Abstract and Introduction
Introduction: The first-line treatment for acromegaly is transsphenoidal surgery. In approximately 50% of patients, however, a cure is not possible with surgery and alternatives are needed. Somatostatin analog therapy is the recommended first-line treatment in patients with such cases. Here we provide the first report of a high-dose lanreotide primary therapy in patients with acromegaly.
Case presentation: Six patients who were not suitable for surgery were given 60 mg of lanreotide (Autogel®) every four weeks. All patients were German nationals and Caucasian.
When the response of our patients was unsatisfactory, the dose was increased sequentially to 90 mg every four weeks, 120 mg every four weeks, 120 mg every three weeks and 180 mg every three weeks. Treatment duration was 12 to 24 months. In all cases, the lanreotide dose was 120 mg every 4 weeks or higher. In five of our patients, growth hormone (GH) levels were successfully reduced (in three patients GH <2.5 ng/ml was achieved). Insulin-like growth factor 1 levels were normalized in three patients and decreased in two patients. One patient failed to show a biochemical response to lanreotide therapy or pegvisomant therapy.
Tumor shrinkage or degeneration was observed in the five responding patients. No drug-related adverse events were noted.
Conclusions: These results suggest that lanreotide at high doses of 120 mg every four weeks or more is an effective first-line therapy for patients with acromegaly that surgery alone cannot treat.
Acromegaly, characterized by elevated growth hormone (GH) and insulin-like growth factor 1 (IGF-1) levels, is associated with a range of cardiovascular, respiratory, endocrine, metabolic and compression symptoms, and with an increased cancer risk.[1–3] Some symptoms can be serious and life-threatening. If untreated, acromegaly reduces life expectancy.[4,5]
Transsphenoidal surgery is the first-line treatment for acromegaly. However, surgery may be impractical. In approximately 50% of patients, surgery alone is unlikely to control the disease. In cases where there is a low probability of surgical cure, primary treatment with a long-acting somatostatin analog is recommended.[6,7]
Two somatostatin analogs are available, such as octreotide (Sandostatin®, Novartis) and lanreotide (Autogel®, Ipsen). There are considerable clinical data on the first-line use of octreotide (for example, Colao et al.). Lanreotide, on the other hand, has been shown to be effective as secondary treatment at starting doses of 30 mg to 120 mg every four weeks, but only recently have data been published on the use of lanreotide 90 mg or 120 mg every four weeks as primary therapy.
We present six patients with acromegaly who received primary treatment with lanreotide at doses higher than those presented in the literature.
GH, IGF-1 and prolactin levels were measured using chemiluminescent immunometric assays with Immulite 2000 (Siemens Medical Solutions Diagnostics, formerly DPC, Los Angeles, USA). Normal GH levels were defined as 0.5 to 5.0 ng/ml and normal age-adjusted IGF-1 levels were between 81 and 483 ng/ml.
Magnetic resonance tomography was conducted with a 1.5 Tesla-System (Siemens, Erlangen) Type AVANTO, and 1.5 T. MR (Avanto, Siemens). Magnetic resonance imaging (MRI) images were produced using a head matrix array. For pituitary imaging, T2w-TSE sag, T1w-SE sag and coronar before and after contrast medium gadolinium (Gadovist, Bayer Healthcare) were used dynamically. The slice size was 2.2 mm.
The six patients with acromegaly presented in this case series were ineligible for surgery because three of them had macroadenoma that were too large and had parasellar and suprasellar extensions (Patients 1, 5 and 6), while one had an adenoma that was too close to the internal carotid artery (Patient 2). One had cardiac insufficiency stage New York Heart Association (NYHA) III and severe insulin-dependent diabetes mellitus and was thus considered high risk for systemic anesthesia (Patient 3), while one had McCune-Albright syndrome and fibrous dysplasia involving the base of the skull which made transsphenoidal surgery impossible (Patient 4).
All patients were German nationals and Caucasian.
All patients initially received lanreotide by deep subcutaneous injection (Autogel®, Ipsen, Paris, France). Each patient was given a single starting dose of 60 mg. After four weeks, their IGF-1 and GH levels were measured. If the IGF-1 levels remained high and the response of our patient to the medication was unsatisfactory, the next dose of lanreotide was increased to 90 mg or 120 mg. If a patient who was receiving treatment with 120 mg, had an unsatisfactory IGF-1 response, the injection interval was reduced to every three weeks. If GH and IGF-1 levels were still elevated in patients receiving lanreotide 120 mg every three weeks, the dose was increased to 180 mg, or 90 mg in each gluteal muscle, every three weeks. For each patient, the dose adjustments were usually made after three injections of lanreotide. In single cases with very high IGF-1-levels, the decision to increase the dose was made earlier based on our previous experience with this treatment.
J Med Case Reports. 2010;4:85 © 2010 Wuster et al; licensee BioMed Central, Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licneses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this: Primary Treatment of Acromegaly with High-dose Lanreotide: A Case Series - Medscape - Mar 08, 2010.