rHGH glucose intolerance is based on growth hormone's direct anti-insulin effect, not IGF. At 2iu it's rarely a problem for anyone. In fact, high IGF improves insulin sensitivity.
The only thing unusual in this case was the doctor's failure to do his job, monitor IGF and reduce rHGH to keep IGF in the physiological range. The doctor didn't, and the expected outcome resulted, acromegaly. It's a rare example because it's rare for doctors to make this mistake for years until this happens. If GH replacement therapy routinely doubled IGF rHGH induced acromegaly wouldn't be rare.
Most modern cases of acromegaly happen in otherwise healthy people, late in life, who develop a pituitary tumor without obvious symptoms. No one checks IGF until the patient asks their doc why they've started looking like an ape.
It's easy to dismiss cases not involving a "healthy" subject. And since no researcher will ever get approval to double someone's IGF with rHGH for years to see what happens it's safe to say that "proof" with a perfectly healthy person will never appear. But we can come close.
In this example. A 40 year old develops brain cancer. The surgery to remove that tumor inadvertently damages his pituitary, so he's no longer making enough GH. He's put on 3iu / day. No one ever checks his IGF. Almost the same amount of time as our guy above, 6 years later, he wants to know why he's two shoe sizes larger and gotten so ugly. IGF 800+. Higher than the first guy, but since he's younger this is again double the upper limit of normal for his age.
www.endocrine-abstracts.org
There's nothing to suggest either of these men were any more prone to developing acromegaly from 2x normal IGF than anyone else, or that somehow, a "healthy" person with the same 2x IGF would be immune to the same problem.
Illicit rHGH users are unlikely to admit use or publish a formal diagnosis, ahem:
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Jawbones don't widen from normal aging.
Bottom line:
The mantra up to now for rHGH use has been "as much as you can afford and tolerate". Clearly price was a limiting factor. Five days on two off was common, to "stretch" precious rHGH.
That's all changed.
Very long term continuous rHGH use as a PED or anti-aging compound has been a rarity, exclusively for pro athletes and the very wealthy, up until the recent massive price drops. It's clear many of us are buying quantities intending to stay on GH for the long term. We have very little to guide safe choices. I think these two documented cases give us some sense of what "crossing the line" looks like. 2x upper IGF limit for more than a couple years seems like it can be reasonably inferred as getting into the danger zone. We also know that up to 1.3x the upper limit of normal IGF seems to be tolerated by doctors, and no cases of acromegaly have been reported in patients after many years at that level. The "many years" IGF safety threshold most likely lies somewhere between 1.3x and below 2x, with the risk growing the closer you get to 2x.
All this has convinced me that staying at 1.3x age adjusted upper limit of normal IGF or below is a reasonable way to keep long term risks low while still benefitting from ongoing GH use.