0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45
14 Acromegalymanagement
What to Do First
■Assess size and resectability of tumor
specific therapy
■Surgical resection of tumor (usually transsphenoidal), esp. if there is
visual field cut
■Medical therapy:
➣Somatostatin analog (octreotide or long-acting octreotide) given
parenterally; can normalize serum IGF-I and GH; some tumor
shrinkage
■Dopamine agonists (bromocriptine or cabergoline): may lower IGF-I
and GH in some cases; often require high doses
■GH antagonists (pegvisomant) : very effective at lowering serum IGF-
I; increases serum GH. Follow LFTs.
■Radiation therapy if surgery and medical therapy fail; may take up to
10 y to normalize serum IGF-I and GH; often causes hypopituitarism
■Observation with repeated pituitary MRI to determine if tumor is
growing
Treatment Goals
■Normalize serum IGF-I level
■Normalize GH response to glucose load
■Diminish size of pituitary tumor
■Maintain normal pituitary function
■Fertility
■Cessation of galactorrhea
■Restoration of libido and potency
Side Effects & Contraindications
■Surgery and radiation: hypopituitarism
■Octreotide: gallstones and gastric upset
■Bromocriptine and cabergoline: gastric upset, nasal stuffiness,
orthostatic hypotension with initial doses
follow-up
■Serum IGF-I postoperatively or 2 wks after changing dose of
medicine
■Repeat pituitary MRI after 3–6 mo to assess pituitary growth
complications and prognosis
■Pituitary apoplexy (in patients with macroadenomas):
➣Presents as very severe headache, altered consciousness, coma
➣Requires emergent surgical intervention and resection of tumor