A practical approach to acromegaly management in Latin America

Abstract

IntroductionEvidence-based treatment guidelines have undoubtedly advanced medical practice and supported optimal management of acromegaly, but their application may be hampered by limited access to the latest treatment options.MethodsIn this retrospective, narrative review, the authors revisited existing treatment guidelines for acromegaly in Latin America. These were considered in conjunction with published evidence chosen at the authors’ discretion.FindingsIn a socially and economically diverse region, such as Latin America, any regional practice guidelines need to appreciate that recommended treatment options, such as surgery by expert pituitary surgical teams and drug therapies, especially somatostatin analogs, are often not available due to limited resources. In these instances, physicians may be obliged to apply less effective therapeutic options.ConclusionsThe current article looks at the practical aspects of acromegaly management in Latin America and discusses this in the context of existing guidelines. Furthermore, we consider potential strategies to make better use of resources through combination and multimodal approaches to treatment.

Screening for acromegaly in adult patients not reporting enlargement of the extremities, but with arterial hypertension associated with another comorbidity of the disease

“…Table 2). No GH suppression in the OGTT was observed in four women with confirmed elevated IGF-1 (patients [16][17][18][19] in Table 2). Since serum IGF-1 and nadir GH were only slightly elevated, MRI showed a normal pituitary and chest and abdominal contrast-enhanced computed tomography revealed no tumor, no intervention was performed.…”

“…This is the case of patients with imaging findings compatible with pituitary adenoma (8). Subjects with a "suspicious phenotype" are also recommended for investigation, but there is no objective definition of this phenotype (9)(10)(11)(12)(13)(14)(15)(16)(17), which is left to the personal impression of each physician.…”

“…Agreement regarding the need to investigate hypersecretion of GH exists for patients with a typical phenotype or imaging results compatible with pituitary adenoma (8). Except for these cases, there are no objective recommendations as to which patients should be evaluated for acromegaly (9)(10)(11)(12)(13)(14)(15)(16)(17), and the "clinical suspicion" is subject to the personal impression of each physician, which is influenced by academic background, degree of suspicion, experience with the disease, and motivation to diagnose it. In an attempt to encourage early detection, some authors and guidelines recommend acromegaly to be investigated in subjects with two or more comorbidities associated with the disease (18,19).…”

Prescription patterns of long-acting somatostatin analogues

“…Approximately 15% of the patients evaluated with acromegaly used cabergoline, which corresponded to more than 56% of those who received somatostatin analogues at maximum doses, most likely due to the difficulty in achieving control of the pathology. 2 , 29 , 30 …”

Combined treatment with octreotide LAR and pegvisomant in patients with pituitary gigantism: clinical evaluation and genetic screening

“…The choice of treatment approach also may be influenced by neurosurgery capacity and local availability of medical therapy. In particular, in Latin America surgical resection remains the standard first-line approach for treatment of intrasellar pituitary adenomas and those macroadenomas causing visual or neurological complications [19], while primary medical therapy with [20,21]. Neither of our patients that underwent first-line surgery achieved disease control following surgery alone.…”