Acromegaly Treatment When Transsphenoidal Surgery Has Not Achieved Remission
Transsphenoidal surgery is the primary treatment approach for acromegaly. When it does not achieve biochemical remission, a structured second-line strategy is required. This protocol addresses that specific clinical situation.
Scenario
The patient has undergone transsphenoidal surgery as primary therapy for acromegaly — performed via the transsphenoidal route using either the operating microscope or the operating endoscope with microsurgical technique — and biochemical remission was not achieved.
When Surgery Did Not Succeed
Prior therapy: Transsphenoidal surgery
Goals not reached: Surgical remission requires a normalized serum IGF-1 and a random serum GH below 1 µg/L (GH below 0.14 µg/L is taken as a marker of surgical remission), assessed at 12 weeks after surgery. Failure to meet these thresholds indicates the need for adjuvant medical therapy.
Next Step: Adjuvant Medical Therapy
Biochemical Targets
Treatment success is defined by an age-normalized serum IGF-1 value and a random GH below 1.0 µg/L. Both markers are measured at 12 weeks, just prior to the next dose.
References
DOI: 10.1210/jc.2014-2700
- 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.
- There are two equally effective long-acting available preparations: im octreotide long-acting release (LAR), and deep sc lanreotide depot/autogel.
- We suggest a biochemical target goal of an age-normalized serum IGF-1 value, which signifies control of acromegaly.
- We suggest using a random GH < 1.0 µg/L as a therapeutic goal, as this correlates with control of acromegaly.
- Effectiveness of treatment is based on measurement of serum IGF-1 and GH, which should be measured after 12 weeks just prior to the next dose.