseltine et a1 concluded that caffeine administered at the end of a high carbohydrate test meal prevented the postprandial fall in blood pressure in healthy elderly subjects.' I agree with the authors that this finding may prove to be clinically significant in treating elderly patients with symptomatic postprandial hypotension. However, I question whether this study can be applied to the general elderly population. The authors fail to describe their population group or the method of selection of their sample group. Therefore, selection bias can not be ruled out of this study. Regarding the study design, it is not clear whether doubleblind bias was considered. All the subjects were daily caffeine drinkers and may have been able to distinguish between the taste of caffeinated coffee and decaffeinated coffee. How was this bias addressed? Although there is concern about bias in this study, the authors' results are significant. It will be interesting to see if this finding can be reproduced in elderly patients with symptomatic postprandial hypotension. ROXANNEBARROW, MD Meharry Medical College, '9 1 Nashville, TN REFERENCE 1 . Heseltine D, Dakkak M, Woodhouse K, et al. The effect of caffeine on postprandial hypotensionin the elderly. J Am Geriatr Soc 1991:39:160.
This letter was referred to the authors of the original paper, and their reply follows.
In reply:-Dr.
Barrow raises some interesting points as regards our recent study on the effect of caffeine on reducing the postprandial fall in blood pressure. The subjects for our study were drawn from a local retirement club, all of whom were fit, living an independent existence, and were not current hospital attenders or taking any regular medication. We took consecutive volunteers who fitted our entry criteria, and there was no systematic bias in the sample group. However, we accept the point that these elderly fit patients are not necessarily representative of those subjects with symptomatic postprandial hypotension. Although all subjects were daily caffeine drinkers, none expressed a preference for either the caffeinated or decaffeinated drink. We have shown in further work that caffeine can prevent the side-effects as well as the postprandial fall in blood pressure in symptomatic individuals,' and we now consider caffeine to be the most suitable treatment for symptomatic postprandial hypotension in the elderly.
D.HESELTINE J. P m University of Leicester Leicester General Hospital Leicester, UK 0002-861 4/91 /$3.50
LETTERS TO THE EDITOR
Growth Hormone in Youth and Old Age (The Old and New Deja Vu) To the Editor:-As a pediatric endocrinologist, I was struck by the similarity of a recent, highly publicized study to one published by the same senior author almost a decade ago.' Rudman et alz have just reported on the favorable effects of administering human growth hormone to 12 healthy elderly men. During treatment, the men gained muscle mass and skin thickness and lost fat; plasma IGF-1 levels rose to the "youthful range." In 1981, Rudman et al' also described short children without growth hormone deficiency as having 'normal-variant short stature." Like the elderly men in the current report, the children were treated with growth hormone for 6 months, the number of subjects was small (five children in each of four subgroups), changes in plasma IGF-1 (somatomedin C) levels were an important measure of treatment success, and the results were impressive; in two of the four subgroups, growth rate accelerated five-fold. Rudman et a1 concluded that their study had identified normal short children who would benefit from long-term administration of growth hormone, but after almost 10 years we have had no follow-up on these children to support this claim. Human growth hormone is still approved by the FDA only for children with demonstrated growth hormone deficiency. Before using growth hormone treatment in the elderly on the basis of enthusiastic preliminary results, the possible dangers of therapy should be considered. The most extensive use of growth hormone has been in children, and there is recent concern about ethical and medical risks in treating normal short children including possible increased incidence of leukemia and diabetes and basic changes in metaboli~m.~ In,old ~ ' age, ~ the potential deleterious effects of growth hormone treatment, including diabetes, hypertension, arthritis, congestive heart failure, and cancer warrant more emphasis because these are all conditions to which the elderly are more susceptible. To paraphrase George Santayana and a quote attributed to Yogi Berra: those who cannot remember the past are condemned to suffer from dkja vu-all over again. Currently it costs $10,000-$20,000 yearly to treat a short child or elderly adult with growth hormone. The American health care system could spend many billions of dollars vainly pursuing increased height for the young and youth for the old. Before considering this, we deserve better scientific evidence of the effectiveness and safety of growth hormone treatment. EDGARJ. SCHOEN,MD Department of Pediatrics Kaiser Permanente Medical Center Oakland, CA
REFERENCES Rudman D, Kutner MH, Blackston RD et al. Children with normal-variant short stature: treatment with human growth hormone for six months. N Engl J Med 1981;305:123-131. Rudman D, Feller AG, Hoskote SN et al. Effects of human growth hormone in men over 60 years old. N Engl J Med 1990; 323:l-6. Fisher DA, Job J-C, Preece M, Underwood LE. Leukaernia in patients treated with growth hormone [letter]. Lancet 1988;1:1159-1160. Lantos J, Siegler M, Cuttler L. Ethical issues in growth hormone therapy. JAMA 1989;46 1 :1020-1 024.
Co 1991 by fhe American Geriafrics Society
5. Walker JM, Bond SA, Voss LD et al. Treatment of short normal children with growth hormone: a cautionary tale? Lancet 1990;336:1331-1334.
Coffee as Therapy for Hypotension To the Editor:-In their double-blind randomized clinical trial, Heseltine et a1 concluded that caffeine administered at the end of a high carbohydrate test meal prevented the postprandial fall in blood pressure in healthy elderly subjects.' I agree with the authors that this finding may prove to be clinically significant in treating elderly patients with symptomatic postprandial hypotension. However, I question whether this study can be applied to the general elderly population. The authors fail to describe their population group or the method of selection of their sample group. Therefore, selection bias can not be ruled out of this study. Regarding the study design, it is not clear whether doubleblind bias was considered. All the subjects were daily caffeine drinkers and may have been able to distinguish between the taste of caffeinated coffee and decaffeinated coffee. How was this bias addressed? Although there is concern about bias in this study, the authors' results are significant. It will be interesting to see if this finding can be reproduced in elderly patients with symptomatic postprandial hypotension. ROXANNEBARROW, MD Meharry Medical College, '9 1 Nashville, TN REFERENCE 1 . Heseltine D, Dakkak M, Woodhouse K, et al. The effect of caffeine on postprandial hypotensionin the elderly. J Am Geriatr Soc 1991:39:160.
This letter was referred to the authors of the original paper, and their reply follows.
In reply:-Dr.
Barrow raises some interesting points as regards our recent study on the effect of caffeine on reducing the postprandial fall in blood pressure. The subjects for our study were drawn from a local retirement club, all of whom were fit, living an independent existence, and were not current hospital attenders or taking any regular medication. We took consecutive volunteers who fitted our entry criteria, and there was no systematic bias in the sample group. However, we accept the point that these elderly fit patients are not necessarily representative of those subjects with symptomatic postprandial hypotension. Although all subjects were daily caffeine drinkers, none expressed a preference for either the caffeinated or decaffeinated drink. We have shown in further work that caffeine can prevent the side-effects as well as the postprandial fall in blood pressure in symptomatic individuals,' and we now consider caffeine to be the most suitable treatment for symptomatic postprandial hypotension in the elderly.
D.HESELTINE J. P m University of Leicester Leicester General Hospital Leicester, UK 0002-861 4/91 /$3.50
