Diagnosing Growth Hormone Deficiency: Can a Combined Arginine and Clonidine Stimulation Test Replace 2 Separate Tests?

Vitamins and their prescription derivatives, amino acids, and nutritional formulations have wide and varied clinical applications. Many are available over the counter, and are often not considered of consequence to patients, making use difficult to monitor. Although well-tolerated in the majority of persons, unique side effects continue to emerge. These products carry potentially harmful side effects in unsuspecting consumers, requiring healthcare providers remain vigilant in questioning, documenting, and counseling patients. This chapter delves into recent literature surrounding vitamin A and its derivatives (isotretinoin, all-trans retinoic acid), vitamin B (pyridoxine, folic acid), vitamins C, D, E, and K, as well as amino acids (arginine, glutamine), enteral and parenteral nutrition. A special review of e-cigarette, or vaping, product use-associated lung injury (EVALI) is included. In most cases, rapid discontinuation of the substance is required; in others, it is the excess or lack of a critical component that leads to toxicity. This chapter reviews literature published between January and December 2020 and will arm healthcare providers with critical knowledge of new and emerging side effects. Ultimately, increased awareness among providers will aid in the rapid identification and management of patients, improving care and outcomes.

Vitamins, amino acids, and drugs and formulations used in nutrition

Current Problems in Pediatric and Adolescent Health Care

Growth hormone deficiency (GHD) in children has significant impacts on growth and metabolism. Two-agent GH stimulation tests are commonly used to diagnose GHD, and these tests are generally considered safe. We report the case of a 5-year 5-month-old boy with a history of anaplastic ependymoma who underwent GH stimulation testing for growth deceleration using clonidine and arginine. He developed bilateral calf myalgia and gross hematuria within 24 hours of the tests. Myalgia and hematuria resolved spontaneously. Importantly, the literature review and database searches for hematuria identified 6 cases with clonidine and 20 cases with arginine. This case highlights an unusual combination of adverse reactions to clonidine and arginine in children undergoing GH stimulation testing to assess for GHD. Pediatric endocrinologists need to be aware of the potential for these side effects to allow appropriate management, and further studies are needed to clarify the mechanisms and frequency of these side effects. We recommend that patients and families need to be counselled about hematuria as an association of GH testing with these medications.

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Myalgia and Hematuria in Association with Clonidine and Arginine Administration for Growth Hormone Stimulation Tests.

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Myalgia and Hematuria in Association with Clonidine and Arginine Administration for Growth Hormone Stimulation Tests.