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TREATMENT AND MANAGEMENT OF ACROMEGALY

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No single treatment is effective for all patients with acromegaly. Treatment should be individualized and should take into account characteristics such as the patient's age, as well as the size of the pituitary tumor.1

Figure adapted from Melmed.1
GH, growth hormone; MRI, magnetic resonance imaging; SRL, somatostatin receptor ligand.

Surgical Treatment for Acromegaly

Transsphenoidal surgery is an invasive procedure performed to remove pituitary tumors. This surgery relieves pressure on the brain regions surrounding the tumor and reduces GH levels. If the surgery is successful, the patient's facial appearance and soft tissue swelling improve within a few days. Surgery is most successful in patients who have pituitary tumors no larger than 10 mm in diameter.2

The expertise of the pituitary surgeon is also extremely important for successful surgical management, with the highest success rates coming from surgeons who conduct at least 50 pituitary procedures a year. The best measures of surgical success are normal levels of GH and IGF-1. A GH level of less than 1 µg/L after an oral glucose load is ideal.2,3

Even after successful surgery and normalization of hormone levels, patients should be monitored closely for possible recurrence as part of patients' lifelong, routine, follow-up plan. More commonly, hormone levels will improve, but these may not return to normal. Additional treatment, usually with drug therapy, may be required.2

Radiation Therapy for Acromegaly

According to the Acromegaly Consensus Group, external pituitary radiotherapy should not be used as the primary therapy except under extraordinary circumstances. The effects of radiotherapy on GH and IGF-1 levels are slow in up to 60% of cases; GH levels are less than 2.5 µg/L at 10 years. In addition, hypopituitarism occurs in 50% of patients after 10 years of radiotherapy, which results in the need for hormone replacement in most patients.1-4

Medical Therapy for Acromegaly

Medical Therapy

Medication for acromegaly may decrease the secretion of GH and the subsequent production of IGF-1, reduce the size of the tumor, and control symptoms. Drug therapy has been used to shrink large tumors before surgery. Medical therapies include dopamine agonists, GH-receptor antagonists, and somatostatin analogs.6,7

Somatostatin analogs
  • Somatostatin analogs (SSAs) are the standard medical therapy option after surgery or when surgery is not an option2
  • More than 90% of GH-secreting pituitary adenomas express somatostatin receptors (sstrs) 2 and 5, and most SSAs act by primarily binding to these same receptors1,7
  • SSAs are effective in suppressing GH levels to below 2–2.5 µg/L and normalizing IGF-1 levels in 50%–70% of cases8
Dopamine agonists
  • Dopamine agonists (DAs) function by binding to dopamine receptors, and thereby suppress GH secretion in some patients with acromegaly9
  • Less effective compared to other classes in lowering GH and/or IGF-1 levels7
GH-receptor antagonists
  • Growth hormone–receptor antagonists (GHRAs) normalize IGF-1 levels by binding to GH receptors to inhibit hormone activity5,8
  • Suppress IGF-1 secretion by competing with GH at the GH-receptor binding site10
  • Effective in normalizing IGF-1 levels7
How effective has Sandostatin® LAR® been in patients with acromegaly? Find out here.

References:
1. Melmed S, Colao A, Barkan A, et al. Guidelines for acromegaly management: an update. J Clin Endocrinol Metab. 2009;94(5):1509-1517. 2. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human Services. Acromegaly. Bethesda, MD: National Institutes of Health; 2008. NIH publication 08-3924. 3. Katznelson L, Atkinson JLD, Cook DM, Ezzat SZ, Hamrahian AH, Miller KK. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly—2011 update. Endocr Pract. 2011;17(suppl 4):1-44. 4. Taboada GF, van Haute FR, Corrêa LL, Casini AF, Gadelha MR. Etiologic aspects and management of acromegaly. Arq Bras Endocrinol Metabol. 2005;49(5):626-640. 5. Chanson P, Salenave S. Acromegaly. Orphanet J Rare Dis. 2008;3:1-17. 6. Giustina A, Barkan A, Casanueva FF, et al. Criteria for cure of acromegaly: a consensus statement. J Clin Endocrinol Metab. 2000;85(2):526-529. 7. Melmed S. Medical progress: acromegaly. N Engl J Med. 2006;355(24):2558-2573. 8. Ayuk J, Sheppard MC. Growth hormone and its disorders. Postgrad Med J. 2006;82(963):24-30. 9. Melmed S, Jackson I, Kleinberg D, Klibanski A. Current treatment guidelines for acromegaly. J Clin Endocrinol Metab. 1998;83(8):2646-2652. 10. Cook DM, Ezzat S, Katznelson L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the diagnosis and treatment of acromegaly. Endocr Pract. 2004;10(3):213-225.

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