Acromegaly Comorbidities Must Be Focus of Care: Consensus Update

By Marilynn Larkin

October 24, 2019

NEW YORK (Reuters Health) - A new consensus update on the diagnosis and treatment of acromegaly comorbidities emphasizes aggressive treatment of cardiovascular, endocrine, metabolic and other conditions, including sleep apnea and bone and joint disorders.

"The most important message is that acromegaly is associated with very high, common comorbidities - mainly cardiovascular, hypertension, diabetes, sleep apnea and rheumatologic - and the cause of death in these patients is really due to exacerbations of those comorbidities," Dr. Shlomo Melmed of Cedars-Sinai Medical Center in Los Angeles told Reuters Health by phone.

"If growth hormone levels are uncontrolled and comorbidities progress, then survival may be diminished by 30%, in some studies," he said. "Therefore, it is vital when treating these patients that we not just focus on the pituitary tumor itself - i.e., having the tumor removed and controlling growth hormone levels biochemically - but that we also focus on managing comorbidities very aggressively."

"Surveillance for the development of these comorbidities is vital, if we're going to maintain mortality rates similar to the non-acromegaly population," he said.

"The biggest change with this update is the aggressive treatment of comorbidities," he stressed. "Older work suggested that once a tumor is removed and growth hormones are controlled, you're home free. That's not exactly true. We should not assume that just because a patient achieves relief from surgery and biochemical control that they will be protected from comorbidities."

For the update, published online October 13 in the Journal of Clinical Endocrinology and Metabolism, the Acromegaly Consensus Group was convened, consisting of 45 experts in the medical and surgical management of acromegaly. Authors received no corporate funding or remuneration.

Dr. Melmed and other group members conducted comprehensive literature searches, reviewed brief presentations, and discussed current practice and recommendations in breakout groups. Members of the scientific committee graded the quality of the supporting evidence and the consensus recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation GRADE system.

Among the recommendations:

- Blood pressure measurement at baseline and every six months or when antihypertensive treatment changes;

-ECG annually, if abnormal;

- Epworth scale or sleep study annually and before surgery if obstructive sleep apnea is suspected;

- Fasting blood glucose or oral glucose tolerance test every six months, particularly in uncontrolled disease and during somatostatin receptor ligand therapy; HbA1c every six months if diabetes or prediabetes is present.

Group members did not completely agree on two recommendations, Dr. Melmed noted. These were frequency of screening colonoscopies and whether an echocardiogram should be done at baseline. He urges clinicians to "look carefully at the language" in the guidelines to help inform decision making on these issues.

Endocrinologist Dr. Laurence Kennedy of Cleveland Clinic in Ohio commented by email that despite substantial improvements in biochemical control of acromegaly in the past 30 years, "too many patients still fail to achieve biochemical control and, as the authors point out, even among those who do achieve biochemical control, many continue to have a relatively poor quality of life."

"One reason why patients may not achieve biochemical control...despite optimal surgery is that medical treatment is not simple," he told Reuters Health. "The most effective drugs currently are given by injection, are expensive, may need to be given in combination, and all too often - in the U.S. system at least - it is a bureaucratic struggle to get approval for medications."

"A major factor in the low quality of life is the effect of acromegaly on musculoskeletal well-being," he added. "Even with long-term normalization of IGF-1 (insulin-like growth factor-1), musculoskeletal symptoms frequently persist. This is likely due to the fact that the diagnosis of acromegaly is almost invariably delayed beyond the point where structural changes in bones and joints are reversible."

"Therefore, earlier diagnosis must remain a major goal," he said. "We need to continue educating other specialists to be on the lookout for this rare condition. For example, I would suggest, dental surgeons, rheumatologists, orthopedic surgeons and sleep disorder specialists could be encouraged to measure IGF-1 in many of their patients."


J Clin Endocrinol Metab 2019.