Transcript Presentation Title goes here.

Incidence of Neuroendocrine Dysfunction in
a Postacute, Brain Injury
Rehabilitation Setting
Lisa A. Kreber, Ph.D., CBIS
[email protected]
Background
• Anterior pituitary hormone deficiencies have
been found in 33-50% of patients with TBI.
• Growth hormone deficiencies have been
found in 21% of patients with TBI.
• Untreated growth hormone deficiency can
negatively influence recovery from brain
injury, even if the patient is undergoing
intensive brain injury rehabilitation
(Bondanelli et al, 2007).
Symptoms
•
•
•
•
•
Fatigue
Memory Impairment
Inability to concentrate
Anxiety
Depression
• Impaired processing
speed
• Decreased lean body
mass
• Reduced exercise
capacity
• Increased abdominal fat
**Considerable overlap with several chronic conditions, including TBI**
Methods
• Patients:
– N=199 adults admitted to an inpatient postacute,
residential brain injury facility (Centre for Neuro
Skills in Bakersfield, CA)
– Patients were admitted over a two year period,
from 2008-2010.
– Only patients with brain injury of a traumatic
nature were included.
Methods
• Admission Endocrine Labs:
– Thyroid panel (TSH, T3, T4)
– Cortisol (AM and PM)
– Follicle Stimulating Hormone (FSH)
– Luteinizing Hormone (LH)
– Prolactin
– Estradiol (females only)
– Testosterone (males only)
– Insulin-like Growth Factor-1 (IGF-1)
Why IGF-1?
• IGF-1 is the best marker of growth hormone
(GH) available (Frieda et al, 1998).
• Low levels of IGF-1 increase the likelihood that
GH levels are also deficient (since GH
stimulates the release of IGF-1).
• However, 50% of adults with GH deficiency
have IGF-1 levels in the normal reference
range (Lissett et al, 2003).
Provocative Testing
• Growth hormone (GH) is released in a
pulsatile fashion, making direct measurement
difficult.
• Provocative testing can be done to stimulate
the release of GH within a specific timeframe
to allow for direct measurement.
• The Glucagon Stimulation Test (GST) was used
as the provocative test in this study.
Glucagon Stimulation Test
• Patients whose IGF-1 level were less than 200
ng/mL were given a GST to determine GH
levels. Patients with levels of IGF-1 less than
100 ng/mL were referred to an
endocrinologist.
• The GST provokes GH to reach its peak level
within a four-hour window, allowing for direct
measurement of GH.
Glucagon Stimulation Test
• A SubQ injection of glucagon (1 mg) is given in
the upper arm.
• Blood samples and glucose levels are drawn
at: T0, T90, T120, T150, and T180.
• Samples are put on dry ice and sent to lab for
analysis.
• Peak GH levels of:
– <3 ug/L=deficient
– 4-5ug/L=insufficient
Results: Patient Demogrpahics
• Of the 199 patients admitted to Centre for
Neuro Skills (Bakersfield, CA facility) that met
inclusion criteria, 102 had low levels of IGF-1
that warranted further testing.
• That’s 51%!!
• Patients were:
– Male: 82 Female: 20
– Average age at time of testing: 42 years
– Average latency from TBI to testing: 350 days
Results
Admitted Patients With Low IGF-1 Levels
N=19
N=28
GST completed
Discharged prior to GST
N=10
Refused
Medical Issues
IGF <100 ng/mL
N=10
N=35
Results: GST
Glucagon Stimulation Test Results
N=5
Deficient
N=14
Insufficient
Normal
N=9
Treatment
• Unfortunately, only 2 individuals in this study
were authorized by their insurance company
to receive GH replacement therapy.
• Consensus guidelines on the treatment of GH
deficiency following TBI exist, were provided
and explained to the funding sources, but to
no avail.
– Ghigo et al, 2005
– Ho et al, 2007
Conclusions
• There is a high incidence of untreated
neuroendocrine deficiencies in the postacute
phase recovery phase following TBI.
• Hormone replacement therapy has the
potential to improve outcome following brain
injury.
• Patients who have received GH replacement
demonstrate decreased abdominal adiposity,
increased alertness, increased cognitive
processing and greater quality of life.
Future Directions
• Standards of care for TBI need to include
routine screenings for post-traumatic
hormone deficiencies.
• Multidisciplinary collaboration between case
managers, endocrinologists and rehabilitation
professionals is essential in order to maximize
the potential for recovery following brain
injury.
Acknowledgements
• Clinical Research and Education Foundation (CREF)
– Dr. Mark Ashley
– Dr. Jessica Ashley
– Sarah Johnson, M.A.
• Dr. Brent Masel (Transitional Learning Center)
• Dr. Randy Urban (UTMB)