Treatment of Acromegaly with Obstructive Sleep Apnea or High-Output Heart Failure When Preoperative Medical Therapy Did Not Reach Its Goals
Acromegaly presenting with severe pharyngeal thickening and obstructive sleep apnea, or with high-output heart failure, poses elevated operative risk. Preoperative medical therapy is used to reduce that risk before surgery, but when it falls short of the required goals, a defined next step applies.
Clinical Scenario
This protocol addresses acromegaly in the setting of severe pharyngeal thickening with obstructive sleep apnea, or high-output heart failure — conditions that increase surgical risk and require specific management before definitive intervention.
Prior Therapy — Escalation Trigger
Preoperative medical therapy with a somatostatin receptor ligand (SRL) — octreotide LAR or lanreotide depot/autogel — was initiated to reduce surgical risk. This protocol is indicated when that therapy did not achieve its intended goals: adequate reduction of soft-tissue swelling and sleep apnea, or sufficient improvement of cardiac function in high-output heart failure.
Next-Step Treatment Approach
The definitive primary therapy involves a surgical approach via the transsphenoidal route. The specific technique and perioperative protocol extend beyond what is summarised here.
Clinical Goals
Success is evaluated at 12 weeks after surgery using specific biochemical thresholds, including normalization of serum IGF-1 and a defined serum GH target. The complete criteria are part of the structured regimen.
For patients with severe pharyngeal thickness and sleep apnea, or high-output heart failure, we suggest medical therapy with SRLs preoperatively to reduce surgical risk from severe comorbidities.
We recommend transsphenoidal surgery as the primary therapy in most patients.
A serum GH < 0.14 µg/L suggests "surgical remission," and a level < 1 µg/L indicates "control" and normalization of the mortality risk.
IGF-1 levels measured at 12 weeks after surgery are a valid reflection of surgical remission.
DOI: 10.1210/jc.2014-2700 View source ↗