Individualised management of acromegaly 2019

Individualised management of acromegaly

SOHEILA SADEGHI

17. Surgery
     Indications
    4.1 -We recommend transsphenoidal surgery as the primary therapy in most patients. (1|QQQE)

        4.2 -We suggest that repeat surgery be considered in a patient with residual intrasellar disease following initial surgery. (2|QQEE)

         Preoperative medical therapy
4.3 -We suggest against the routine use of preoperative medical therapy to improve biochemical control after surgery. (2|QQEE)

        4.4- For patients with severe pharyngeal thickness and sleep apnea, or high-output heart failure, we suggest medical therapy with somatostatin receptor ligands (SRLs) preoperatively to reduce surgical risk from severe comorbidities. (2|QEEE)

        Surgical debulking

       4.5 -In a patient with parasellar disease making total surgical resection unlikely, we suggest surgical debulking  to improve subsequent response to medical therapy. (2|QQEE)

      Postoperative testing

       4.6 -Following surgery, we suggest measuring an IGF-1 level and a random GH at 12weeks or later (2|QQQE).We also suggest measuring a nadir GH level after a glucose load in a patient with a GH greater than 1 g/L. (2|QQQE)

        4.7 -We recommend performing an imaging study at least 12weeks after surgery to visualize residual tumor and adjacent structures (1|QQQE). We suggest MRI as the imaging modality of choice followed by CT scan when MRI is contraindicated or unavailable. (2|QQEE)

17. 
     Medical therapy

                   5.1 -We recommend medical therapy in a patient with persistent disease following surgery. (1|QQQQ)

         5.2 - In a patient with significant disease (ie, with moderate-to-severe signs and symptoms of GH excess and without local mass effects), we suggest use of either a SRL or pegvisomant as the initial adjuvant medical therapy. (2|QQEE)

        5.3 - In a patient with only modest elevations of serum IGF-1 and mild signs and symptoms of GH excess, we suggest a trial of a dopamine agonist, usually cabergoline, as the initial adjuvant medical therapy. (2|QQEE)

        5.4 - We suggest against routine abdominal ultrasound to monitor for gallstone disease in a patient receiving a SRL (2|QQEE). Ultrasound should be performed if the patient has signs and symptoms of gallstone disease. (2|QQEE)

        5.5 - We suggest serial imaging with MRI scan to evaluate tumor size in a patient receiving pegvisomant. (2|QQEE)

        5.6 - We suggest monitoring liver function tests monthly for the first 6 months and then every 6 months in a patient receiving pegvisomant, with consideration of discontinuation of pegvisomant if the transaminases are greater than 3-fold elevated. (2|QQEE)

        5.7 - We suggest addition of pegvisomant or cabergoline in a patient with inadequate response to an SRL. (2|QQEE)

        5.8 - We suggest use of an SRL as primary therapy in a patient who cannot be cured by surgery, has extensive cavernous sinus invasion, does not have chiasmal compression, or is a poor surgical candidate. (2|QQQE)