Consensus: Guidelines for acromegaly management

Treatment of acromegaly is determined by the availability of local neuroendocrine, imaging, and surgical expertise as well as patient access to costly evaluations and therapeutic choices, which may be unique for regions and countries. Nevertheless, controlled GH suppression should be optimized (37). In deciding on appropriate means to achieve biochemical control and relieve mass effects, the treating physician team should balance risk and benefits, and treatment contraindications and side-effects for each patient (2, 38). Factors to be considered include disease severity, tumor mass effect on central structures, tumor expression of somatostatin receptor subtypes, and potential for long-term pituitary damage, especially in younger reproductive-aged patients. In patients who have low GH levels and already have irreversible hypopituitarism, radiation therapy may be preferred because there is no further risk for this complication, although tumor resection often relieves compressive hypopituitarism. The depicted flowsheet recommends surgery as the first line therapy followed by medical therapy should surgery not be curative. In selected patients with unacceptable anesthetic risk, cardiovascular or pulmonary complications, and macroadenomas not impinging on the optic chiasm, primary SRL therapy may be offered (13, 39). If control is inadequately achieved with maximal doses of SRLs and added dopamine agonists, radiotherapy should be considered or no further action should be proposed, depending on clinical disease activity and degree of biochemical disease persistence. Reoperation or treatment with investigational GH receptor antagonists (25) should be considered for patients resistant to surgical, medical, and radiotherapeutic approaches (26). In conclusion, considering the potentially serious treatment adverse effects that limit their efficacy, there is consensus that integrated treatment decisions should be made by a team including endocrinologists, surgeons, and radiation therapists. The patient's choice of therapy should be based upon an informed understanding of the potential disadvantages of therapeutic approaches vs. their effectiveness in managing this complex metabolic disorder, reducing its comorbidities, and ultimately achieving favorable mortality outcomes.

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