Treatment Pros and Cons
The new AACE guidelines (PDF 93KB) conclude that surgery remains the usual first course of therapy, particularly for patients with microadenomas or with symptoms requiring tumor decompression. Medical options include somatostatin analogues such as Sandostatin LAR® Depot (octreotide acetate for injectable suspension), which control hypersecretion at the site of the tumor where hormone overproduction starts, and GH receptor antagonists, such as pegvisomant, which act peripherally. This guideline confirms that somatostatin analogues benefit patients with persistently nonsuppressible GH and high IGF-1 levels after a pituitary surgical procedure. The guidelines reserve radiotherapy for those patients whose hormone levels fail to normalize after medical therapy. Effective medical therapy provides clinicians with the ability to aggressively manage patients with persistently active acromegaly.
Surgery
Surgery is the first course of action recommended for most patients. The goal of surgery is to remove the tumor and normalize GH and IGF-1 levels. If successful, hormone control is reestablished. If not, medical therapy may be the next choice.
| Surgery Pros | Cons |
|---|---|
Possible cure if complete removal of the tumor Possible GH and IGF-1 control, as well as symptom relief, even if resection is incomplete |
Success depends on size and location of tumor Invasive procedure May be surgical complications |
Medical Therapy
Somatostatin Analogues (SAs)
When surgery fails, the mainstay for medical treatment is a class of drugs known as somatostatin analogues. Somatostatin analogues, including Sandostatin LAR® Depot (octreotide acetate for injectable suspension), work directly at the site of the pituitary tumor by shutting off the hormones that cause the symptoms of acromegaly. Somatostatin analogues may also be used instead of surgery in patients at risk for complications from anesthesia, patients with heart or lung complications, or patients whose tumors are large but not next to the optic nerve.
| Somatostatin Analogue Pros | Cons |
|---|---|
|
Control of hypersecretion at the site of the tumor where hormone overproduction starts Reduces GH and IGF-1 levels in the majority of patients Improves symptoms Can be administered as once-a-month therapy Long-term safety profile |
Patients may not tolerate possible side effects Ongoing cost |
GH Receptor Antagonist
For select patients, GH receptor antagonists (GHRAs) may be prescribed. These include patients in whom mainstay treatments such as surgery, somatostatin analogues, and dopamine agonists have proven ineffective or poorly tolerated, or those whose IGF-1 levels are extremely high.
| GH Receptor Antagonist Pros | Cons |
|---|---|
Reduces IGF-1 levels Improves symptoms |
No long-term safety experience Does not control GH levels Ongoing cost Patients may not tolerate possible side effects |
Dopamine Agonists
Patients also may be prescribed drugs called dopamine agonists. These agents work on dopamine receptors to inhibit GH release from the tumor.
| Dopamine Agonist Pros | Cons |
|---|---|
Improves symptoms Tolerable by some patients who cannot tolerate other medical therapies |
Patients may not tolerate possible side effects Ongoing cost |
Radiotherapy
Radiotherapy involves the use of radiation to kill rapidly growing tumor cells. After radiation, tumors typically stop growing and may even begin to shrink; however, elevated hormone levels fall much more slowly. Medical therapy with an SA is often needed to normalize hormone levels and control symptoms before radiation starts to work.
| Radiotherapy Pros | Cons |
|---|---|
Reduces GH and IGF-1 levels Relatively few side effects One-time cost |
Takes a long time to show effectiveness Potential for pituitary and optic nerve damage Risk of secondary malignancy |
