Professional Documents
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C l i n i c a l P r a c t i c e G u i d e l i n e
Objective: The aim was to formulate clinical practice guidelines for acromegaly.
Participants: The Task Force included a chair selected by the Endocrine Society Clinical Guidelines
Subcommittee (CGS), five experts in the field, and a methodologist. The authors received no
corporate funding or remuneration. This guideline is cosponsored by the European Society of
Endocrinology.
Evidence: This evidence-based guideline was developed using the Grading of Recommendations,
Assessment, Development, and Evaluation (GRADE) system to describe both the strength of rec-
ommendations and the quality of evidence. The Task Force reviewed primary evidence and com-
missioned two additional systematic reviews.
Consensus Process: One group meeting, several conference calls, and e-mail communications
enabled consensus. Committees and members of the Endocrine Society and the European Society
of Endocrinology reviewed drafts of the guidelines.
Conclusions: Using an evidence-based approach, this acromegaly guideline addresses important clin-
ical issues regarding the evaluation and management of acromegaly, including the appropriate bio-
chemical assessment, a therapeutic algorithm, including use of medical monotherapy or combination
therapy, and management during pregnancy. (J Clin Endocrinol Metab 99: 3933–3951, 2014)
ISSN Print 0021-972X ISSN Online 1945-7197 Abbreviations: CI, confidence interval; CT, computed tomography; LAR, long-acting re-
Printed in U.S.A. lease; MRI, magnetic resonance imaging; RT, radiotherapy; SRL, somatostatin receptor
Copyright © 2014 by the Endocrine Society ligand; SRT, stereotactic RT; SST, somatostatin receptor subtype.
Received June 18, 2014. Accepted September 15, 2014.
First Published Online October 30, 2014
doi: 10.1210/jc.2014-2700 J Clin Endocrinol Metab, November 2014, 99(11):3933–3951 jcem.endojournals.org 3933
3934 Katznelson et al Acromegaly Clinical Practice Guidelines J Clin Endocrinol Metab, November 2014, 99(11):3933–3951
tumor size and appearance, as well as parasellar extent preoperatively to reduce surgical risk from severe comor-
(1|QQQQ). We suggest magnetic resonance imaging bidities. (2|QEEE)
(MRI) as the imaging modality of choice, followed by
computed tomography (CT) scan when MRI is contrain- Surgical debulking
dicated or unavailable. (2|QQEE) 4.5 In a patient with parasellar disease making total
1.7 We suggest performing formal visual field testing surgical resection unlikely, we suggest surgical debulking
when the tumor is found to abut the optic chiasm on an to improve subsequent response to medical therapy.
imaging study. (2|QQQE) (2|QQEE)
6.0 Radiotherapy (RT)/Stereotactic Radiotherapy tailed description of the grading scheme has been pub-
(SRT) lished elsewhere (2). The Task Force used the best avail-
6.1 We suggest use of radiation therapy in the setting of able research evidence to develop the recommendations.
residual tumor mass following surgery, and if medical The Task Force also used consistent language and graphic
therapy is unavailable, unsuccessful, or not tolerated. descriptions of both the strength of a recommendation and
(2|QQEE) the quality of evidence. In terms of the strength of the
6.2 We suggest use of stereotactic radiotherapy (SRT) recommendation, strong recommendations use the phrase
over conventional radiation therapy in patients with ac- “we recommend” and the number 1, and weak recom-
romegaly, unless the technique is not available, there is mendations use the phrase “we suggest” and the number
significant residual tumor burden, or the tumor is too close 2. Cross-filled circles indicate the quality of the evidence,
to the optic chiasm resulting in an exposure of more than such that QEEE denotes very low quality evidence;
benefits. Completed forms are available through the En- aly, especially those with acral and facial features.
docrine Society office. (1|QQQE)
Funding for this guideline was derived solely from the 1.2 We suggest the measurement of IGF-1 in patients
Endocrine Society, and thus the Task Force received no without the typical manifestations of acromegaly, but who
funding or remuneration from commercial or other have several of these associated conditions: sleep apnea
entities. syndrome, type 2 diabetes mellitus, debilitating arthritis,
cromegaly is a chronic disorder caused by GH hyper- carpal tunnel syndrome, hyperhidrosis, and hypertension.
A secretion. GH circulates and stimulates production
of IGF-1 from the liver and systemic tissues; IGF-1 in large
(2|QQEE)
different laboratories (27). It is important for the clinician poor reproducibility between laboratories and assays, im-
to have knowledge of the specific assay used. precise standards, and the lack of robust normal control val-
ues using sensitive immunometric assays (39). Basal GH lev-
1.3 We recommend measuring serum IGF-1 to rule out els correlate with multisample day curves and nadir GH
acromegaly in a patient with a pituitary mass. (1|QQQE) levels after glucose load in most studies (40 – 42). However,
these procedures are both time-consuming and cumbersome.
Evidence
Pituitary incidentalomas may secrete any spectrum of 1.6 Following biochemical diagnosis of acromegaly, we
anterior pituitary hormones, and GH hypersecretion may recommend performing an imaging study to visualize tu-
not be clinically apparent (28). A subset of patients present mor size and appearance, as well as parasellar extent
with few symptoms and minimal physical disease features (1|QQQQ). We suggest MRI as the imaging modality of
tension, diabetes mellitus, cardiovascular disease, osteo- due to a central sleep apnea mechanism (60). Although
arthritis, and sleep apnea. (2|QQEE) lowering GH/IGF-1 improves sleep apnea severity, up to
2.2 We also recommend that such comorbidities be lon- 40% of those with controlled acromegaly have persistent
gitudinally monitored and rigorously managed. (Un- sleep apnea, and initiation or titration of positive airway
graded recommendation) pressure treatment may be necessary (60 – 62).
2.3 We suggest screening for colon neoplasia with The impact of acromegaly and its control on neoplasia
colonoscopy at diagnosis. (2|QQEE) risk and mortality is controversial (63, 64). A meta-anal-
2.4 We suggest a thyroid ultrasound if there is palpable ysis of studies has shown that the risk of colonic polyps is
thyroid nodularity. (2|QQEE) increased in acromegaly (65), although the true risk is
unknown. Colonic screening in acromegaly may be chal-
Evidence lenging due to redundant, tortuous bowel and the presence
Acromegaly may be associated with an increased risk of proach was developed to aid practitioners in the care of
vertebral compression fractures despite normal bone den- patients with acromegaly (Figure 1).
sity, and fracture risk may be accelerated by hypogonad- 3.1 We suggest a biochemical target goal of an age-
ism (76). Gonadal steroid replacement is important be- normalized serum IGF-1 value, which signifies control of
cause hypogonadism contributes to loss of bone mineral acromegaly. (2|QQEE)
density (77, 78). Maxillary and mandibular overgrowth 3.2 We suggest using a random GH ⬍ 1.0 g/L as a
can lead to painful jaw malocclusion requiring maxillo- therapeutic goal, as this correlates with control of acro-
facial reconstruction. It is important to hold off on such megaly. (2|QEEE)
reconstruction until GH/IGF-1 levels are stable because 3.3 We suggest maintaining the same GH and IGF-1
overgrowth may persist in the uncontrolled state. Periph- assay in the same patient throughout management.
eral neuropathies with sensory disturbances in hands and (2|QQEE)
4.4 For patients with severe pharyngeal thickness and may reflect surgical stress with normal somatotroph GH
sleep apnea, or high-output heart failure, we suggest med- production (123). The decline in IGF-1 is more delayed
ical therapy with SRLs preoperatively to reduce surgical compared with GH, likely due to differential half-life of
risk from severe comorbidities. (2|QEEE) IGF-binding proteins. IGF-1 levels measured at 12 weeks
after surgery are a valid reflection of surgical remission (124,
Evidence 125). If the IGF-1 level has declined but is still not normal,
There is an increased risk of anesthetic complications measurement of a repeat IGF-1 level is warranted due to
including difficulty with intubation due to laryngeal and variability in the IGF-1 assay. A serum GH ⬍ 0.14 g/L
pharyngeal soft tissue and vocal cord swelling (115, 116). suggests “surgical remission,” and a level ⬍ 1 g/L indicates
Oropharyngeal swelling and macroglossia result in sleep “control” and normalization of the mortality risk (126).
apnea syndrome, which may complicate both the pre- and
Evidence Evidence
Although GH testing may be performed as early as If the biochemical and clinical evaluation after surgery
postoperative day 1, the role of an immediate postopera- reveals persistent disease, then adjuvant therapy is neces-
tive GH value may be limited because an elevated value sary. Medical therapy is initiated for disease control.
3942 Katznelson et al Acromegaly Clinical Practice Guidelines J Clin Endocrinol Metab, November 2014, 99(11):3933–3951
Somatostatin receptor ligands (SRLs) mg/ mo. In patients who respond well to low-dose SRL
There are two equally effective long-acting available therapy, treatment intervals may be lengthened (145).
preparations: im octreotide long-acting release (LAR),
and deep sc lanreotide depot/autogel (128 –131). These Side effects. Abdominal cramps, flatulence, and diarrhea
are usually administered monthly. Lanreotide depot/au- are common and usually abate with continued treatment.
togel may be self- or partner-injected (130, 131). The ap- Side effects also include occasional local skin irritation and
proved starting octreotide LAR dose is 20 mg monthly, pain at the injection site. Less common are reversible hair
with dose titration every 3– 6 months down to 10 mg or up loss and, rarely, alopecia. Because SRLs may inhibit both
to 40 mg monthly. For lanreotide autogel/depot, the ap- insulin and glucagon as well as GH secretion, glucose con-
proved starting dose is 90 mg monthly, with dose titrations trol usually improves but rarely may worsen (146).
down to 60 mg or up to 120 mg monthly. The lanreotide
compared with a controlled trial environment. Recent tri- increased hepatotoxicity caused by pegvisomant (165),
als indicate efficacy of using once or twice a week dosing, although another study did not support this finding (166).
although this is mostly used when pegvisomant is com-
bined with a SRL (see Section 5.7) (157). IGF-1 measure- Evidence
ment is recommended as the effective biomarker of drug Dopamine agonist. A meta-analysis showed that approx-
efficacy. GH levels should not be measured as a marker of imately 30% of patients attained biochemical control with
efficacy with pegvisomant because GH hypersecretion cabergoline (167). Cabergoline is most likely to be useful
persists and because of interference of pegvisomant in in patients with just modest elevations of GH and IGF-1
commercially available GH assays. As pegvisomant ex- levels, with or without concomitant hyperprolactinemia
hibits a favorable benefit for glycemic control, this med- (168). Despite initial efficacy of cabergoline, the response
ication may be useful when comorbid diabetes mellitus is to cabergoline appears to decrease with time. In one study,
SRL ⴙ cabergoline. Combined cabergoline- and SRL-nor- therapy is unavailable, unsuccessful, or not tolerated.
malized IGF-1 levels occurred in 42– 60% of patients, and (2|QQEE)
GH levels ⬍ 2.5 g/L were achieved in 21–71% of patients 6.2 We suggest use of SRT over conventional radiation
whose levels had not normalized with a SRL alone (167, therapy in patients with acromegaly, unless the technique
175). This suggests that cabergoline may be added to a is not available, there is significant residual tumor burden,
SRL, particularly if the GH/IGF-1 levels are mildly or the tumor is too close to the optic chiasm resulting in an
elevated. exposure of more than 8 Gy. (2|QQEE)
6.3 To monitor the efficacy of radiation therapy, we
Pegvisomant ⴙ cabergoline. In a prospective trial of 24 recommend annual GH/IGF-1 reassessment following
patients with acromegaly, cabergoline at 0.5 mg daily nor- medication withdrawal. (1|QQQE)
malized IGF-1 in 11%, whereas addition of pegvisomant
SRT appears similar to that after conventional RT (190 – 7.3 During pregnancy, we recommend that acromegaly
192). The risk of cerebrovascular disease in patients with medical therapy be withheld and administered only for
acromegaly is increased after conventional RT (44). Com- tumor and headache control. (1|QQEE)
plications of conventional RT in patients with pituitary 7.4 During pregnancy, we suggest serial visual field
tumors include radiation-induced cranial nerve damage, testing in patients with macroadenomas. (2|QQQE)
secondary tumors, radionecrosis, and cognitive changes 7.5 We suggest against monitoring GH and/or IGF-1
(193–197). Radionecrosis is a rare complication of levels during pregnancy. (2|QQQE)
gamma knife SRT (198). It has been suggested that SRLs
may limit the effectiveness of RT, although this finding Evidence
was based on nonrandomized and retrospective studies In patients with acromegaly who have autonomous GH
and has been refuted by subsequent studies (183, 199, secretion and become pregnant, both the normal pituitary
discontinued if pregnancy is considered and that contra- Pituitary Society; Significant Financial Interest or Leader-
ception be used when these drugs are administered. Short- ship Position: none declared.
acting octreotide sc injections can be utilized for disease * Evidence-based reviews for this guideline were pre-
control while awaiting conception. Considering the pro- pared under contract with the Endocrine Society.
longed nature of the course of most patients with acro-
megaly, interruption of medical therapy for 9 –12 months
should not have a particularly adverse effect on the long- References
term outcome. On the other hand, these drugs can control
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