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 Endocrine Practice 27 (2021) 856e857

Contents lists available at ScienceDirect

Endocrine Practice
journal homepage: www.endocrinepractice.org

Letter to the Editor

Acromegaly Management in a Tertiary Referral Center After 1 Year of

the Coronavirus 2019 Pandemic: A Double Challenge

To the Editor: management of acromegaly in our center by comparing the num-

ber of outpatient accesses and the rate of disease control in 2019
The global pandemic due to coronavirus 2019 (COVID-19) repre- and 2020. Ninety-five patients were in active follow-up, and the
sents by far the toughest challenge faced by health care systems in 177 on-site visits performed in 2019 (median: 2 visits/patient/
modern history.1 Undoubtedly, it has a strong impact on resource year) dropped to 118 in 2020 (median: 1 visit/patient/year) (Fig.
allocation, forcing the rethinking of patients’ care, particularly the A). This 33% reduction of on-site evaluations was partially mitigated
management of chronic and rare diseases. by performing 21 telephonic follow-ups.
Acromegaly is a rare systemic endocrine disorder, mostly due to In 2019, we had 8 new diagnoses of acromegaly, while we
a growth hormone-secreting pituitary tumor, characterized by counted only 4 newly diagnosed patients in 2020. However,
peculiar clinical manifestations and comorbidities due to the due to the well-known variability in the incidence of acro-
chronic exposure to excess amounts of growth hormone and megaly, a detrimental impact of the pandemic can only be
insulin-like growth factor 1 (IGF-1). This leads to higher mortality hypothesized.
compared with the general population.2 Our Endocrinology Unit Surprisingly, we found that median IGF-1 levels in 2019
(University Hospital San Martino, Genoa) is the Regional hub for (expressed as a ratio to the age-adjusted upper limit of normal
endocrine diseases, covering a geographic area including about [ULN]) were superimposable to that observed at the end of
1.5 to 2 million inhabitants in Northwest Italy, receiving approxi- 2020 (IGF-1
ULN, median [interquartile range, IQR]: 0.735
mately 20 000 outpatient visits per year. As a certified European [0.543-0.98] vs 0.740 [0.615-1.015], P ¼ .339). This finding
Reference Center for pituitary diseases, we follow up about 100 pa- was confirmed in the subgroup of patients with an available
tients with acromegaly. hormonal assessment for both 2019 and 2020 (IGF-1

However, due to the pandemic, our ward was converted into a ULN, median [IQR]: 0.780 [0.570-0.99] vs 0.740 [0.610-0.930],
COVID-19 unit during the 2 waves of 2020, forcing us to exert extra P ¼ .665). Therefore, the percentage of controlled patients
effort to guarantee the care of our patients with pituitary disorders. did not change significantly between 2019 and 2020, ranging
Recently, we evaluated the impact of the pandemic on the from 75% to 79% (Fig. B and C). Of note, patients missing their

On site visits
A (2019 - 2020 comparison) B IGF-1 C IGF-1
(all available data) (2019 - 2020 matched values)
100 100
5 2019 (total: 177)
(numbe r pe r patie nt)

4 2020 (total: 118) 80 80

Patie nts (%)

Patie nts (%)

3 60
Visits

60
2 40 40
2019 (n=92) 2019 (n=71)
1
20 2020 (n=76) 20 2020 (n=71)
0
0 0
0 10 20 30 40 50 0.0 0.5 1.0 1.5 2 3 4 0.0 0.5 1.0 1.5 2 3 4
Patients n. Age-adjusted IGF-1 levels Age-adjusted IGF-1 levels
(ratio/upper limit of normality) (ratio/upper limit of normality)

Fig. Impact of coronavirus 2019 pandemic on acromegaly management in a referral center for pituitary diseases in Northern Italy. Detailed representation of the number of on-site
outpatient clinic evaluations per year performed on patients with acromegaly in 2019 and 2020 (A). Percentage of patients with biochemical control (defined as insulin-like growth
factor [IGF]-1 levels below the age-adjusted upper limit of normal) for (B) all patients with a recorded IGF-1 measurement in 2019 or 2020 and (C) only patients with at least one
IGF-1 measurement available in both 2019 and 2020).

Abbreviations: COVID-19, coronavirus 2019; IGF-1, insulin-like

growth factor-1; IQR, interquartile range; ULN, upper limit of normal.

https://doi.org/10.1016/j.eprac.2021.05.005
1530-891X/© 2021 AACE. Published by Elsevier Inc. All rights reserved.
F. Gatto, K. Khorrami, F. Nista et al. Endocrine Practice 27 (2021) 856e857

visits in 2020 had controlled disease at their last evaluation in 2. Melmed S. Medical progress: acromegaly. N Engl J Med. 2006;355(24):
2558e2573.
2019 (IGF-1
ULN, median [IQR]: 0.560 [0.440-0.800]), with a
3. Casanueva FF, Barkan AL, Buchfelder M, et al. Criteria for the definition of Pitu-
median follow-up of 13 years (IQR 4.5-26.7). itary Tumor Centers of Excellence (PTCOE): a Pituitary Society statement. Pitui-
We believe that our experience may reflect the scenario tary. 2017;20(5):489e498.
observed in most acromegaly referral centers. The cure rate in ter-
tiary centers is generally high (>70%), and patients’ follow-ups are Federico Gatto, MD
long enough to establish strong relationships with them, educating Endocrinology Unit
them on the adherence to and persistence with treatment as well as IRCCS Ospedale Policlinico San Martino
on self-management.3 Largo Rosanna Benzi 10, 16132
However, although a positive outcome was observed in the Genoa, Italy
short-term management of our patients, we are aware that the
COVID-19 emergency might have a stronger impact in the long Keyvan Khorrami, MD, Federica Nista, MD, Giuliana Corica, MD
term. Therefore, we need to play out all the scenarios to face the Endocrinology Unit
pandemic and, most importantly, to adapt the care of chronic and Department of Internal Medicine and Center of Excellence for
rare (endocrine) diseases to the “new normal,” which we need to Biomedical Research
build up after this historical and dramatic experience. University of Genoa
Viale Benedetto XV 6, 16132
Disclosure Genoa, Italy
Diego Ferone, MD
F.G. received honoraria for lectures, presentations, manuscript Endocrinology Unit
writing, and educational events as well as support for attending IRCCS Ospedale Policlinico San Martino
meetings and/or participation on advisory boards from Novartis, Largo Rosanna Benzi 10, 16132
Ipsen, Pfizer, AMCO, and IONIS Pharmaceuticals. D.F. received hon- Genoa, Italy
oraria for lectures, presentations, manuscript writing, and educa-
tional events as well as support for attending meetings and/or Endocrinology Unit
participation on advisory boards and steering committees from Department of Internal Medicine and Center of Excellence for
Novartis, Ipsen, Pfizer, and Camurus. The other authors declare no Biomedical Research
competing interests. University of Genoa
Viale Benedetto XV 6, 16132
Genoa, Italy
References E-mail address: ferone@unige.it.
1. Alam U, Nabyonga-Orem J, Mohammed A, Malac DR, Nkengasong JN, Moeti MR.
Redesigning health systems for global heath security. Lancet Glob Health. 29 April 2021
2021;9(4):e393ee394. Available online 21 May 2021

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