Acromegaly medical therapy: Difference between revisions

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{{Acromegaly}}
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==Overview==
 
The goals of treatment are to reduce GH production to normal levels, to relieve the pressure that the growing pituitary tumor exerts on the surrounding brain areas, to preserve normal pituitary function, and to reverse or ameliorate the symptoms of acromegaly. Currently, treatment options include surgical removal of the tumor, medical therapy, and [[radiation therapy]] of the pituitary.
== Overview ==
Patients with acromegaly are treated with [[somatostatin]] analogs like [[octreotide]], [[dopamine agonists]] like [[bromocriptine]], and [[GH]] receptor [[antagonist]] like [[pegvisomant]]. [[Radiation therapy]] is indicated in patients who do not respond to surgery or the medical therapy.
 
==Medical Therapy==
==Medical Therapy==
Two medications currently are used to treat acromegaly. These drugs reduce both GH secretion and tumor size. Medical therapy is sometimes used to shrink large tumors before surgery. [[Bromocriptine]] (Parlodel) in divided doses of about 20 mg daily reduces GH secretion from some pituitary tumors. Side effects include gastrointestinal upset, nausea, vomiting, light-headedness when standing, and nasal congestion. These side effects can be reduced or eliminated if medication is started at a very low dose at bedtime, taken with food, and gradually increased to the full therapeutic dose. Because bromocriptine can be taken orally, it is an attractive choice as primary drug or in combination with other treatments. However, bromocriptine lowers GH and [[IGF-1]] levels and reduces tumor size in less than half of patients with acromegaly. Some patients report improvement in their symptoms although their GH and IGF-1 levels still are elevated.
*Pharmacologic medical therapy is recommended among patients with persistent high growth hormone level after the surgery.<ref name="pmid25356808">{{cite journal| author=Katznelson L, Laws ER, Melmed S, Molitch ME, Murad MH, Utz A et al.| title=Acromegaly: an endocrine society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 11 | pages= 3933-51 | pmid=25356808 | doi=10.1210/jc.2014-2700 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25356808  }} </ref>
*Pharmacologic medical therapies for acromegaly include [[somatostatin]] analogs, [[dopamine agonists]], and [[GH]] receptor [[antagonists]].


The second medication used to treat acromegaly is [[octreotide]] (Sandostatin) and lanreotide (Somatulin). Both are synthetic forms of a brain hormone, somatostatin, that stops GH production. The long-acting forms of these drugs must be injected every 2 to 4 weeks for effective treatment. Most patients with acromegaly respond to this medication. In many patients, GH levels fall within one hour and headaches improve within minutes after the injection. Several studies have shown that octreotide and lanreotide are effective for long-term treatment. Octreotide and lanreotide have also been used successfully to treat patients with acromegaly caused by non-pituitary tumors.
===Different treatment regimens===


Because octreotide inhibits gastrointestinal and pancreatic function, long-term use causes digestive problems such as loose stools, nausea, and gas in one third of patients. In addition, approximately 25 percent of patients develop [[gallstone]]s, which are usually asymptomatic. In rare cases, octreotide treatment can cause [[diabetes]]. On the other hand, scientists have found that in some acromegaly patients who already have diabetes, octreotide can reduce the need for [[insulin]] and improve blood sugar control.
* 1.1.1 '''Somatostatin analogs''':
** Preferred regimen (1): [[Octreotide]] 50 mcg q8hr subcutaneous as initial dose and 100 mcg q8hr as effective dose.  
** Preferred regimen (2): [[Lanreotide]] 90 mg q4week for 3 months every 4 weeks subcutaneous.
** Preferred regimen (3): [[Pasireotide]] 40 mg q4wk intramuscular.


The latest development in the medical treatment of acromegaly is the use of growth hormone receptor antagonists. The only available member of this family is pegvisomant (Somavert). By blocking the action of the endogenous growth hormone molecules, this compound is able to control disease activity of acromegaly in virtually all patients. Pegvisomant has to be administered subcutaneously by daily injections. Combinations of long-acting somatostatin analogues and weekly injections of pegvisomant seem to be equally effective as daily injections of pegvisomant.
*1.1.2 '''Dopamine agonists''':
** Preferred regimen (1): [[Cabergoline]] 0.25 mg 2x/week orally.
** Preferred regimen (2): [[Bromocriptine]]  1.25-2.5 mg qDay orally.
 
*1.1.3 '''GH receptor antagonist''':
**Preferred regimen (1): [[Pegvisomant]] 10 mg qDay subcutaneous.
 
=== Radiation therapy ===
* [[Radiation therapy]] is indicated in the patients that still have an excess level of [[Growth hormone|GH]] and [[IGF-1]] after surgery and medical therapy. It is also indicated in patients who still have [[tumor]] remaining after surgery.
* It is recommended by the endocrine society to use the stereotactic [[Radiation therapy|radiotherapy]] (SRT) over conventional radiation in the treatment of the acromegaly.
* Follow up with the level of the [[GH]] and [[IGF-1]] annually to determine the efficacy of the [[radiation]] in the treatment of acromegaly.


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
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Latest revision as of 18:28, 24 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Patients with acromegaly are treated with somatostatin analogs like octreotide, dopamine agonists like bromocriptine, and GH receptor antagonist like pegvisomant. Radiation therapy is indicated in patients who do not respond to surgery or the medical therapy.

Medical Therapy

  • Pharmacologic medical therapy is recommended among patients with persistent high growth hormone level after the surgery.[1]
  • Pharmacologic medical therapies for acromegaly include somatostatin analogs, dopamine agonists, and GH receptor antagonists.

Different treatment regimens

  • 1.1.1 Somatostatin analogs:
    • Preferred regimen (1): Octreotide 50 mcg q8hr subcutaneous as initial dose and 100 mcg q8hr as effective dose.
    • Preferred regimen (2): Lanreotide 90 mg q4week for 3 months every 4 weeks subcutaneous.
    • Preferred regimen (3): Pasireotide 40 mg q4wk intramuscular.
  • 1.1.2 Dopamine agonists:
    • Preferred regimen (1): Cabergoline 0.25 mg 2x/week orally.
    • Preferred regimen (2): Bromocriptine 1.25-2.5 mg qDay orally.
  • 1.1.3 GH receptor antagonist:
    • Preferred regimen (1): Pegvisomant 10 mg qDay subcutaneous.

Radiation therapy

  • Radiation therapy is indicated in the patients that still have an excess level of GH and IGF-1 after surgery and medical therapy. It is also indicated in patients who still have tumor remaining after surgery.
  • It is recommended by the endocrine society to use the stereotactic radiotherapy (SRT) over conventional radiation in the treatment of the acromegaly.
  • Follow up with the level of the GH and IGF-1 annually to determine the efficacy of the radiation in the treatment of acromegaly.

References

  1. ↑ Katznelson L, Laws ER, Melmed S, Molitch ME, Murad MH, Utz A; et al. (2014). "Acromegaly: an endocrine society clinical practice guideline". J Clin Endocrinol Metab. 99 (11): 3933–51. doi:10.1210/jc.2014-2700. PMID 25356808.

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