To optimize the growth promoting effect of growth hormone (GH), 65 previously untreated girls with Turner syndrome (TS), chronological age (CA)2-11 yr, were randomized into 3 dosage regimen groups: A, B, and C, with a daily recombinant-human GH dose during 4 study years of 4-4-4-4, 4-6-6-6, and 4-6-8-8 IU/m2 b.s. The first GH dosage increase in groups B and C resulted in a significantly higher mean height velocity (HV) compared with constant dose group A. During the third year, when the dose was raised again only in group C, mean HV was significantly higher in groups B and C than in group A, and in group C compared with group B. In year 4 only group C mean HV remained significantly higher than group A. The pattern of change in HSDS(CA) (Dutch-Swedish-Danish Turner references) was identical; however, in year 4 mean ΔHSDS(CA) in group B also remained significantly higher than group A. After 4 yr GH treatment, the following was determined. 1) The mean ΔHSDS(CA) was significantly higher for groups B and C compared with group A, but not significantly different between groups B and C. 2) Although significantly higher compared with estimated values for untreated Dutch girls with TS, bone maturation of the GH treated girls was not significantly different between groups. 3) It was positively related with the degree of bone age (BA) retardation at start of study and negatively with baseline CA. 4) Both the modified Index of Potential Height (mIPH(RUS)) and a recently developed Turner-specific final height (FH) prediction method (PTS(RUS)), based on regression coefficients for H, CA, and bone age, showed significant increases in mean FH prediction, without significant differences between groups. PTS(RUS) values were markedly higher than the mIPH(RUS) values. Dose dependency could be shown for the area under the curve (AUC) for GH, but ΔHSDS(CA) was not linearly related with AUC. Baseline GH binding protein (BP) levels were in 84% of the cases within the normal age range; the decrease in mean levels after 6 months GH was not significant. Mean insulin- like growth factor I (IGF-I) and IGFBP-3 plasma levels increased significantly, without significant differences between groups. ΔHSDS(CA) during GH was dependent on IGF-I plasma levels at baseline and during the study period, β-0.002 and β-0.0004. Thus, a stepwise GH-dosing approach reduced the 'waning' effect of the growth response after 4 yr treatment without undue bone maturation. FH prediction was not significantly different between treatment groups. Irrespective of the GH dose used, initiation of GH treatment at a younger age was beneficial after 4 yr GH when expressed as actual cm gained or as gain in FH prediction, but was not statistically significant when expressed as ΔHSDS(CA) over the study period.,
Journal of Clinical Endocrinology and Metabolism
Erasmus MC: University Medical Center Rotterdam

van Teunenbroek, A, de Muinck Keizer-Schrama, S.M.P.F, Stijnen, Th, Jansen, M, Otten, B.J, Delemarre-van de Waal, H.A, … Drop, S.L.S. (1996). Yearly stepwise increments of the growth hormone dose results in a better growth response after four years in girls with Turner syndrome. Journal of Clinical Endocrinology and Metabolism, 81(11), 4013–4021. doi:10.1210/jc.81.11.4013