Accepted Manuscript

Growth and endocrine issues in children with thalassemia

Preeti Singh, Anju Seth

PII: S2468-1245(17)30149-3
DOI: 10.1016/j.phoj.2017.12.005
Reference: PHOJ 68

To appear in: Pediatric Hematology Oncology Journal

Received Date: 9 October 2017

Revised Date: 18 December 2017
Accepted Date: 19 December 2017

Please cite this article as: Singh P, Seth A, Growth and endocrine issues in children with thalassemia,
Pediatric Hematology Oncology Journal (2018), doi: 10.1016/j.phoj.2017.12.005.

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 ACCEPTED MANUSCRIPT
Growth and Endocrine Issues in Children with Thalassemia

Preeti Singh, Anju Seth

Dr Preeti Singh, MD Pediatrics

Assistant Professor
Department of Pediatrics,

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Lady Hardinge Medical College and Kalawati Saran Children’s Hospital
New Delhi

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INDIA.
Email: drpreetisingh3@gmail.com

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Dr Anju Seth, MD Pediatrics

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Director Professor
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Department of Pediatrics
Lady Hardinge Medical College and Kalawati Saran Children’s Hospital
New Delhi
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INDIA.
Email: anjuseth.peds@gmail.com
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Institutions name: Lady Hardinge Medical College and Kalawati Saran Children’s Hospital,
Shaheed Bhagat Singh Marg, New Delhi, India
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Email for Correspondence: anjuseth.peds@gmail.com

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Growth and Endocrine Issues in Children with Thalassemia

INTRODUCTION

With the advent of intensive transfusion and chelation regimes, life expectancy has increased
significantly in patients with β- thalassemia major (TM). However, progressive iron

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deposition in tissues as a result of repeated blood transfusions and enhanced dietary
absorption of iron due to ineffective erythropoiesis leads to many complications that may

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emerge as these children grow into adolescence and adulthood. The deleterious effects of
excessive iron deposition are primarily observed in the heart, liver and endocrine organs like

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pituitary- gonadal axis, GH-IGF axis, thyroid, parathyroid, pancreas and adrenals. Thus, in
this era, the endocrine complications have emerged as an important cause of morbidity and an
important determinant of quality of life in children with TM.

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The earliest case of multiple endocrine dysfunction in thalassemia intermedia was reported
around 50 years ago [1]. The data on prevalence of endocrine dysfunction in patients with
TM is limited and shows a wide variation due to differences in the study cohorts, age at onset
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of transfusion and chelation and compliance to both. The predominant clinical phenotypes
include short stature, delayed/arrested puberty, abnormal bone mineralisation, impaired
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glucose tolerance, hypothyroidism and hypoparathyroidism. Table1 shows the comparative

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prevalence of endocrine complications reported in children with TM in various settings over

last 2 decades [2-7].
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The underlying patho-physiological mechanism underlying these complications is excessive

iron load, a consequence of repeated blood transfusions that these children receive from early
childhood. Endocrine glands have high levels of transferrin receptors that promote iron
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accumulation and hence increase vulnerability of these glands to iron toxicity. Iron stored in
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endocrine glands binds to intracellular transferrin. As the storage capacity of transferrin gets
exceeded, pathological quantities of metabolically active iron catalyses formation of free
radicals, which in turn damage intra-membrane lipids and other macro-molecules, ultimately
causing cell death and organ failure. The degree and the severity of iron toxicity depends
upon the frequency/need for transfusions determined by genotype of the individual, the age at
initiation of chelation therapy and compliance to it [8].
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In this review, we present an overview of the various endocrine dysfunctions observed in
patients with TM.

GROWTH FAILURE

Growth failure is one of the most common co-morbidities witnessed in children and
adolescents with TM and an important cause of poor body image in these children. The

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prevalence of growth failure and short stature in children with thalassemia varies from 30-
50% in most studies [2]. The causes are multifactorial. The key factors responsible for growth
disturbances are summarized in Table 2. The relative contribution of various factors may vary

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at different ages. Chronic anaemia, hypoxia and nutritional factors are usually operational
before 5 years especially in children who do not receive regular transfusions. Between 5-10

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years, the adverse effects of transfusion associated iron overload on linear growth (GH-IGF-1
axis) are apparent in the absence of adequate chelation. Beyond the age of 10 years, absent

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/reduced pubertal spurt due to involvement of hypothalamo-pituitary-gonadal (HPG axis) axis
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makes a significant contribution. At all stages, co-morbidities can add further adverse
influence [9]. Children who are well transfused and adequately chelated have the best
prognosis for reaching optimum height.
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In the current era, children receiving regular blood transfusions and optimal chelation therapy
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usually do not exhibit signs of growth failure until the end of first decade. Most patients with
poor growth present either in the peri-pubertal phase with impaired growth or during puberty
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with arrested or absent puberty and absence of growth spurt. The growth plate fusion is also
delayed in these children until the end of second decade and thus they have a potential for
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growing when most unaffected children have completed their growth. This is primarily due to
iron load affecting the Growth Hormone – Insulin like Growth Factor axis (GH-IGF axis) and
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the HPG axis. The anterior pituitary is particularly sensitive towards free radical oxidative
stress from iron toxicity.
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The short stature (SS) encountered in thalassemia is often disproportionate with a low upper
segment to lower segment ratio [10]. The exact reason is not clear and an interplay of
multiple factors are responsible for it. In thalassemia, there is a progressive impairment in
spinal growth observed since early childhood [11]. Besides, other factors implicated in body
disproportion include iron overload (impaired cartilage growth), early use of desferrioxamine
(DFO) for chelation and delayed puberty (hypogonadism). Use of DFO between 2-5 years
has a paradoxical adverse effect on growth through inhibition of cell proliferation, DNA
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synthesis, and collagen formation and trace mineral deposition like Zn and Cu resulting in
flattening of vertebrae (platyspondylosis) and reduced spinal height [12]. Short trunk, genu
valgum, metaphyseal widening and joint stiffness is noted. The radiological changes seen are
thickened growth plates with widening and cupping of metaphyses, sclerosis of subchondral
bone with small radiolucent areas localised to the metaphyses and osteoporosis and increased
trabecular pattern of long bones. Off late, deferiprone treatment has been reported to be

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associated with arthropathy mainly of the knees [13, 14]. MRI studies indicate that damage to
the cartilage and the subchondral bone persist despite stopping treatment.

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Several mechanisms influencing the Growth Hormone Releasing Hormone (GHRH)-GH-
IGF- axis have been proposed to explain the growth faltering in patients with TM [15]:

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(1) Hypothalamic GH-releasing hormone deficiency (2) pituitary GH deficiency; (3)
neurosecretory dysfunction and (4) relative GH insensitivity. Growth Hormone deficiency

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(GHD) is seen in 20-30% of thalassemia patients while the remaining 70-80% show a peak
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growth hormone levels lower than those found in patients with constitutional short stature in
response to GH provocative stimuli like clonidine. Children with TM exhibit low IGF-1
levels in both GH deficient (GHD) and GH sufficient (GHS) subgroups. This was evident
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from a prospective study to assess the age related changes in serum IGF-1 concentrations in
thalassemia patients compared to age and sex matched normal cohort. The normal healthy
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cohorts experienced a peak in IGF-1 levels at 13 years (boys) @ 8-9 times the baseline. The
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thalassemia patients with GHD did not show peak rise in IGF-1 levels till 18 years while the
subgroup with GHS reported a late and attenuated peak IGF-1 levels at 16-18 years (@ 3
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times from baseline) [16]. Further, the IGF-1 response to exogenous administration of GH is
significantly lower in children with thalassemia and GHD as compared to ones who have
idiopathic GHD [17]. There is another subgroup of thalassemia children who show a normal
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GH response to provocative tests but their IGF-1 levels continue to be low suggesting a low
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GH sensitivity (secondary to liver dysfunction) or a neurosecretory dysfunction. The latter

manifests as an abnormal nocturnal GH secretory pulse pattern (due to high somatostatin
tone) and lack of negative feedback regulation (in response to low IGF-1 levels) at the
hypothalamus-pituitary level [17].

Puberty (spontaneous/induced) plays a significant role in achieving the desired growth spurt
in adolescents by augmenting the GH pulse amplitude that leads to a rise in IGF-1 and IGF-
BP-3 levels. There is a mutual amplifying effect in the concentration of GH, IGF-1 levels and
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sex steroids observed during the progressive stages of puberty that results in growth spurt,
appearance of secondary sexual characteristics, increase in muscle mass and bone mineral
accretion. Children with thalassemia experience delay/arrest in puberty due to the
hypogonadotropic hypogonadism with or without loss of gonadal function [18].

Growth monitoring in children with thalassemia

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1. A longitudinal record of weight and height (along with Mid parental height (MPH)
and Target range) and BMI should be maintained on a growth chart at six monthly
interval to facilitate early detection of growth faltering. MPH is calculated by adding

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6.5 cm to the average of the mother’s and father’s height in the case of boy and by
subtracting 6.5 cm in the case of girl. Statistically 95% of the children are expected to

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reach an adult height within a range of about 8.5 cm above or below the MPH
percentile (i.e. ±2SD on either side of MPH). This range is called as Target range. The

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annual growth velocity (GV) is assessed, if <25th percentile consider it a red flag.
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2. Compare the height indices (height for age) of the patient (height SDS or centiles)
with the population data as well as with the mid‑parental height (SDS or centiles).
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Definition of Short stature:

•
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Height is less than the 3rd percentile or 2 SD below the mean height for age and
sex; OR
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• Height is within normal but GV is consistently <25th percentile over 6-12 months;
OR
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• The patient is excessively short for his/her mid‑parental height, though his
absolute height may be within the normal percentiles.
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3. Assess for onset and progress of puberty (SMR using Tanners staging) annually for
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all children above 10 years of age. The varied phenotypes of pubertal delay are
described in table 3.

Assessment in a child with short stature

1. The following points in HISTORY should be inquired in a child who has TM.

• Onset of disease and the need for blood transfusions

• Pre-transfusion haemoglobin level

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• Annual packed cell volume requirement

• Chelation type, dose, compliance

• Serum ferritin levels

• Any associated comorbidity like features suggestive of endocrine complications or

coinfection with blood borne agents like Hepatitis B, C or HIV.

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2. The EXAMINATION would include:

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• General Physical Examination: A note is made on the skin pigmentation, pallor,
icterus, cyanosis, clubbing, and thyromegaly.

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• Stable vitals

• Anthropometry: Weight, Height; Assess standing and sitting heights and calculate
upper/lower segment ratio.
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• Sexual Maturity Ratings (Tanner)

• Systemic Examination: Hepatosplenomegaly

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3. Bone age assessment (X-ray of wrist and hand)

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In cases with disproportionate SS- radiographs of tibia and spine to exclude the presence of
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platylospondylosis or metaphyseal cartilaginous dysplasia changes.

4. Co-morbidity screening: specially; hepatitis B, C, HIV.

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5. Assess for other endocrinopathies: Serum free T4, TSH, fasting glucose and oral
glucose tolerance testing (OGTT) in case of impaired fasting glucose (IFG), morning
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cortisol levels. The HbA1c level is not reliable in screening for diabetes.
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6. Biochemical investigations: Serum calcium, ionized calcium, inorganic phosphate,

magnesium, and alkaline phosphatase, KFT, LFT.

7. Screening for Celiac Disease (in both boys and girls) using serum tTG levels and
Turner Syndrome (in girls).

8. Assessment of GH secretion is performed in cases with height ≤ - 3 SD and delayed

bone age (described later).
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9. LH, FSH, sex steroids (after 12-13 years if no clinical pubertal development, any time
thereafter in case of pubertal arrest).

Management: Key components of management of short stature in children with TM include:

i. Treatment of anaemia and optimizing chelation therapy.

ii. Correction of nutritional deficiencies if any, undernutrition and mineral deficiencies

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(zinc)

iii. Treatment of overt hypothyroidism

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iv. GH treatment is indicated in established cases with GH deficiency.

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v. Timely replacement therapy with sex steroids in children with failure of spontaneous
pubertal onset / poor progression of puberty.

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vi. Psychosocial support
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Assessment of GH secretion

i) Serum levels of IGF‑1 and IGF BP‑3 are estimated in children with height ≤ - 3 SD and
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delayed bone age (more than 2 SD or delay > 2 years from chronological age). They are
useful indicators of growth hormone secretion and nutrition (low in chronic liver disease and
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malnutrition) - Low levels indicate GH deficiency or defect in IGF-1 generation.

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ii) Growth hormone stimulation testing: Normal thyroid functions are ensured before
conducting the GH stimulation test. Peripubertal children require priming with sex steroids
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before evaluation by GH stimulation test. This is done for boys by giving a single
intramuscular injection of testosterone enanthate 100 mg seven days prior to testing and for
girls by giving oral ethinyl estradiol 50µg for 3 days before testing. Another alternative
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regime that can be used in both boys and girls is conjugated estrogen 5mg orally given night
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before and morning of the test. Girls whose bone age is less than 9 years and boys whose
bone age is less than 10 years do not need priming [19]. Significant GH insufficiency may be
diagnosed by a reduced response of GH to two provocative tests (GH peak <10 ng/ml) in
children and adolescents or reduced response of GH in one test plus low IGF-1 and IGF BP-3
concentrations [20].

MRI of the hypothalamic-pituitary region is useful to evaluate pituitary iron overload as well
as the size of pituitary gland (atrophy).
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Management: Treatment with recombinant human growth hormone (rhGH) is indicated in
cases with established GH deficiency. These subjects often need higher doses due to co-
existing partial GH insensitivity. In children with pubertal delay best results are observed
with concomitant sex steroid replacement. Puberty induction with low dose sex steroids may
accelerate linear growth similar to the effect of rhGH therapy [21]. The efficacy of rhGH
treatment in the management of children with BTM having growth failure secondary to

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Growth hormone deficiency has been a matter of debate. The linear growth velocity attained
after exogenous GH administration in children with thalassemia is reported to be lower than

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that seen in children with primary GH deficiency, possibly due to GH insensitivity [22].
Since children with thalassemia have delayed bone age, some improvement in linear growth

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is witnessed in the second decade of life even without rhGH therapy. The current evidence
supports the short term use of rhGH therapy in thalassemia patients with short stature as it
augments the linear growth velocity with maximum benefit being observed in first year of

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therapy, However, data to demonstrate its long term benefit in improving final height is
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lacking [23, 24]. There is uncertainty regarding the ideal time to start GH therapy and the
dosage. Finally, the decision to use rhGH therapy should depend on the patient profile (age,
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pubertal status), comorbidities (iron overload and chronic liver disease), cost benefit ratio and
the risk of adverse events (impaired glucose tolerance). During GH treatment, patients should
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be monitored at 3-monthly intervals with a clinical assessment and an evaluation for

parameters of GH response (growth parameters, compliance) and adverse effects.
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PUBERTAL DISORDERS
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The prevalence of pubertal disorders in adolescents with thalassemia despite regular

transfusions and optimal chelation therapy ranges between 30-70% in various studies [2].
Early recognition and adequate management of such children can not only help in optimizing
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growth and puberty but also improve the quality of life and restore the fertility potential. The
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key factor implicated is the iron overload that mediates its oxidative damage (through iron-
generated free radicals) to the hypothalamic- pituitary- gonadal axis. The cause is usually
damage to gonadotrophs in anterior pituitary leading to failure of adequate production of
gonadotrophins LH & FSH. Direct gonadal damage by iron overload is much less likely. In
fact, many patients have normal ovarian function and can produce expected number of ova
after stimulation and thus achieve fertility.
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The clinical presentation can range from a delay in the onset of puberty to pubertal arrest and
complete failure (Table 3). Presence of pubertal abnormalities has many implications apart
from potential infertility. It contributes towards short stature due to absent/poor pubertal
growth spurt. Associated poor sexual development contributes towards poor body image in
the adolescent subject with thalassemia. Since sex steroids have an important role to play in
pubertal bone mass accrual, these subjects fail to achieve optimum bone mass, a factor that

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contributes towards osteopathy observed thalassemia. The adolescent girls usually suffer
from primary amenorrhea while secondary amenorrhea likely to be encountered in the older

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age group (late twenties). The uterus and gonads show a subnormal growth and reach a final
size smaller than their age matched healthy cohorts. Similarly, the boys fail to show the

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pubertal growth spurt, appearance/progression of secondary sexual characteristics and
increase in the testicular volume. MRI brain is a useful tool to assess the degree of siderosis
in the pituitary (reduced signal intensity in anterior pituitary) to provide an insight to the
disease progression and prognosis.
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Assessment of delayed puberty in thalassemia

In thalassemia, a close clinical, biochemical and at times USG monitoring is of utmost

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importance to determine any deviation from the course of normal pubertal development.
Besides a regular growth monitoring, the progression of puberty is assessed by SMR staging
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(Tanner staging) every six months starting from the age of 10 years. Girls without evidence
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of puberty by 13 years and boys by 14 years require further evaluation for delayed puberty. If
bone age for pubertal onset has been achieved (11 year in girls & 12 years in boys), serum
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levels of LH, FSH, and estradiol/testosterone are estimated to determine the functioning of
the HPG axis. Low FSH and LH for age indicate hypogonadotropic hypogonadism (HH)
(hypothalamic-pituitary lesion). In subjects with equivocal results, GnRH analogue
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stimulation test (with Injection tryptorelin 0.1 mg/m2 S/C) is needed for evaluating the
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pituitary ability to synthesize and secrete gonadotropins. If LH and/or FSH are low (peak
serum LH level <5 IU/L after 4 hrs) after GnRH stimulation, it indicates that pituitary is not
yet primed to enter puberty, indicating delayed puberty or possible hypogonadotrophic
hypogonadism (HH). Rarely, pubertal failure may be due to direct gonadal damage this
would be indicated by presence of elevated FSH and LH levels.

Bone age evaluation is useful for prediction of the remaining growth potential and final adult
height of these patients. Pelvic ultrasound is useful in assessing ovarian and uterine
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maturation. MRI pituitary (T2*) can be utilized as an early tool to detect iron deposits in the
pituitary.

Management

There are no standard recommendations to guide pubertal induction in chronic diseases like
thalassemia. The protocols used to induce puberty in constitutional delay of puberty can be

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applied in such cases with delayed puberty [19,25]. The primary goal in the management of
delayed puberty is to mimic biological and biochemical pubertal events with concomitant
promotion of sexual maturation and linear growth. These goals can be achieved by pubertal

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induction at a bone age of >11 years and >12 years for girls and boys respectively; in
adolescents with pubertal delay. It is underscored that the children planning to go to TM who

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have delayed puberty should not undergo pubertal induction as that simply increases the risk
of infertility.

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The puberty induction should not be delayed beyond 14 years to maximise growth potential
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and avoid deleterious effects on bone mineral accrual. The optimal regime depends on the
patient profile (age, height and expected height, financial condition, psychological state, the
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set treatment goals and the personal experience of the treating endocrinologist. Chatterjee et
al [26] reported successful outcome of priming by low dose sex steroid in a small Indian
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cohort. In a 6-year prospective study of 55 Indian TM children (15-18 years) with stunted
growth and delayed/arrested puberty, 80% reported favourable response to low dose sex
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steroid priming (6–12 months) with increase in height, growth spurt and completed pubertal
maturation (Tanner stage 4–5) [26].
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BOYS: Boys are treated with a depot testosterone preparation @ 50 mg i.m every 4 weeks
for a duration of 6 months [19, 25]. This leads to an increase in penile size and the
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appearance of pubic hair. If during this time an increase in testicular volume is observed, it
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indicates activation of the H-P-G axis and release of gonadotrophins (FSH and LH). In this
situation, no further doses are given and children followed closely for progression of
spontaneous puberty.

GIRLS: Adolescent girls with pubertal delay are primed with a low dose oral estrogen
preparation. At our centre, we use ethinyl estradiol (initial dose 2.5 – 5 µg/day) or estradiol
valerate 0.5 mg/day for 6 months. During this time, they are followed for spontaneous
progression indicated by breast development more than that expected for the low dose of sex
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steroids given. In such girls, the therapy is stopped after 6 months and follow up continued
for spontaneous pubertal induction [19, 25].

Adolescents who do not sustain pubertal development after withdrawal of sex steroids as
given above are likely to have permanent hypogonadism and require induction of puberty
using exogenous Hormone Replacement Therapy or gonadotrophins [19, 25].

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Pubertal induction in boys: In boys, therapy consists of gradually increasing doses of
intramuscular depot preparations of testosterone enanthate starting from 50 mg every 4
weeks, with progressive increase in the dose every 6–12 months in increments of 50 mg until

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the adult replacement dose is achieved (over a period of 3–4 years), which is 300 mg every 3
weeks In cases where testicular volume is pre/early pubertal, the above therapy is combined

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with injection hCG @ 500–1500 IU (s,c or i.m) on alternative days or a combination of hCG
and FSH (human menopausal gonadotropin, highly purified urinary FSH or recombinant

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FSH), the latter @ 75– 100 IU (s.c or i.m) on alternate days. In this situation the therapy is
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initially started with injection hCG; and FSH added after 6-12 months if the testicular volume
plateaus [25].
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Pubertal induction in girls: for girls who do not show any response to the low dose estrogen
therapy after 6-12 months or in cases of ovarian failure, dose of estrogen is gradually
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escalated (usually every 6–12 months) over a period of 2–3 years), until a daily adult
replacement dose is achieved. This corresponds to 0.6–1.25 mg conjugated equine oestrogen,
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20 µg ethinylestradiol or 2 mg/day of estradiol valerate. When menarche is achieved, or after

2 years of estrogen therapy, a cyclic progestogen: medroxyprogesterone (5–10 mg/day) or
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norethisterone (0.7–1.0 mg/day) is added for 10-14 days every month, with the objective of
establishing regular monthly menstrual cycles.
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A similar hormone therapy is indicated in adolescents with pubertal arrest after spontaneous
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onset of puberty or those who seek care later during adolescence. In these adolescents,
therapeutic regime is guided by the growth potential, clinical response and emotional factors.
It is seen that ovarian and testicular reserves are usually preserved in HH patients, as they are
still able to increase estradiol or testosterone levels following gonadotrophin stimulation test
to produce ova or sperms in females and males, respectively [27,28].

IMPAIRED PANCREATIC β-CELL FUNCTION

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The intensive management of thalassemia in children with regular blood transfusions and
chelation therapy has led to progressive decline in the prevalence of Impaired Glucose
tolerance (IGT) and Diabetes mellitus (DM) from 30-70% (early 90’s) to 5-24% [29, 30].
Like other endocrine complications, IGT and DM usually develop in second decade of life or
later. The prevalence of DM and IGT in adolescents and young adults with thalassemia
conventionally treated with DFO varies in different series from 0 to 10.5 % [2, 31] and from

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17 to 24 %, respectively [29, 32, 33].

Mechanism of toxicity: The pathophysiology of impaired glucose homeostasis in β-

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thalassemia is complex and multifactorial [34-39]. The key factors responsible for the
development of diabetes in thalassemia are iron overload, chronic liver disease, viral hepatic

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infections (transfusion-associated infections like Hepatitis C) and genotype of the individual.
A state of hyperinsulinemia secondary to iron overload induced hepatic and pancreatic

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dysfunction is observed during the second decade in thalassemia. Further, the secondary
hemosiderosis in liver and muscles lead to peripheral Insulin resistance possibly due to
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abnormalities of Insulin receptors or glucose transporters. Gradually over time, impaired
pancreatic β-cell function results in progressive β-cell exhaustion culminating to Insulin
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deficiency. Both Insulin resistance and deficiency, alone or in combination lead to a state of
impaired glucose tolerance (IGT) and subsequently evolve to Type 1 Diabetes mellitus. The
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diabetes in thalassemia differs from the classical Type 1 DM by the absence of Islet cell
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antibodies, no relation with HLA DR/DR4 and infrequent association with DKA [40].
However diabetics with thalassemia are more predisposed to develop nephropathy (oxidative
stress) [41] and less likely to develop retinopathy (low IGF-1 levels) [42]. The progression
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from IGT to DM is usually slow and can-not be predicted. In one of the prospective study,
the progression from IGT to DM was reported in 12.4% adolescent thalassemics over a
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period of 10 years [32]. Beside iron overload, chronic anaemia, Zinc deficiency and increased
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collagen deposition (secondary to increased activity of iron dependent protocollagen proline

hydroxylase enzyme) leading to disturbed microcirculation in the pancreas are implicated in
the development of diabetes in thalassemia.

Assessment of glucose homeostasis in thalassemia

Early recognition of problems due to impaired glucose homeostasis is essential. Children

with impaired glucose tolerance and diabetes are identified using the recommendations given
by American Diabetes Association [43]. A fasting plasma glucose is assessed annually
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beyond 10 years of age, OGTT being indicated in patients with FPG >110 mg/dl. Continuous
glucose monitoring system (CGMS) has emerged as a promising and valid tool in detecting
early glucose derangements in children and adults with thalassemia [44,45] and is considered
to be more sensitive than OGTT which may miss episodic hyperglycemia. The HbA1c levels
are unsuitable for monitoring the long-term glycaemic control in thalassemia patients with
diabetes, fructosamine may be used instead [46].

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Diabetes in thalassemia significantly increases the risk for cardiac complications, heart
failure, hyperkinetic arrhythmias and myocardial fibrosis [47]. Combined intensive iron

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chelation therapy with DFO and deferiprone (DFP) is associated with an improvement in
glucose intolerance, particularly in patients in early stages of glucose intolerance [48].

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However, it is less effective in preventing insulin resistance and does not prevent the
progression to type 1 DM in all patients [49].

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Management
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Regular screening of hepatitis associated infections and intensive chelation therapy are
important to prevent or delay the development of diabetes in children with thalassemia.
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Dietary modification (judicious selection of complex carbohydrate and proteins with

moderate restriction of fat) and exercise play a vital role in the management of children with
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thalassemia and IGT especially during the early stages. Evidence supports the use of the oral
biguanide (metformin), in addition to diet and exercise to delay or prevent the progression to
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overt DM [50]. In addition, oral glibenclamide [51] and Acarbose [52] have shown a
promising role in achieving glycemic control especially in children with Insulin resistance.
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The role of Insulin therapy comes into play when all the other measures fail and Insulin
deficiency develops.
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OSTEOPOROSIS
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Reduced bone mass, fractures and bone pain are the common causes of morbidity and
disability in children with thalassemia. Despite intensive transfusion regimes and chelation,
the prevalence of osteopenia and osteoporosis is reported to be as high as 50%-90% in
various studies [53, 54]. The pathogenesis of osteoporosis is distinct from the development of
bony deformities secondary to ineffective erythropoiesis and progressive marrow expansion
seen in children receiving inadequate transfusions. The key factors implicated in osteoporosis
are delayed puberty, diabetes, hypothyroidism, hypoparathyroidism, GH-IGF-1 deficiency,
and ineffective erythropoiesis with marrow expansion [55]. Expansion of bone marrow leads
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to mechanical interruption in bone formation, cortical thinning, and fragility. The above
factors create an imbalance in bone remodelling; they inhibit osteoblast activation and/or
increase osteoclast function, leading to bone loss and osteoporosis. Chronic anaemia
stimulates erythropoietin synthesis that results in bone resorption through high RANKL
levels. Iron overload in thalassemia patients impairs the osteoid maturation and
mineralization by incorporation of iron in the hydroxyapatite crystals thereby reducing the

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tensile strength and resulting in focal osteomalacia. The use of high dose DFO has been
associated with bony deformities due to its adverse effects on the cartilage. Some studies

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have suggested an important role of gene polymorphisms in the development of poor bone
mineral density, though their precise role in thalassemia is still not clear. Malnutrition, lack of

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physical activity, deficiency of vitamin C, D and calcium are other contributory factors in the
development of osteoporosis. There is increased risk of vitamin D deficiency in patients with
thalassemia compared to age matched controls [56]. Vitamin D sufficiency is critical for

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optimal bone health, reducing the risk of fractures and improving the myocardial function
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especially in cases with cardiac iron overload [57, 58].

Assessment
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Assessment of the bone mineral content (BMC) and the areal bone mineral density (aBMD)
is done using Dual energy X-ray absorptiometry (DXA) despite its limitations in reporting
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and interpretation in the pediatric population (before 20 years). The antero-posterior lumbar
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spine (L1–4) and total body less head (TBLH) are the preferred skeletal sites for
measurement in most children. In pediatric patients, BMC or aBMD values of < -2 SD are
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considered as having low bone mass for age. The diagnosis of osteoporosis in pediatrics is
based upon vertebral fractures alone or low bone density and multiple long bone fractures
(two or more long bone fractures by age the 10 years or three or more long bone fractures
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before age 19 years) [55]. BMD interpretation is related to age (and the height in short
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subjects) sex and pubertal status. A baseline DXA evaluation should be done at 10-12 years
for girls and boys annually and every 2 years thereafter. Bone Densitometry should always be
a part of the comprehensive bone health screen, which includes complete blood count,
erythrocyte sedimentation rate, serum calcium, phosphorus, alkaline phosphatase, intact PTH,
total 25 hydroxy vitamin D, BUN, creatinine, and urinary calcium to creatinine ratio.

Management
 ACCEPTED MANUSCRIPT
Prevention, early diagnosis and prompt management of low bone mass are the corner stones
of optimizing bone health in thalassemia. Intensive transfusion and chelation regimes,
adequate calcium (500-1000 mg/day) intake in combination with vitamin D supplements and
good physical activity improve bone mineralization and prevent bone loss. Vitamin D
deficiency is actively looked for and treated with supplements to ensure sufficiency in all
cases with thalassemia for optimizing bone health [59]. In addition, treatment of other

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endocrinopathies (hypothyroidism, diabetes, hypoparathyroidism) and puberty induction
using sex steroids is critical in achieving adequate bone mineral accretion in children and

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adolescents with thalassemia. Recent studies have reported role of bisphosphonates in the
management of thalassemia children with osteoporosis [60] but further studies are needed to

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clarify their long-term benefits and side effects.

HYPOPARATHYROIDISM

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The prevalence of hypoparathyroidism, observed usually during the second decade or
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beyond, is reported to vary from 3.6% to 20% [61]. Parathyroid dysfunction develops
because of iron overload in parathyroid cells and resultant tissue fibrosis. Increased bone
resorption in response to chronic anaemia and ineffective erythropoiesis can suppress the
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PTH secretion from parathyroid gland.

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Assessment
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Hypoparathyroidism (HPT) is detected either as part of routine biochemical screening (low

serum calcium and or high fasting serum phosphate) or signs and symptoms of
hypocalcaemia like tetany, seizures, carpopedal spasm, laryngeal stridor or paraesthesia in the
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hands and feet. HPT is diagnosed on the basis of low serum calcium along with high
phosphorous (fasting), low/normal PTH and low 1,25 (OH)2 D levels. The 24 hours urinary
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calcium and phosphorous levels are low in these cases. In late cases, intracranial
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calcifications (basal ganglia, frontoparietal areas of brain, thalami, and internal capsule) may
be detected.

Management

Treatment of symptomatic hypocalcemia in HPT is done by using intravenous 10% calcium

gluconate solution. In an asymptomatic child oral calcium supplements (1g/day) in divided
doses are prescribed. This is combined with active vitamin D supplements calcitriol @ 15-30
ng/kg/day (max 1.5 µg/day) to maintain the serum calcium concentrations in low normal
 ACCEPTED MANUSCRIPT
range [19]. Weekly blood tests (serum calcium and phosphorous) are needed at the start of
therapy, followed by quarterly plasma and urinary calcium and phosphorous measurements to
monitor for hypercalciuria.

ADRENAL FUNCTIONS

Children with thalassemia experience adrenal dysfunction because of excessive iron deposits

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affecting the hypothalamic-pituitary- adrenal axis at different levels. Clinically overt adrenal
insufficiency is uncommon in thalassemia. However, various studies have reported presence
of biochemical adrenal insufficiency in the range of 0-45% [61]. The variable prevalence can

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be explained by the differences in the cut offs used for serum cortisol and the degree of
hemosiderosis. Adrenarche is usually delayed in thalassemia patients, due to low adrenal

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androgen production. In the subset with primary adrenal insufficiency, the cortisol,
aldosterone, and androgen secretion are impaired, each to a variable extent, while secondary

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or tertiary adrenal insufficiency (pituitary or hypothalamic affected) causes no
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mineralocorticoid defect [62]. The thalassemia patients with chronic liver disease often
falsely report low cortisol levels due to the low cortisol binding globulin levels (CBG),
synthesized in liver.
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Assessment of adrenal functions

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Adrenal function is assessed every 1-2 years beginning from the age of 9 years, especially in
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children with growth hormone deficiency receiving rhGH therapy. A morning cortisol levels
(8 a.m.) is done in all patients and values < 138 nmol/L are considered low. An ACTH
stimulation test with cortisol measured 60 minutes after an intravenous injection of ACTH
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(Synacthen, 0.25 mg) detects subclinical adrenal insufficiency as indicated by cortisol level
of <500 nmol/L (18 µg/dL) 60 min after ACTH administration.
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Management
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Under basal conditions, subclinical impairment of adrenocortical function in patients with

thalassemia is of not much clinical significance. However, it has relevance during stressful
situations where in glucocorticoid supplementation may be indicated to prevent adrenal crisis
[63].

HYPOTHYROIDISM
 ACCEPTED MANUSCRIPT
The thyroid dysfunction in thalassemia develops as a result of thyroidal cell siderosis, usually
seen in the second decade of life. Primary hypothyroidism occurs much before the iron
toxicity affects the hypothalamic-pituitary axis; making secondary hypothyroidism a much
rarer entity. The prevalence of hypothyroidism varies from 0-18 % as demonstrated in
various studies [3]. The mechanisms of injury are possibly lipid peroxidation, free radical
release and oxidative stress due to iron overload. The degree of thyroid dysfunction is

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directly related to the degree of iron overload, with the early stages being reversible by
intensive chelation therapy. However, the progression of subclinical to overt hypothyroidism

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is not foreseeable and may take many years [64]. The patients are usually asymptomatic and
have an impalpable thyroid gland. Studies have reported serum ferritin to positively correlate

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with the TSH and USG of the thyroid gland (reduced echogenicity with reduced volume and
thickening of the thyroid capsule), and predict the progression of the thyroid dysfunction in
thalassemia [65]. Apart from contributing towards statural growth and bone mineralisation,

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optimising thyroid functions is important for improving the cardiac function, since cardiac
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failure is the most important cause of mortality in thalassemia.
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Assessment of thyroid functions

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It is recommended to have annual evaluation of thyroid function tests beginning at the age of
10 years (unless symptomatic hypothyroidism is present) [19]. Assessment of thyroid
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functions involves measurement of serum T4 (free) and TSH levels. The patient can have
biochemical features of subclinical (low or normal free T4 with a high TSH) or overt
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hypothyroidism (low free T4 with a high TSH).

Management
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Good compliance with chelation therapy may prevent or reverse thyroid dysfunction in early
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stages. Sub-clinical hypothyroidism-basal TSH 5 to 7 mIU/ml will require regular follow-up

and optimizing chelation therapy [19]. Cases with overt hypothyroidism are managed with
age appropriate dose of L-thyroxine.

ANNUAL ENDOCRINE SCREENING

Since most endocrine complications make an appearance during the second decade of life and
beyond, it is recommended that all children with TM undergo a comprehensive annual
endocrine screening beginning 9 years of age (Table 4) [19]. Prior to that, a regular growth
 ACCEPTED MANUSCRIPT
monitoring is done every 6 months from enrolment and pubertal onset and progression are
determined every 6 months after the age of 10 years. The annual endocrine includes thyroid
function tests (free T4 and TSH), fasting glucose, oral glucose tolerance test (if indicated),
serum Calcium , serum phosphate (fasting), vitamin D and PTH (if indicated by clinical
symptoms or biochemical features), and bone age. The LH, FSH, and sex steroids are
evaluated in the adolescents with delayed/arrested puberty. A baseline DXA scan followed by

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annual/once in 2 years screening of bone mineral density is also recommended.

SUMMARY AND CONCLUSIONS

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Management of a child with thalassemia requires regular evaluation by an endocrinologist
beginning second decade of life due to a high prevalence of endocrine dysfunctions seen in

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these patients. Prevention is the best approach since efficacy of intensive chelation in
reversing established endocrinopathies is unknown. Thus, preventing anaemia through a

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regular transfusion schedule, optimum chelation, maintaining an adequate nutritional status
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and prompt recognition and treatment of co-morbidities form the cornerstones of
endocrinopathy prevention. However, the endocrinopathies are still being seen because the
majority of TM patients lack adequate clinical care. Early identification and prompt
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management of the endocrine complications have a significant role in reducing morbidity and
mortality of thalassemia patients.
D
TE
C EP
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 ACCEPTED MANUSCRIPT
Table 1- Comparative prevalence of endocrinal complications of children with TM

Cyprus Italy Iran (2003) TIF North India

[2] (1995) [4] (2004) America (2014)
[3] [5] (2004) [7]
[6]
Number of Patients 435 1861 220 3817 342 89

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Hypogonadism (%) 32.5 49 22.9 (males), 40.5 35 54.1
12.2

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(females)
Short Stature (%) 35 39.3 30.8 55

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Sitting Height (%) 72
Hypothyroidism 5.9 6.2 7.7 3.2 9 8.9

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(%)
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Hypoparathyroidism 1.2 3.6 7.6 6.9 4 10.1
(%)
DM/IGT (%) 9.4 4.9 8.7 3.2/6.5 10 13
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Table 2: Factors contributing to growth failure in children and adolescents with TM

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a. Chronic anaemia with ineffective erythropoiesis

b. Under nutrition (Zinc Deficiency)

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c. Iron overload resulting in chronic liver disease and cardiac dysfunction

d. Transfusion associated infections like hepatitis C, B, HIV

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e. Endocrinal dysfunctions- Defective GH-IGF-1 axis

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Defective Pituitary-Gonadal axis

Hypothyroidism, hypoparathyroidism

Diabetes mellitus

f. Side effects of chelation therapy on skeletal growth

g. Psychosocial stress
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Table 3 Definitions in pubertal delay

I. Delayed Puberty: Absence of gonadarche (Testicular Volume ≥ 4 ml) in males by 14

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years and thelarche (appearance of breast bud) in females by 13 years.

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II. Arrested puberty: Arrested puberty is defined as the absence of further pubertal
progression once puberty has started for more than 1 year, where testicular volume in

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boys never progressed beyond 6–8 mL and breast size in girls remained unchanged.

III. Primary amenorrhoea: Failure in menarche by 16 years.

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IV. Secondary amenorrhoea: Absence of menstrual periods for >12 months after
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menarche.

Table 4 Protocol to screen endocrinopathies in children with TM

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ISSUES ASSESMENT
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Poor Growth Height and weight monitoring 6 monthly

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Maintain a longitudinal record on a growth chart

Delayed/Arrested Puberty Biannual (every 6 months) assessment of growth (height,
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weight) and pubertal progress using SMR staging.

Impaired β cell function Annual Blood Glucose (fasting/post prandial) ; Oral
Glucose tolerance test if clinically indicated
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Osteoporosis Annual/Biennial DEXA

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Hypoparathyroidism Serum Ca/PO4/ALP 6 monthly

Annual Vitamin 25 (OH)D and PTH
Hypothyroidism Annual FT4/TSH
Adrenal insufficiency Annual morning serum cortisol
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Growth and Endocrine Issues in Children with Thalassemia

INTRODUCTION

With the advent of intensive transfusion and chelation regimes, life expectancy has increased
significantly in patients with β- thalassemia major (TM). However, progressive iron

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deposition in tissues as a result of repeated blood transfusions and enhanced dietary
absorption of iron due to ineffective erythropoiesis leads to many complications that may

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emerge as these children grow into adolescence and adulthood. The deleterious effects of
excessive iron deposition are primarily observed in the heart, liver and endocrine organs like

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pituitary- gonadal axis, GH-IGF axis, thyroid, parathyroid, pancreas and adrenals. Thus, in
this era, the endocrine complications have emerged as an important cause of morbidity and an
important determinant of quality of life in children with TM.

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The earliest case of multiple endocrine dysfunction in thalassemia intermedia was reported
around 50 years ago [1]. The data on prevalence of endocrine dysfunction in patients with
TM is limited and shows a wide variation due to differences in the study cohorts, age at onset
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of transfusion and chelation and compliance to both. The predominant clinical phenotypes
include short stature, delayed/arrested puberty, abnormal bone mineralisation, impaired
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glucose tolerance, hypothyroidism and hypoparathyroidism. Table1 shows the comparative

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prevalence of endocrine complications reported in children with TM in various settings over

last 2 decades [2-7].
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The underlying patho-physiological mechanism underlying these complications is excessive

iron load, a consequence of repeated blood transfusions that these children receive from early
childhood. Endocrine glands have high levels of transferrin receptors that promote iron
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accumulation and hence increase vulnerability of these glands to iron toxicity. Iron stored in
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endocrine glands binds to intracellular transferrin. As the storage capacity of transferrin gets
exceeded, pathological quantities of metabolically active iron catalyses formation of free
radicals, which in turn damage intra-membrane lipids and other macro-molecules, ultimately
causing cell death and organ failure. The degree and the severity of iron toxicity depends
upon the frequency/need for transfusions determined by genotype of the individual, the age at
initiation of chelation therapy and compliance to it [8].
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In this review, we present an overview of the various endocrine dysfunctions observed in
patients with TM.

GROWTH FAILURE

Growth failure is one of the most common co-morbidities witnessed in children and
adolescents with TM and an important cause of poor body image in these children. The

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prevalence of growth failure and short stature in children with thalassemia varies from 30-
50% in most studies [2]. The causes are multifactorial. The key factors responsible for growth
disturbances are summarized in Table 2. The relative contribution of various factors may vary

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at different ages. Chronic anaemia, hypoxia and nutritional factors are usually operational
before 5 years especially in children who do not receive regular transfusions. Between 5-10

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years, the adverse effects of transfusion associated iron overload on linear growth (GH-IGF-1
axis) are apparent in the absence of adequate chelation. Beyond the age of 10 years, absent

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/reduced pubertal spurt due to involvement of hypothalamo-pituitary-gonadal (HPG axis) axis
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makes a significant contribution. At all stages, co-morbidities can add further adverse
influence [9]. Children who are well transfused and adequately chelated have the best
prognosis for reaching optimum height.
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In the current era, children receiving regular blood transfusions and optimal chelation therapy
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usually do not exhibit signs of growth failure until the end of first decade. Most patients with
poor growth present either in the peri-pubertal phase with impaired growth or during puberty
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with arrested or absent puberty and absence of growth spurt. The growth plate fusion is also
delayed in these children until the end of second decade and thus they have a potential for
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growing when most unaffected children have completed their growth. This is primarily due to
iron load affecting the Growth Hormone – Insulin like Growth Factor axis (GH-IGF axis) and
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the HPG axis. The anterior pituitary is particularly sensitive towards free radical oxidative
stress from iron toxicity.
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The short stature (SS) encountered in thalassemia is often disproportionate with a low upper
segment to lower segment ratio [10]. The exact reason is not clear and an interplay of
multiple factors are responsible for it. In thalassemia, there is a progressive impairment in
spinal growth observed since early childhood [11]. Besides, other factors implicated in body
disproportion include iron overload (impaired cartilage growth), early use of desferrioxamine
(DFO) for chelation and delayed puberty (hypogonadism). Use of DFO between 2-5 years
has a paradoxical adverse effect on growth through inhibition of cell proliferation, DNA
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synthesis, and collagen formation and trace mineral deposition like Zn and Cu resulting in
flattening of vertebrae (platyspondylosis) and reduced spinal height [12]. Short trunk, genu
valgum, metaphyseal widening and joint stiffness is noted. The radiological changes seen are
thickened growth plates with widening and cupping of metaphyses, sclerosis of subchondral
bone with small radiolucent areas localised to the metaphyses and osteoporosis and increased
trabecular pattern of long bones. Off late, deferiprone treatment has been reported to be

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associated with arthropathy mainly of the knees [13, 14]. MRI studies indicate that damage to
the cartilage and the subchondral bone persist despite stopping treatment.

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Several mechanisms influencing the Growth Hormone Releasing Hormone (GHRH)-GH-
IGF- axis have been proposed to explain the growth faltering in patients with TM [15]:

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(1) Hypothalamic GH-releasing hormone deficiency (2) pituitary GH deficiency; (3)
neurosecretory dysfunction and (4) relative GH insensitivity. Growth Hormone deficiency

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(GHD) is seen in 20-30% of thalassemia patients while the remaining 70-80% show a peak
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growth hormone levels lower than those found in patients with constitutional short stature in
response to GH provocative stimuli like clonidine. Children with TM exhibit low IGF-1
levels in both GH deficient (GHD) and GH sufficient (GHS) subgroups. This was evident
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from a prospective study to assess the age related changes in serum IGF-1 concentrations in
thalassemia patients compared to age and sex matched normal cohort. The normal healthy
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cohorts experienced a peak in IGF-1 levels at 13 years (boys) @ 8-9 times the baseline. The
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thalassemia patients with GHD did not show peak rise in IGF-1 levels till 18 years while the
subgroup with GHS reported a late and attenuated peak IGF-1 levels at 16-18 years (@ 3
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times from baseline) [16]. Further, the IGF-1 response to exogenous administration of GH is
significantly lower in children with thalassemia and GHD as compared to ones who have
idiopathic GHD [17]. There is another subgroup of thalassemia children who show a normal
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GH response to provocative tests but their IGF-1 levels continue to be low suggesting a low
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GH sensitivity (secondary to liver dysfunction) or a neurosecretory dysfunction. The latter

manifests as an abnormal nocturnal GH secretory pulse pattern (due to high somatostatin
tone) and lack of negative feedback regulation (in response to low IGF-1 levels) at the
hypothalamus-pituitary level [17].

Puberty (spontaneous/induced) plays a significant role in achieving the desired growth spurt
in adolescents by augmenting the GH pulse amplitude that leads to a rise in IGF-1 and IGF-
BP-3 levels. There is a mutual amplifying effect in the concentration of GH, IGF-1 levels and
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sex steroids observed during the progressive stages of puberty that results in growth spurt,
appearance of secondary sexual characteristics, increase in muscle mass and bone mineral
accretion. Children with thalassemia experience delay/arrest in puberty due to the
hypogonadotropic hypogonadism with or without loss of gonadal function [18].

Growth monitoring in children with thalassemia

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1. A longitudinal record of weight and height (along with Mid parental height (MPH)
and Target range) and BMI should be maintained on a growth chart at six monthly
interval to facilitate early detection of growth faltering. MPH is calculated by adding

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6.5 cm to the average of the mother’s and father’s height in the case of boy and by
subtracting 6.5 cm in the case of girl. Statistically 95% of the children are expected to

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reach an adult height within a range of about 8.5 cm above or below the MPH
percentile (i.e. ±2SD on either side of MPH). This range is called as Target range. The

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annual growth velocity (GV) is assessed, if <25th percentile consider it a red flag.
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2. Compare the height indices (height for age) of the patient (height SDS or centiles)
with the population data as well as with the mid‑parental height (SDS or centiles).
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Definition of Short stature:

•
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Height is less than the 3rd percentile or 2 SD below the mean height for age and
sex; OR
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• Height is within normal but GV is consistently <25th percentile over 6-12 months;
OR
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• The patient is excessively short for his/her mid‑parental height, though his
absolute height may be within the normal percentiles.
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3. Assess for onset and progress of puberty (SMR using Tanners staging) annually for
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all children above 10 years of age. The varied phenotypes of pubertal delay are
described in table 3.

Assessment in a child with short stature

1. The following points in HISTORY should be inquired in a child who has TM.

• Onset of disease and the need for blood transfusions

• Pre-transfusion haemoglobin level

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• Annual packed cell volume requirement

• Chelation type, dose, compliance

• Serum ferritin levels

• Any associated comorbidity like features suggestive of endocrine complications or

coinfection with blood borne agents like Hepatitis B, C or HIV.

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2. The EXAMINATION would include:

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• General Physical Examination: A note is made on the skin pigmentation, pallor,
icterus, cyanosis, clubbing, and thyromegaly.

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• Stable vitals

• Anthropometry: Weight, Height; Assess standing and sitting heights and calculate
upper/lower segment ratio.
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• Sexual Maturity Ratings (Tanner)

• Systemic Examination: Hepatosplenomegaly

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3. Bone age assessment (X-ray of wrist and hand)

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In cases with disproportionate SS- radiographs of tibia and spine to exclude the presence of
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platylospondylosis or metaphyseal cartilaginous dysplasia changes.

4. Co-morbidity screening: specially; hepatitis B, C, HIV.

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5. Assess for other endocrinopathies: Serum free T4, TSH, fasting glucose and oral
glucose tolerance testing (OGTT) in case of impaired fasting glucose (IFG), morning
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cortisol levels. The HbA1c level is not reliable in screening for diabetes.
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6. Biochemical investigations: Serum calcium, ionized calcium, inorganic phosphate,

magnesium, and alkaline phosphatase, KFT, LFT.

7. Screening for Celiac Disease (in both boys and girls) using serum tTG levels and
Turner Syndrome (in girls).

8. Assessment of GH secretion is performed in cases with height ≤ - 3 SD and delayed

bone age (described later).
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9. LH, FSH, sex steroids (after 12-13 years if no clinical pubertal development, any time
thereafter in case of pubertal arrest).

Management: Key components of management of short stature in children with TM include:

i. Treatment of anaemia and optimizing chelation therapy.

ii. Correction of nutritional deficiencies if any, undernutrition and mineral deficiencies

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(zinc)

iii. Treatment of overt hypothyroidism

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iv. GH treatment is indicated in established cases with GH deficiency.

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v. Timely replacement therapy with sex steroids in children with failure of spontaneous
pubertal onset / poor progression of puberty.

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vi. Psychosocial support
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Assessment of GH secretion

i) Serum levels of IGF‑1 and IGF BP‑3 are estimated in children with height ≤ - 3 SD and
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delayed bone age (more than 2 SD or delay > 2 years from chronological age). They are
useful indicators of growth hormone secretion and nutrition (low in chronic liver disease and
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malnutrition) - Low levels indicate GH deficiency or defect in IGF-1 generation.

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ii) Growth hormone stimulation testing: Normal thyroid functions are ensured before
conducting the GH stimulation test. Peripubertal children require priming with sex steroids
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before evaluation by GH stimulation test. This is done for boys by giving a single
intramuscular injection of testosterone enanthate 100 mg seven days prior to testing and for
girls by giving oral ethinyl estradiol 50µg for 3 days before testing. Another alternative
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regime that can be used in both boys and girls is conjugated estrogen 5mg orally given night
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before and morning of the test. Girls whose bone age is less than 9 years and boys whose
bone age is less than 10 years do not need priming [19]. Significant GH insufficiency may be
diagnosed by a reduced response of GH to two provocative tests (GH peak <10 ng/ml) in
children and adolescents or reduced response of GH in one test plus low IGF-1 and IGF BP-3
concentrations [20].

MRI of the hypothalamic-pituitary region is useful to evaluate pituitary iron overload as well
as the size of pituitary gland (atrophy).
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Management: Treatment with recombinant human growth hormone (rhGH) is indicated in
cases with established GH deficiency. These subjects often need higher doses due to co-
existing partial GH insensitivity. In children with pubertal delay best results are observed
with concomitant sex steroid replacement. Puberty induction with low dose sex steroids may
accelerate linear growth similar to the effect of rhGH therapy [21]. The efficacy of rhGH
treatment in the management of children with BTM having growth failure secondary to

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Growth hormone deficiency has been a matter of debate. The linear growth velocity attained
after exogenous GH administration in children with thalassemia is reported to be lower than

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that seen in children with primary GH deficiency, possibly due to GH insensitivity [22].
Since children with thalassemia have delayed bone age, some improvement in linear growth

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is witnessed in the second decade of life even without rhGH therapy. The current evidence
supports the short term use of rhGH therapy in thalassemia patients with short stature as it
augments the linear growth velocity with maximum benefit being observed in first year of

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therapy, However, data to demonstrate its long term benefit in improving final height is
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lacking [23, 24]. There is uncertainty regarding the ideal time to start GH therapy and the
dosage. Finally, the decision to use rhGH therapy should depend on the patient profile (age,
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pubertal status), comorbidities (iron overload and chronic liver disease), cost benefit ratio and
the risk of adverse events (impaired glucose tolerance). During GH treatment, patients should
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be monitored at 3-monthly intervals with a clinical assessment and an evaluation for

parameters of GH response (growth parameters, compliance) and adverse effects.
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PUBERTAL DISORDERS
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The prevalence of pubertal disorders in adolescents with thalassemia despite regular

transfusions and optimal chelation therapy ranges between 30-70% in various studies [2].
Early recognition and adequate management of such children can not only help in optimizing
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growth and puberty but also improve the quality of life and restore the fertility potential. The
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key factor implicated is the iron overload that mediates its oxidative damage (through iron-
generated free radicals) to the hypothalamic- pituitary- gonadal axis. The cause is usually
damage to gonadotrophs in anterior pituitary leading to failure of adequate production of
gonadotrophins LH & FSH. Direct gonadal damage by iron overload is much less likely. In
fact, many patients have normal ovarian function and can produce expected number of ova
after stimulation and thus achieve fertility.
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The clinical presentation can range from a delay in the onset of puberty to pubertal arrest and
complete failure (Table 3). Presence of pubertal abnormalities has many implications apart
from potential infertility. It contributes towards short stature due to absent/poor pubertal
growth spurt. Associated poor sexual development contributes towards poor body image in
the adolescent subject with thalassemia. Since sex steroids have an important role to play in
pubertal bone mass accrual, these subjects fail to achieve optimum bone mass, a factor that

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contributes towards osteopathy observed thalassemia. The adolescent girls usually suffer
from primary amenorrhea while secondary amenorrhea likely to be encountered in the older

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age group (late twenties). The uterus and gonads show a subnormal growth and reach a final
size smaller than their age matched healthy cohorts. Similarly, the boys fail to show the

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pubertal growth spurt, appearance/progression of secondary sexual characteristics and
increase in the testicular volume. MRI brain is a useful tool to assess the degree of siderosis
in the pituitary (reduced signal intensity in anterior pituitary) to provide an insight to the
disease progression and prognosis.
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Assessment of delayed puberty in thalassemia

In thalassemia, a close clinical, biochemical and at times USG monitoring is of utmost

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importance to determine any deviation from the course of normal pubertal development.
Besides a regular growth monitoring, the progression of puberty is assessed by SMR staging
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(Tanner staging) every six months starting from the age of 10 years. Girls without evidence
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of puberty by 13 years and boys by 14 years require further evaluation for delayed puberty. If
bone age for pubertal onset has been achieved (11 year in girls & 12 years in boys), serum
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levels of LH, FSH, and estradiol/testosterone are estimated to determine the functioning of
the HPG axis. Low FSH and LH for age indicate hypogonadotropic hypogonadism (HH)
(hypothalamic-pituitary lesion). In subjects with equivocal results, GnRH analogue
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stimulation test (with Injection tryptorelin 0.1 mg/m2 S/C) is needed for evaluating the
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pituitary ability to synthesize and secrete gonadotropins. If LH and/or FSH are low (peak
serum LH level <5 IU/L after 4 hrs) after GnRH stimulation, it indicates that pituitary is not
yet primed to enter puberty, indicating delayed puberty or possible hypogonadotrophic
hypogonadism (HH). Rarely, pubertal failure may be due to direct gonadal damage this
would be indicated by presence of elevated FSH and LH levels.

Bone age evaluation is useful for prediction of the remaining growth potential and final adult
height of these patients. Pelvic ultrasound is useful in assessing ovarian and uterine
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maturation. MRI pituitary (T2*) can be utilized as an early tool to detect iron deposits in the
pituitary.

Management

There are no standard recommendations to guide pubertal induction in chronic diseases like
thalassemia. The protocols used to induce puberty in constitutional delay of puberty can be

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applied in such cases with delayed puberty [19,25]. The primary goal in the management of
delayed puberty is to mimic biological and biochemical pubertal events with concomitant
promotion of sexual maturation and linear growth. These goals can be achieved by pubertal

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induction at a bone age of >11 years and >12 years for girls and boys respectively; in
adolescents with pubertal delay. It is underscored that the children planning to go to TM who

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have delayed puberty should not undergo pubertal induction as that simply increases the risk
of infertility.

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The puberty induction should not be delayed beyond 14 years to maximise growth potential
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and avoid deleterious effects on bone mineral accrual. The optimal regime depends on the
patient profile (age, height and expected height, financial condition, psychological state, the
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set treatment goals and the personal experience of the treating endocrinologist. Chatterjee et
al [26] reported successful outcome of priming by low dose sex steroid in a small Indian
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cohort. In a 6-year prospective study of 55 Indian TM children (15-18 years) with stunted
growth and delayed/arrested puberty, 80% reported favourable response to low dose sex
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steroid priming (6–12 months) with increase in height, growth spurt and completed pubertal
maturation (Tanner stage 4–5) [26].
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BOYS: Boys are treated with a depot testosterone preparation @ 50 mg i.m every 4 weeks
for a duration of 6 months [19, 25]. This leads to an increase in penile size and the
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appearance of pubic hair. If during this time an increase in testicular volume is observed, it
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indicates activation of the H-P-G axis and release of gonadotrophins (FSH and LH). In this
situation, no further doses are given and children followed closely for progression of
spontaneous puberty.

GIRLS: Adolescent girls with pubertal delay are primed with a low dose oral estrogen
preparation. At our centre, we use ethinyl estradiol (initial dose 2.5 – 5 µg/day) or estradiol
valerate 0.5 mg/day for 6 months. During this time, they are followed for spontaneous
progression indicated by breast development more than that expected for the low dose of sex
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steroids given. In such girls, the therapy is stopped after 6 months and follow up continued
for spontaneous pubertal induction [19, 25].

Adolescents who do not sustain pubertal development after withdrawal of sex steroids as
given above are likely to have permanent hypogonadism and require induction of puberty
using exogenous Hormone Replacement Therapy or gonadotrophins [19, 25].

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Pubertal induction in boys: In boys, therapy consists of gradually increasing doses of
intramuscular depot preparations of testosterone enanthate starting from 50 mg every 4
weeks, with progressive increase in the dose every 6–12 months in increments of 50 mg until

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the adult replacement dose is achieved (over a period of 3–4 years), which is 300 mg every 3
weeks In cases where testicular volume is pre/early pubertal, the above therapy is combined

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with injection hCG @ 500–1500 IU (s,c or i.m) on alternative days or a combination of hCG
and FSH (human menopausal gonadotropin, highly purified urinary FSH or recombinant

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FSH), the latter @ 75– 100 IU (s.c or i.m) on alternate days. In this situation the therapy is
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initially started with injection hCG; and FSH added after 6-12 months if the testicular volume
plateaus [25].
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Pubertal induction in girls: for girls who do not show any response to the low dose estrogen
therapy after 6-12 months or in cases of ovarian failure, dose of estrogen is gradually
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escalated (usually every 6–12 months) over a period of 2–3 years), until a daily adult
replacement dose is achieved. This corresponds to 0.6–1.25 mg conjugated equine oestrogen,
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20 µg ethinylestradiol or 2 mg/day of estradiol valerate. When menarche is achieved, or after

2 years of estrogen therapy, a cyclic progestogen: medroxyprogesterone (5–10 mg/day) or
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norethisterone (0.7–1.0 mg/day) is added for 10-14 days every month, with the objective of
establishing regular monthly menstrual cycles.
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A similar hormone therapy is indicated in adolescents with pubertal arrest after spontaneous
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onset of puberty or those who seek care later during adolescence. In these adolescents,
therapeutic regime is guided by the growth potential, clinical response and emotional factors.
It is seen that ovarian and testicular reserves are usually preserved in HH patients, as they are
still able to increase estradiol or testosterone levels following gonadotrophin stimulation test
to produce ova or sperms in females and males, respectively [27,28].

IMPAIRED PANCREATIC β-CELL FUNCTION

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The intensive management of thalassemia in children with regular blood transfusions and
chelation therapy has led to progressive decline in the prevalence of Impaired Glucose
tolerance (IGT) and Diabetes mellitus (DM) from 30-70% (early 90’s) to 5-24% [29, 30].
Like other endocrine complications, IGT and DM usually develop in second decade of life or
later. The prevalence of DM and IGT in adolescents and young adults with thalassemia
conventionally treated with DFO varies in different series from 0 to 10.5 % [2, 31] and from

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17 to 24 %, respectively [29, 32, 33].

Mechanism of toxicity: The pathophysiology of impaired glucose homeostasis in β-

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thalassemia is complex and multifactorial [34-39]. The key factors responsible for the
development of diabetes in thalassemia are iron overload, chronic liver disease, viral hepatic

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infections (transfusion-associated infections like Hepatitis C) and genotype of the individual.
A state of hyperinsulinemia secondary to iron overload induced hepatic and pancreatic

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dysfunction is observed during the second decade in thalassemia. Further, the secondary
hemosiderosis in liver and muscles lead to peripheral Insulin resistance possibly due to
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abnormalities of Insulin receptors or glucose transporters. Gradually over time, impaired
pancreatic β-cell function results in progressive β-cell exhaustion culminating to Insulin
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deficiency. Both Insulin resistance and deficiency, alone or in combination lead to a state of
impaired glucose tolerance (IGT) and subsequently evolve to Type 1 Diabetes mellitus. The
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diabetes in thalassemia differs from the classical Type 1 DM by the absence of Islet cell
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antibodies, no relation with HLA DR/DR4 and infrequent association with DKA [40].
However diabetics with thalassemia are more predisposed to develop nephropathy (oxidative
stress) [41] and less likely to develop retinopathy (low IGF-1 levels) [42]. The progression
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from IGT to DM is usually slow and can-not be predicted. In one of the prospective study,
the progression from IGT to DM was reported in 12.4% adolescent thalassemics over a
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period of 10 years [32]. Beside iron overload, chronic anaemia, Zinc deficiency and increased
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collagen deposition (secondary to increased activity of iron dependent protocollagen proline

hydroxylase enzyme) leading to disturbed microcirculation in the pancreas are implicated in
the development of diabetes in thalassemia.

Assessment of glucose homeostasis in thalassemia

Early recognition of problems due to impaired glucose homeostasis is essential. Children

with impaired glucose tolerance and diabetes are identified using the recommendations given
by American Diabetes Association [43]. A fasting plasma glucose is assessed annually
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beyond 10 years of age, OGTT being indicated in patients with FPG >110 mg/dl. Continuous
glucose monitoring system (CGMS) has emerged as a promising and valid tool in detecting
early glucose derangements in children and adults with thalassemia [44,45] and is considered
to be more sensitive than OGTT which may miss episodic hyperglycemia. The HbA1c levels
are unsuitable for monitoring the long-term glycaemic control in thalassemia patients with
diabetes, fructosamine may be used instead [46].

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Diabetes in thalassemia significantly increases the risk for cardiac complications, heart
failure, hyperkinetic arrhythmias and myocardial fibrosis [47]. Combined intensive iron

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chelation therapy with DFO and deferiprone (DFP) is associated with an improvement in
glucose intolerance, particularly in patients in early stages of glucose intolerance [48].

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However, it is less effective in preventing insulin resistance and does not prevent the
progression to type 1 DM in all patients [49].

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Management
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Regular screening of hepatitis associated infections and intensive chelation therapy are
important to prevent or delay the development of diabetes in children with thalassemia.
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Dietary modification (judicious selection of complex carbohydrate and proteins with

moderate restriction of fat) and exercise play a vital role in the management of children with
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thalassemia and IGT especially during the early stages. Evidence supports the use of the oral
biguanide (metformin), in addition to diet and exercise to delay or prevent the progression to
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overt DM [50]. In addition, oral glibenclamide [51] and Acarbose [52] have shown a
promising role in achieving glycemic control especially in children with Insulin resistance.
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The role of Insulin therapy comes into play when all the other measures fail and Insulin
deficiency develops.
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OSTEOPOROSIS
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Reduced bone mass, fractures and bone pain are the common causes of morbidity and
disability in children with thalassemia. Despite intensive transfusion regimes and chelation,
the prevalence of osteopenia and osteoporosis is reported to be as high as 50%-90% in
various studies [53, 54]. The pathogenesis of osteoporosis is distinct from the development of
bony deformities secondary to ineffective erythropoiesis and progressive marrow expansion
seen in children receiving inadequate transfusions. The key factors implicated in osteoporosis
are delayed puberty, diabetes, hypothyroidism, hypoparathyroidism, GH-IGF-1 deficiency,
and ineffective erythropoiesis with marrow expansion [55]. Expansion of bone marrow leads
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to mechanical interruption in bone formation, cortical thinning, and fragility. The above
factors create an imbalance in bone remodelling; they inhibit osteoblast activation and/or
increase osteoclast function, leading to bone loss and osteoporosis. Chronic anaemia
stimulates erythropoietin synthesis that results in bone resorption through high RANKL
levels. Iron overload in thalassemia patients impairs the osteoid maturation and
mineralization by incorporation of iron in the hydroxyapatite crystals thereby reducing the

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tensile strength and resulting in focal osteomalacia. The use of high dose DFO has been
associated with bony deformities due to its adverse effects on the cartilage. Some studies

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have suggested an important role of gene polymorphisms in the development of poor bone
mineral density, though their precise role in thalassemia is still not clear. Malnutrition, lack of

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physical activity, deficiency of vitamin C, D and calcium are other contributory factors in the
development of osteoporosis. There is increased risk of vitamin D deficiency in patients with
thalassemia compared to age matched controls [56]. Vitamin D sufficiency is critical for

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optimal bone health, reducing the risk of fractures and improving the myocardial function
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especially in cases with cardiac iron overload [57, 58].

Assessment
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Assessment of the bone mineral content (BMC) and the areal bone mineral density (aBMD)
is done using Dual energy X-ray absorptiometry (DXA) despite its limitations in reporting
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and interpretation in the pediatric population (before 20 years). The antero-posterior lumbar
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spine (L1–4) and total body less head (TBLH) are the preferred skeletal sites for
measurement in most children. In pediatric patients, BMC or aBMD values of < -2 SD are
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considered as having low bone mass for age. The diagnosis of osteoporosis in pediatrics is
based upon vertebral fractures alone or low bone density and multiple long bone fractures
(two or more long bone fractures by age the 10 years or three or more long bone fractures
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before age 19 years) [55]. BMD interpretation is related to age (and the height in short
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subjects) sex and pubertal status. A baseline DXA evaluation should be done at 10-12 years
for girls and boys annually and every 2 years thereafter. Bone Densitometry should always be
a part of the comprehensive bone health screen, which includes complete blood count,
erythrocyte sedimentation rate, serum calcium, phosphorus, alkaline phosphatase, intact PTH,
total 25 hydroxy vitamin D, BUN, creatinine, and urinary calcium to creatinine ratio.

Management
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Prevention, early diagnosis and prompt management of low bone mass are the corner stones
of optimizing bone health in thalassemia. Intensive transfusion and chelation regimes,
adequate calcium (500-1000 mg/day) intake in combination with vitamin D supplements and
good physical activity improve bone mineralization and prevent bone loss. Vitamin D
deficiency is actively looked for and treated with supplements to ensure sufficiency in all
cases with thalassemia for optimizing bone health [59]. In addition, treatment of other

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endocrinopathies (hypothyroidism, diabetes, hypoparathyroidism) and puberty induction
using sex steroids is critical in achieving adequate bone mineral accretion in children and

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adolescents with thalassemia. Recent studies have reported role of bisphosphonates in the
management of thalassemia children with osteoporosis [60] but further studies are needed to

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clarify their long-term benefits and side effects.

HYPOPARATHYROIDISM

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The prevalence of hypoparathyroidism, observed usually during the second decade or
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beyond, is reported to vary from 3.6% to 20% [61]. Parathyroid dysfunction develops
because of iron overload in parathyroid cells and resultant tissue fibrosis. Increased bone
resorption in response to chronic anaemia and ineffective erythropoiesis can suppress the
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PTH secretion from parathyroid gland.

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Assessment
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Hypoparathyroidism (HPT) is detected either as part of routine biochemical screening (low

serum calcium and or high fasting serum phosphate) or signs and symptoms of
hypocalcaemia like tetany, seizures, carpopedal spasm, laryngeal stridor or paraesthesia in the
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hands and feet. HPT is diagnosed on the basis of low serum calcium along with high
phosphorous (fasting), low/normal PTH and low 1,25 (OH)2 D levels. The 24 hours urinary
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calcium and phosphorous levels are low in these cases. In late cases, intracranial
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calcifications (basal ganglia, frontoparietal areas of brain, thalami, and internal capsule) may
be detected.

Management

Treatment of symptomatic hypocalcemia in HPT is done by using intravenous 10% calcium

gluconate solution. In an asymptomatic child oral calcium supplements (1g/day) in divided
doses are prescribed. This is combined with active vitamin D supplements calcitriol @ 15-30
ng/kg/day (max 1.5 µg/day) to maintain the serum calcium concentrations in low normal
 ACCEPTED MANUSCRIPT
range [19]. Weekly blood tests (serum calcium and phosphorous) are needed at the start of
therapy, followed by quarterly plasma and urinary calcium and phosphorous measurements to
monitor for hypercalciuria.

ADRENAL FUNCTIONS

Children with thalassemia experience adrenal dysfunction because of excessive iron deposits

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affecting the hypothalamic-pituitary- adrenal axis at different levels. Clinically overt adrenal
insufficiency is uncommon in thalassemia. However, various studies have reported presence
of biochemical adrenal insufficiency in the range of 0-45% [61]. The variable prevalence can

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be explained by the differences in the cut offs used for serum cortisol and the degree of
hemosiderosis. Adrenarche is usually delayed in thalassemia patients, due to low adrenal

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androgen production. In the subset with primary adrenal insufficiency, the cortisol,
aldosterone, and androgen secretion are impaired, each to a variable extent, while secondary

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or tertiary adrenal insufficiency (pituitary or hypothalamic affected) causes no
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mineralocorticoid defect [62]. The thalassemia patients with chronic liver disease often
falsely report low cortisol levels due to the low cortisol binding globulin levels (CBG),
synthesized in liver.
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Assessment of adrenal functions

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Adrenal function is assessed every 1-2 years beginning from the age of 9 years, especially in
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children with growth hormone deficiency receiving rhGH therapy. A morning cortisol levels
(8 a.m.) is done in all patients and values < 138 nmol/L are considered low. An ACTH
stimulation test with cortisol measured 60 minutes after an intravenous injection of ACTH
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(Synacthen, 0.25 mg) detects subclinical adrenal insufficiency as indicated by cortisol level
of <500 nmol/L (18 µg/dL) 60 min after ACTH administration.
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Management
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Under basal conditions, subclinical impairment of adrenocortical function in patients with

thalassemia is of not much clinical significance. However, it has relevance during stressful
situations where in glucocorticoid supplementation may be indicated to prevent adrenal crisis
[63].

HYPOTHYROIDISM
 ACCEPTED MANUSCRIPT
The thyroid dysfunction in thalassemia develops as a result of thyroidal cell siderosis, usually
seen in the second decade of life. Primary hypothyroidism occurs much before the iron
toxicity affects the hypothalamic-pituitary axis; making secondary hypothyroidism a much
rarer entity. The prevalence of hypothyroidism varies from 0-18 % as demonstrated in
various studies [3]. The mechanisms of injury are possibly lipid peroxidation, free radical
release and oxidative stress due to iron overload. The degree of thyroid dysfunction is

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directly related to the degree of iron overload, with the early stages being reversible by
intensive chelation therapy. However, the progression of subclinical to overt hypothyroidism

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is not foreseeable and may take many years [64]. The patients are usually asymptomatic and
have an impalpable thyroid gland. Studies have reported serum ferritin to positively correlate

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with the TSH and USG of the thyroid gland (reduced echogenicity with reduced volume and
thickening of the thyroid capsule), and predict the progression of the thyroid dysfunction in
thalassemia [65]. Apart from contributing towards statural growth and bone mineralisation,

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optimising thyroid functions is important for improving the cardiac function, since cardiac
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failure is the most important cause of mortality in thalassemia.
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Assessment of thyroid functions

D

It is recommended to have annual evaluation of thyroid function tests beginning at the age of
10 years (unless symptomatic hypothyroidism is present) [19]. Assessment of thyroid
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functions involves measurement of serum T4 (free) and TSH levels. The patient can have
biochemical features of subclinical (low or normal free T4 with a high TSH) or overt
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hypothyroidism (low free T4 with a high TSH).

Management
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Good compliance with chelation therapy may prevent or reverse thyroid dysfunction in early
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stages. Sub-clinical hypothyroidism-basal TSH 5 to 7 mIU/ml will require regular follow-up

and optimizing chelation therapy [19]. Cases with overt hypothyroidism are managed with
age appropriate dose of L-thyroxine.

ANNUAL ENDOCRINE SCREENING

Since most endocrine complications make an appearance during the second decade of life and
beyond, it is recommended that all children with TM undergo a comprehensive annual
endocrine screening beginning 9 years of age (Table 4) [19]. Prior to that, a regular growth
 ACCEPTED MANUSCRIPT
monitoring is done every 6 months from enrolment and pubertal onset and progression are
determined every 6 months after the age of 10 years. The annual endocrine includes thyroid
function tests (free T4 and TSH), fasting glucose, oral glucose tolerance test (if indicated),
serum Calcium , serum phosphate (fasting), vitamin D and PTH (if indicated by clinical
symptoms or biochemical features), and bone age. The LH, FSH, and sex steroids are
evaluated in the adolescents with delayed/arrested puberty. A baseline DXA scan followed by

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annual/once in 2 years screening of bone mineral density is also recommended.

SUMMARY AND CONCLUSIONS

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Management of a child with thalassemia requires regular evaluation by an endocrinologist
beginning second decade of life due to a high prevalence of endocrine dysfunctions seen in

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these patients. Prevention is the best approach since efficacy of intensive chelation in
reversing established endocrinopathies is unknown. Thus, preventing anaemia through a

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regular transfusion schedule, optimum chelation, maintaining an adequate nutritional status
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and prompt recognition and treatment of co-morbidities form the cornerstones of
endocrinopathy prevention. However, the endocrinopathies are still being seen because the
majority of TM patients lack adequate clinical care. Early identification and prompt
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management of the endocrine complications have a significant role in reducing morbidity and
mortality of thalassemia patients.
D
TE
C EP
AC
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Table 1- Comparative prevalence of endocrinal complications of children with TM

Cyprus Italy Iran (2003) TIF North India

[2] (1995) [4] (2004) America (2014)
[3] [5] (2004) [7]
[6]
Number of Patients 435 1861 220 3817 342 89

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Hypogonadism (%) 32.5 49 22.9 (males), 40.5 35 54.1
12.2

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(females)
Short Stature (%) 35 39.3 30.8 55

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Sitting Height (%) 72
Hypothyroidism 5.9 6.2 7.7 3.2 9 8.9

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(%)
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Hypoparathyroidism 1.2 3.6 7.6 6.9 4 10.1
(%)
DM/IGT (%) 9.4 4.9 8.7 3.2/6.5 10 13
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Table 2: Factors contributing to growth failure in children and adolescents with TM

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a. Chronic anaemia with ineffective erythropoiesis

b. Under nutrition (Zinc Deficiency)

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c. Iron overload resulting in chronic liver disease and cardiac dysfunction

d. Transfusion associated infections like hepatitis C, B, HIV

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e. Endocrinal dysfunctions- Defective GH-IGF-1 axis

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Defective Pituitary-Gonadal axis

Hypothyroidism, hypoparathyroidism

Diabetes mellitus

f. Side effects of chelation therapy on skeletal growth

g. Psychosocial stress
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Table 3 Definitions in pubertal delay

I. Delayed Puberty: Absence of gonadarche (Testicular Volume ≥ 4 ml) in males by 14

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years and thelarche (appearance of breast bud) in females by 13 years.

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II. Arrested puberty: Arrested puberty is defined as the absence of further pubertal
progression once puberty has started for more than 1 year, where testicular volume in

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boys never progressed beyond 6–8 mL and breast size in girls remained unchanged.

III. Primary amenorrhoea: Failure in menarche by 16 years.

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IV. Secondary amenorrhoea: Absence of menstrual periods for >12 months after
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menarche.

Table 4 Protocol to screen endocrinopathies in children with TM

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ISSUES ASSESMENT
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Poor Growth Height and weight monitoring 6 monthly

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Maintain a longitudinal record on a growth chart

Delayed/Arrested Puberty Biannual (every 6 months) assessment of growth (height,
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weight) and pubertal progress using SMR staging.

Impaired β cell function Annual Blood Glucose (fasting/post prandial) ; Oral
Glucose tolerance test if clinically indicated
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Osteoporosis Annual/Biennial DEXA

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Hypoparathyroidism Serum Ca/PO4/ALP 6 monthly

Annual Vitamin 25 (OH)D and PTH
Hypothyroidism Annual FT4/TSH
Adrenal insufficiency Annual morning serum cortisol
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