151
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Zahr R, Fleseriu M. Updates in Diagnosis and Treatment of Acromegaly. EUROPEAN ENDOCRINOLOGY 2018; 14:57-61. [PMID: 30349595 PMCID: PMC6182922 DOI: 10.17925/ee.2018.14.2.57] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/03/2018] [Indexed: 12/13/2022]
Abstract
Acromegaly is a rare disease, caused largely by a growth hormone (GH) pituitary adenoma. Incidence is higher than previously thought. Due to increased morbidity and mortality, if not appropriately treated, early diagnosis efforts are essential. Screening is recommended for all patients with clinical features of GH excess. There is increased knowledge that classical diagnostic criteria no longer apply to all, and some patients can have GH excess with normal GH response to glucose. Treatment is multifactorial and personalised therapy is advised.
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Affiliation(s)
- Roula Zahr
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
- Department of Neurological Surgery
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, US
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152
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Melmed S, Bronstein MD, Chanson P, Klibanski A, Casanueva FF, Wass JAH, Strasburger CJ, Luger A, Clemmons DR, Giustina A. A Consensus Statement on acromegaly therapeutic outcomes. Nat Rev Endocrinol 2018; 14:552-561. [PMID: 30050156 PMCID: PMC7136157 DOI: 10.1038/s41574-018-0058-5] [Citation(s) in RCA: 315] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The 11th Acromegaly Consensus Conference in April 2017 was convened to update recommendations on therapeutic outcomes for patients with acromegaly. Consensus guidelines on the medical management of acromegaly were last published in 2014; since then, new pharmacological agents have been developed and new approaches to treatment sequencing have been considered. Thirty-seven experts in the management of patients with acromegaly reviewed the current literature and assessed changes in drug approvals, clinical practice standards and clinical opinion. They considered current treatment outcome goals with a focus on the impact of current and emerging somatostatin receptor ligands, growth hormone receptor antagonists and dopamine agonists on biochemical, clinical, tumour mass and surgical outcomes. The participants discussed factors that would determine pharmacological choices as well as the proposed place of each agent in the guidelines. We present consensus recommendations highlighting how acromegaly management could be optimized in clinical practice.
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Affiliation(s)
- Shlomo Melmed
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Marcello D Bronstein
- Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Hôpital Bicêtre, Paris, France
- UMR S-1185, Faculté de Médecine Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paris, France
| | - Anne Klibanski
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Felipe F Casanueva
- Department of Medicine, Santiago de Compostela University, Santiago de Compostela, Spain
| | - John A H Wass
- Department of Endocrinology, Churchill Hospital, Oxford, UK
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - David R Clemmons
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrea Giustina
- Department of Endocrinology and Metabolism, San Raffaele University Hospital Milan, Milan, Italy
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153
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Mazziotti G, Frara S, Giustina A. Pituitary Diseases and Bone. Endocr Rev 2018; 39:440-488. [PMID: 29684108 DOI: 10.1210/er.2018-00005] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/16/2018] [Indexed: 12/12/2022]
Abstract
Neuroendocrinology of bone is a new area of research based on the evidence that pituitary hormones may directly modulate bone remodeling and metabolism. Skeletal fragility associated with high risk of fractures is a common complication of several pituitary diseases such as hypopituitarism, Cushing disease, acromegaly, and hyperprolactinemia. As in other forms of secondary osteoporosis, pituitary diseases generally affect bone quality more than bone quantity, and fractures may occur even in the presence of normal or low-normal bone mineral density as measured by dual-energy X-ray absorptiometry, making difficult the prediction of fractures in these clinical settings. Treatment of pituitary hormone excess and deficiency generally improves skeletal health, although some patients remain at high risk of fractures, and treatment with bone-active drugs may become mandatory. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary diseases.
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Affiliation(s)
| | - Stefano Frara
- Institute of Endocrinology, Università Vita-Salute San Raffaele, Milan, Italy
| | - Andrea Giustina
- Institute of Endocrinology, Università Vita-Salute San Raffaele, Milan, Italy
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154
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Dummer R, Michielin O, Nägeli MC, Goldinger SM, Campigotto F, Kriemler-Krahn U, Schmid H, Pedroncelli A, Micaletto S, Schadendorf D. Phase I, open-label study of pasireotide in patients with BRAF-wild type and NRAS-wild type, unresectable and/or metastatic melanoma. ESMO Open 2018; 3:e000388. [PMID: 30094073 PMCID: PMC6069912 DOI: 10.1136/esmoopen-2018-000388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/25/2018] [Accepted: 05/26/2018] [Indexed: 01/20/2023] Open
Abstract
Introduction Somatostatin analogues exert antitumour activity via direct and indirect mechanisms. The present study was designed to assess the safety and efficacy of pasireotide in patients with BRAF-wild type (WT) and NRAS-WT metastatic melanoma. Patients and methods Patients with unresectable and/or metastatic melanoma or Merkel cell carcinoma were eligible. Pasireotide was administered at different doses for ≤8 weeks in dose-escalation phase, followed by long-acting pasireotide 80 mg or lower dose in case of toxicity in follow-up phase up to six additional months. Primary endpoint was safety in the first 8 weeks of dose-escalation phase. Results The study was terminated early due to slow recruitment. Of the 10 patients with metastatic melanoma enrolled, only four reached the high dose level: two patients reached 3600 µg in dose-escalation and follow-up phases and two patients reached 3600 µg in dose-escalation and long-acting pasireotide 80 mg in follow-up phases and were stable for >5 months. Most common adverse events (AEs) during dose-escalation phase in ≥2 patients (20%) were: diarrhoea (50%), nausea (50%), fatigue (20%), hyperglycaemia (20%), hypophosphatemia (20%), chills (20%) and tumour pain (20%). Grade 3 or 4 study drug-related AEs were diarrhoea and nausea, reported in one patient. Partial response was documented in one patient and stable disease in another. Conclusions Pasireotide was well tolerated, and safety results were similar to those previously reported in other indications. Further studies are needed to evaluate its antitumour activity alone and in combination with other drugs in melanoma.
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Affiliation(s)
- Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland.
| | - Olivier Michielin
- Multidisciplinary Oncology Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Simone M Goldinger
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Federico Campigotto
- Global Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Herbert Schmid
- Clinical Development, Novartis Pharma AG, Basel, Switzerland
| | | | - Sara Micaletto
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany & German Cancer Consortium, Heidelberg, Germany
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155
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Salomon MP, Wang X, Marzese DM, Hsu SC, Nelson N, Zhang X, Matsuba C, Takasumi Y, Ballesteros-Merino C, Fox BA, Barkhoudarian G, Kelly DF, Hoon DSB. The Epigenomic Landscape of Pituitary Adenomas Reveals Specific Alterations and Differentiates Among Acromegaly, Cushing's Disease and Endocrine-Inactive Subtypes. Clin Cancer Res 2018; 24:4126-4136. [PMID: 30084836 DOI: 10.1158/1078-0432.ccr-17-2206] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/19/2017] [Accepted: 05/15/2018] [Indexed: 11/16/2022]
Abstract
Purpose: Pituitary adenomas are one of the most common benign neoplasms of the central nervous system. Although emerging evidence suggests roles for both genetic and epigenetic factors in tumorigenesis, the degree to which these factors contribute to disease remains poorly understood.Experimental Design: A multiplatform analysis was performed to identify the genomic and epigenomic underpinnings of disease among the three major subtypes of surgically resected pituitary adenomas in 48 patients: growth hormone (GH)-secreting (n = 17), adrenocorticotropic hormone (ACTH)-secreting (n = 13, including 3 silent-ACTH adenomas), and endocrine-inactive (n = 18). Whole-exome sequencing was used to profile the somatic mutational landscape, whole-transcriptome sequencing was used to identify disease-specific patterns of gene expression, and array-based DNA methylation profiling was used to examine genome-wide patterns of DNA methylation.Results: Recurrent single-nucleotide and small indel somatic mutations were infrequent among the three adenoma subtypes. However, somatic copy-number alterations (SCNA) were identified in all three pituitary adenoma subtypes. Methylation analysis revealed adenoma subtype-specific DNA methylation profiles, with GH-secreting adenomas being dominated by hypomethylated sites. Likewise, gene-expression patterns revealed adenoma subtype-specific profiles. Integrating DNA methylation and gene-expression data revealed that hypomethylation of promoter regions are related with increased expression of GH1 and SSTR5 genes in GH-secreting adenomas and POMC gene in ACTH-secreting adenomas. Finally, multispectral IHC staining of immune-related proteins showed abundant expression of PD-L1 among all three adenoma subtypes.Conclusions: Taken together, these data stress the contribution of epigenomic alterations to disease-specific etiology among adenoma subtypes and highlight potential targets for future immunotherapy-based treatments. This article reveals novel insights into the epigenomics underlying pituitary adenomas and highlights how differences in epigenomic states are related to important transcriptome alterations that define adenoma subtypes. Clin Cancer Res; 24(17); 4126-36. ©2018 AACR.
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Affiliation(s)
- Matthew P Salomon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Xiaowen Wang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Diego M Marzese
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Sandy C Hsu
- Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California
| | - Nellie Nelson
- Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California
| | - Xin Zhang
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Chikako Matsuba
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Yuki Takasumi
- Department of Pathology, Saint John's Health Center, PHS, Santa Monica, California
| | | | - Bernard A Fox
- Earle A. Chiles Research Institute, Providence Cancer Center, PHS, Portland, Oregon
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, PHS, Santa Monica, California.,John Wayne Cancer Institute Brain Tumor Center, Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Daniel F Kelly
- Pacific Neuroscience Institute, PHS, Santa Monica, California.,John Wayne Cancer Institute Brain Tumor Center, Saint John's Health Center, Providence Health System, Santa Monica, California
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, John Wayne Cancer Institute at Saint John's Health Center, Providence Health System, Santa Monica, California. .,Sequencing Center, John Wayne Cancer Institute at Saint John's Health Center, Providence Health and Service (PHS), Santa Monica, California.,Pacific Neuroscience Institute, PHS, Santa Monica, California
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156
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Rodriguez M, Frost JA, Schonbrunn A. Real-Time Signaling Assays Demonstrate Somatostatin Agonist Bias for Ion Channel Regulation in Somatotroph Tumor Cells. J Endocr Soc 2018; 2:779-793. [PMID: 30151433 PMCID: PMC6106105 DOI: 10.1210/js.2018-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
Acromegaly is a neuroendocrine disorder caused by excess secretion of GH by somatotroph tumor cells. It is often treated with somatostatin receptor (SSTR) 2 agonists, which suppress GH secretion. SOM230 is a somatostatin analogue that targets multiple SSTRs and was recently approved for patients with treatment-resistant acromegaly. Previous reports indicate that SOM230 may function as a biased agonist, suggesting that its ability to selectively activate SSTR-dependent signaling events may contribute to its therapeutic efficacy. To better understand how SOM230 modulates Sstr2A function, which is the most commonly expressed SSTR in somatotrophs, we used real-time assays to study SOM230-dependent signaling in rat pituitary tumor cells. We observed that SOM230 suppressed cAMP production in a Gαi-dependent manner, similar to conventional Sstr2A agonists. However, it did not cause receptor internalization as would be expected for an Sstr2A agonist. Surprisingly, SOM230 did not cause membrane hyperpolarization, which is an important mechanism by which Sstr2a activation suppresses intracellular calcium (Ca2+) accumulation and GH secretion. In fact, SOM230 inhibited the ability of conventional somatostatin analogues to control membrane potential. However, SOM230 still inhibited intracellular Ca2+ accumulation in a novel, Gβγ-dependent manner. These studies show that SOM230 exhibits strong agonist bias in regulating signaling pathways downstream of Sstr2A that control GH secretion.
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Affiliation(s)
- Melissa Rodriguez
- Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jeffrey A Frost
- Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Agnes Schonbrunn
- Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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157
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Leonart LP, Ferreira VL, Tonin FS, Fernandez-Llimos F, Pontarolo R. Medical Treatments for Acromegaly: A Systematic Review and Network Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:874-880. [PMID: 30005760 DOI: 10.1016/j.jval.2017.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/28/2017] [Accepted: 12/11/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Acromegaly results from the hypersecretion of growth hormone. Because of the low incidence rates of this disease worldwide, few clinical trials evaluating drug treatments have been conducted. OBJECTIVES To conduct the first network meta-analysis simultaneously comparing all available drugs used in acromegaly treatment so as to provide more robust evidence in this field. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Collaboration recommendations (PROSPERO database under the registration number CRD42017059880). The electronic searches were conducted in PubMed (MEDLINE), Scopus, and Web of Science databases. Randomized controlled trials comparing any drug for the treatment of acromegaly head-to-head or versus placebo were included. Outcomes concerning the efficacy and safety of treatments were evaluated. The statistical analyses were performed using Aggregate Data Drug Information System version 1.16.8 (drugis.org, Groningen, The Netherlands). RESULTS The initial search retrieved 2059 articles. Of these, 10 randomized controlled trials were included in a qualitative analysis and 7 in a quantitative analysis. The network meta-analysis for the efficacy outcome (number of patients achieving insulinlike growth factor 1 control) showed that pegvisomant and lanreotide autogel were statistically superior to placebo (odds ratio [95% credible interval] 0.06 [0.00-0.55] and 0.09 [0.01-0.88]). No further differences were found. The probability rank indicated that pegvisomant and pasireotide have the highest probabilities (33% and 34%, respectively) of being the best therapeutic options. No major side effects were noted. CONCLUSIONS Pegvisomant is still a good option for acromegaly treatment, but pasireotide seems to be a promising alternative. Nevertheless, other important key factors such as drug costs and effectiveness (real-world results) should be taken into account when selecting acromegaly treatment.
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Affiliation(s)
- Letícia P Leonart
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Vinicius L Ferreira
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Fernanda S Tonin
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Fernando Fernandez-Llimos
- Department of Social Pharmacy, Faculty of Pharmacy, Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal
| | - Roberto Pontarolo
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil.
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158
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Lovato CM, Kapsner PL. Analgesic effect of long-acting somatostatin receptor agonist pasireotide in a patient with acromegaly and intractable headaches. BMJ Case Rep 2018; 2018:bcr-2017-219686. [PMID: 29925553 DOI: 10.1136/bcr-2017-219686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
A 22-year-old woman presented with worsening vision loss and headaches. A diagnosis of acromegaly was confirmed after detection of an invasive pituitary macroadenoma and biochemical testing. Despite two attempts of surgical debulking of the tumour and administration of long-acting octreotide and cabergoline, growth hormone (GH) and insulin-like growth factor 1 (IGF-1) levels were uncontrolled. The patient experienced persistent headaches despite surgery, gamma knife radiation and ventriculoperitoneal shunt placement; she was then enrolled in the ACCESS trial (ClinicalTrials.gov identifier, NCT01995734). Pasireotide (Signifor; Signifor LAR) was initiated, which led to reduced GH and IGF-1 levels and resolution of her intractable headaches. This highlights the use of monthly pasireotide in resolving headaches and improved biochemical control in a patient with acromegaly. We postulate that the headaches improved due to an analgesic and/or anti-inflammatory effect mediated by somatostatin receptors targeted by pasireotide. This may represent an additional benefit of pasireotide and requires further investigation.
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Affiliation(s)
- Christina M Lovato
- Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Patricia L Kapsner
- Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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159
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van Esdonk MJ, van Zutphen EJM, Roelfsema F, Pereira AM, van der Graaf PH, Biermasz NR, Stevens J, Burggraaf J. How are growth hormone and insulin-like growth factor-1 reported as markers for drug effectiveness in clinical acromegaly research? A comprehensive methodologic review. Pituitary 2018; 21:310-322. [PMID: 29605877 PMCID: PMC5942341 DOI: 10.1007/s11102-018-0884-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE In rare disease research, most randomized prospective clinical trials can only use limited number of patients and are comprised of highly heterogeneous populations. Therefore, it is crucial to report the results in such a manner that it allows for comparison of treatment effectiveness and biochemical control between studies. The aim of this review was to investigate the current methods that are being applied to measure and report growth hormone (GH) and insulin-like growth factor-1 (IGF-1) as markers for drug effectiveness in clinical acromegaly research. SEARCH STRATEGY A systematic search of recent prospective and retrospective studies, published between 2012 and 2017, that studied the effects of somatostatin analogues or dopamine agonists in acromegaly patients was performed. The markers of interest were GH, IGF-1, and the suppression of GH after an oral glucose tolerance test (OGTT). Additionally, the use of pharmacokinetic (PK) measurements in these studies was analyzed. The sampling design, cut-off for biochemical control, reported units, and used summary statistics were summarized. RESULTS A total of 49 articles were selected out of the 263 screened abstracts. IGF-1 concentrations were measured in all 49 studies, GH in 45 studies, and an OGTT was performed in 11 studies. A wide range of different cut-off values and sampling designs were used to determine biochemical control in acromegaly patients. The summary statistics were reported in various ways, with the percentage of biochemical control most frequently used. Nine studies sampled the PK at one or more time points. Non-compartmental analyses were commonly performed on the available PK data. CONCLUSIONS The way GH and IGF-1 are measured and reported in acromegaly research varies considerably. A consensus on how to report study results would enable better comparisons between studies, thereby improving evidence based decision making to optimize treatment in acromegaly.
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Affiliation(s)
- Michiel J van Esdonk
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Centre for Human Drug Research, Leiden, The Netherlands.
| | - Eline J M van Zutphen
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Ferdinand Roelfsema
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Piet H van der Graaf
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Certara QSP, Canterbury, UK
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jasper Stevens
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacobus Burggraaf
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Centre for Human Drug Research, Leiden, The Netherlands
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160
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Criterios para el diagnóstico y el control poscirugía de la acromegalia, y el cribado y el manejo de sus comorbilidades: recomendaciones de expertos. ENDOCRINOL DIAB NUTR 2018; 65:297-305. [DOI: 10.1016/j.endinu.2018.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 01/25/2018] [Indexed: 12/29/2022]
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161
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Strasburger CJ, Mattsson A, Wilton P, Aydin F, Hey-Hadavi J, Biller BMK. Increasing frequency of combination medical therapy in the treatment of acromegaly with the GH receptor antagonist pegvisomant. Eur J Endocrinol 2018; 178:321-329. [PMID: 29371335 PMCID: PMC5863474 DOI: 10.1530/eje-17-0996] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/25/2018] [Indexed: 12/14/2022]
Abstract
Pegvisomant monotherapy is effective and safe in treatment of acromegaly. However, some clinicians combine pegvisomant with somatostatin analogues (SSA) or dopamine agonist (DA). In this analysis of ACROSTUDY, a long-term non-interventional study, the use of combination regimens was evaluated. Based on their baseline treatment, 2043 patients were retrospectively categorized as: long-acting SSA combined with pegvisomant, 'Combo SSA' 768 patients (38%); DA combined with pegvisomant, 'Combo DA' 123 (6%); pegvisomant monotherapy, 'Peg mono' 1128 (55%). Treatment patterns changed over the 10-year period, with recent patients more likely to receive any combination (20% in 2003 vs 54% in 2012). Combo SSA use varied widely among countries from 22% to 78%. Exposure periods of the three treatment modalities were defined from pegvisomant start until the last visit in ACROSTUDY; patients could switch treatment categories. At year 4, IGF-I was normal in 62% of Combo SSA, 63% of Combo DA and 65% of Peg mono groups. Pegvisomant was initiated as daily injections in 94% of patients in the Peg mono group, 66% of Combo SSA and 91% of Combo DA patients. During 6169 years of treatment exposure, 3424 adverse events (AEs) were reported in 946 (51%) patients, of which 617 (18%) were serious and 401 (12%) were considered treatment related. The reported incidence of serious AEs and treatment-related non-serious AEs were similar among the three treatment modalities. This analysis describes real-world clinical care and shows favorable efficacy and safety for Peg mono and combinations. Novel findings include an increased use of combination therapy over time and variability in treatment modalities between countries.
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Affiliation(s)
- Christian J Strasburger
- Department of Medicine for EndocrinologyDiabetes and Nutritional Medicine, Charité Universitätsmedizin, Campus Mitte, Berlin, Germany
| | | | | | - Ferah Aydin
- Endocrine CarePfizer Health AB, Sollentuna, Sweden
| | | | - Beverly M K Biller
- Neuroendocrine UnitMassachusetts General Hospital, Boston, Massachusetts, USA
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162
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Abstract
Pituitary adenomas are one of the most common primary central nervous system tumors and have an estimated prevalence of 17%. Approximately half of pituitary adenomas secrete distinct pituitary hormones (most often prolactin, growth hormone, or adrenocorticotropic hormone). While these tumors are histologically benign, they have potent endocrine effects that lead to significant morbidity and shortened lifespan. Because of their pathophysiologic endocrine secretion and anatomic location near critical neural/vascular structures, hormone-secreting pituitary adenomas require defined management paradigms that can include relief of mass effect and biochemical remission. Management of hormone-secreting pituitary adenomas involves a multidisciplinary approach that can incorporate surgical, medical, and/or radiation therapies. Early and effective treatment of hormone-secreting pituitary adenomas can reduce morbidity and mortality. Consequently, understanding clinical features as well as therapeutic options in the context of the specific biological features of each type of hormone-secreting pituitary adenoma is critical for optimal management.
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Affiliation(s)
- Gautam U Mehta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Russell R Lonser
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.,Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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163
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Kasuki L, Wildemberg LE, Gadelha MR. MANAGEMENT OF ENDOCRINE DISEASE: Personalized medicine in the treatment of acromegaly. Eur J Endocrinol 2018; 178:R89-R100. [PMID: 29339530 DOI: 10.1530/eje-17-1006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Abstract
Acromegaly is associated with high morbidity and elevated mortality when not adequately treated. Surgery is the first-line treatment for most patients as it is the only one that can lead to immediate cure. In patients who are not cured by surgery, treatment is currently based on a trial-and-error approach. First-generation somatostatin receptor ligands (fg-SRL) are initiated for most patients, although approximately 25% of patients present resistance to this drug class. Some biomarkers of treatment outcome are described in the literature, with the aim of categorizing patients into different groups to individualize their treatments using a personalized approach. In this review, we will discuss the current status of precision medicine for the treatment of acromegaly and future perspectives on the use of personalized medicine for this purpose.
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Affiliation(s)
- Leandro Kasuki
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrine Unit, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
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Muhammad A, van der Lely AJ, Delhanty PJD, Dallenga AHG, Haitsma IK, Janssen JAMJL, Neggers SJCMM. Efficacy and Safety of Switching to Pasireotide in Patients With Acromegaly Controlled With Pegvisomant and First-Generation Somatostatin Analogues (PAPE Study). J Clin Endocrinol Metab 2018; 103:586-595. [PMID: 29155991 DOI: 10.1210/jc.2017-02017] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/10/2017] [Indexed: 11/19/2022]
Abstract
AIM To assess the efficacy and safety of pasireotide long-acting release (PAS-LAR) alone or in combination with pegvisomant by switching patients with acromegaly who were well controlled with long-acting somatostatin analogues (LA-SSAs) and pegvisomant to PAS-LAR with or without pegvisomant. METHODS Sixty-one patients with acromegaly were enrolled in a prospective open-label study. We included patients with an insulin-like growth factor I (IGF-I) ≤1.2 × upper limit of normal (ULN) during treatment with LA-SSAs and pegvisomant. At baseline, the pegvisomant dose was reduced by 50% up to 12 weeks. When IGF-I remained ≤1.2 × ULN after 12 weeks, patients were switched to PAS-LAR 60 mg monotherapy. When IGF-I was >1.2 × ULN, patients were switched to PAS-LAR 60 mg, and they continued with the 50% reduced pegvisomant dose. RESULTS At baseline, mean IGF-I was 0.97 × ULN, and the median pegvisomant dose was 80 mg/wk. At 12 weeks, mean IGF-I increased to 1.59 × ULN, and IGF-I levels ≤1.2 ULN were observed in 24.6% of participants. At 24 weeks, IGF-I levels were reduced into the reference range in 73.8% of patients. Between baseline and 24 weeks, the pegvisomant dose was reduced by 66.1%. PAS-LAR was well tolerated, but hyperglycemia was the most frequent adverse event. The frequency of diabetes increased from 32.8% at baseline to 68.9% at 24 weeks. CONCLUSIONS Switching to PAS-LAR, either as monotherapy or combination with pegvisomant, can control IGF-I levels in most patients. PAS-LAR demonstrated a pegvisomant-sparing effect of 66% compared with the combination with LA-SSAs. Hyperglycemia was the most important safety issue.
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Affiliation(s)
- Ammar Muhammad
- Department of Medicine, Endocrinology Section, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aart J van der Lely
- Department of Medicine, Endocrinology Section, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Patric J D Delhanty
- Department of Medicine, Endocrinology Section, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alof H G Dallenga
- Department of Neurosurgery, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Iain K Haitsma
- Department of Neurosurgery, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joseph A M J L Janssen
- Department of Medicine, Endocrinology Section, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sebastian J C M M Neggers
- Department of Medicine, Endocrinology Section, Pituitary Center Rotterdam, Erasmus University Medical Center, Rotterdam, The Netherlands
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Biagetti B, Obiols G, Martinez Saez E, Cordero E, Mesa J. Pasireotide in acromegaly by aggressive tumors, description of four clinical cases. Towards a personalized medicine. ACTA ACUST UNITED AC 2018; 65:130-132. [PMID: 29371000 DOI: 10.1016/j.endinu.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Gabriel Obiols
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Elena Martinez Saez
- Servicio de Anatomía Patológica, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Esteban Cordero
- Servicio de Neurocirugía, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Jordi Mesa
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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166
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Ciresi A, Radellini S, Guarnotta V, Giordano C. Efficacy of combined treatment with pasireotide, pegvisomant and cabergoline in an acromegalic patient resistant to other treatments: a case report. BMC Endocr Disord 2018; 18:2. [PMID: 29361932 PMCID: PMC5781307 DOI: 10.1186/s12902-018-0231-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/18/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The approach to acromegalic patients with persistent acromegaly after surgery and inadequate response to first-generation somatostatin receptor ligands (SRLs) should be strictly tailored. Current options include new pituitary surgery and/or radiosurgery, or alternative medical treatment with SRLs high dose regimens, pegvisomant (PEG) as monotherapy, or combined therapy with the addition of PEG or cabergoline to SRLs. A new pharmacological approach includes pasireotide, a second-generation SRL approved for patients who do not adequately respond to surgery and/or for whom surgery is not an option. No reports on efficacy and safety of combined therapy with pasireotide and pegvisomant (PEG) in acromegaly are available. CASE PRESENTATION Here we report the case of a 41-year-old acromegalic man with a mixed GH/PRL pituitary adenoma post-surgical resistant to first-generation SRLs both alone and in combination with cabergoline and PEG who achieved biochemical and tumor control with the combined triple treatment with pasireotide, PEG and cabergoline without adverse events and with a good compliance to treatment. CONCLUSIONS Twelve months of therapy with pasireotide, PEG and cabergoline proved to be safe and effective in this particular patient and the clinical improvement of disease resulted in an improved compliance to treatment.
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Affiliation(s)
- A. Ciresi
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
| | - S. Radellini
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
| | - V. Guarnotta
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
| | - C. Giordano
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
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167
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Lacroix A, Gu F, Gallardo W, Pivonello R, Yu Y, Witek P, Boscaro M, Salvatori R, Yamada M, Tauchmanova L, Roughton M, Ravichandran S, Petersenn S, Biller BMK, Newell-Price J. Efficacy and safety of once-monthly pasireotide in Cushing's disease: a 12 month clinical trial. Lancet Diabetes Endocrinol 2018; 6:17-26. [PMID: 29032078 DOI: 10.1016/s2213-8587(17)30326-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/25/2017] [Accepted: 09/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cushing's disease is a rare debilitating endocrine disorder for which few prospective interventional studies have been done. We report results of the first phase 3 trial assessing long-acting intramuscular pasireotide in patients with Cushing's disease. METHODS In this phase 3 clinical trial we recruited patients aged 18 years or older with persistent, recurrent, or de-novo (non-surgical candidates) Cushing's disease who had a mean urinary free cortisol (mUFC) concentration (from three 24 h samples) of 1·5-5·0 times the upper limit of normal (ULN), a normal or greater than normal morning plasma adrenocorticotropic hormone concentration, and a pituitary source of Cushing's syndrome, from 57 sites across 19 countries. Exclusion criteria included previous pasireotide treatment, mitotane therapy within 6 months, and pituitary irradiation within 10 years. We randomly allocated patients 1:1 (block size of four) using an interactive-response-technology system to intramuscular pasireotide 10 mg or 30 mg every 4 weeks for 12 months (in the core phase). We stratified randomisation by screening mUFC concentration (1·5 to <2·0 × ULN and 2·0-5·0 × ULN). The dose could be uptitrated (from 10 mg to 30 mg or from 30 mg to 40 mg) at month 4 if the mUFC concentration was greater than 1·5 × ULN, and at month 7, month 9, or month 12 if the mUFC concentration was greater than 1·0 × ULN. Investigators, patients, site personnel, and those assessing outcomes were masked to dose group allocation. The primary endpoint was the proportion of patients in each group with an mUFC concentration of less than or equal to the ULN at month 7. Efficacy analyses were based on intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01374906. FINDINGS Between Dec 28, 2011, and Dec 9, 2014, we randomly allocated 150 patients to receive pasireotide 10 mg (74 [49%] patients) or 30 mg (76 [51%] patients). The primary efficacy endpoint was met by 31 (41·9% [95% CI 30·5-53·9]) of 74 patients in the 10 mg group and 31 (40·8% [29·7-52·7]) of 76 in the 30 mg group. The most common adverse events were hyperglycaemia (36 [49%] in the 10 mg group and 36 [47%] in the 30 mg group), diarrhoea (26 [35%] and 33 [43%]), cholelithiasis (15 [20%] and 34 [45%]), diabetes mellitus (14 [19%] and 18 [24%]), and nausea (15 [20%] and 16 [21%]). Serious adverse events suspected to be study drug related were reported in eight (11%) patients in the 10 mg group and four (5%) in the 30 mg group. Two (3%) patients in the 30 mg group died during the study (pulmonary artery thrombosis and cardiorespiratory failure); neither death was judged to be related to the study drug. INTERPRETATION Long-acting pasireotide normalised mUFC concentration in about 40% of patients with Cushing's disease at month 7 and had a similar safety profile to that of twice-daily subcutaneous pasireotide. Long-acting pasireotide is an efficacious treatment option for some patients with Cushing's disease who have persistent or recurrent disease after initial surgery or are not surgical candidates, and provides a convenient monthly administration schedule. FUNDING Novartis Pharma AG.
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Affiliation(s)
- André Lacroix
- Division of Endocrinology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
| | - Feng Gu
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
| | - Wilson Gallardo
- Endocrinology Service, Hospital Guillermo Almenara, Lima, Peru
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Naples, Italy
| | - Yerong Yu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Przemysław Witek
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes and Metabolism and Pituitary Center, Johns Hopkins University, Baltimore, MD, USA
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University, Maebashi, Gunma, Japan
| | | | | | | | | | - Beverly M K Biller
- Neuroendocrine Clinical Center, Massachusetts General Hospital, Boston, MA, USA
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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Ferraù F, Albani A, Ciresi A, Giordano C, Cannavò S. Diabetes Secondary to Acromegaly: Physiopathology, Clinical Features and Effects of Treatment. Front Endocrinol (Lausanne) 2018; 9:358. [PMID: 30034367 PMCID: PMC6043782 DOI: 10.3389/fendo.2018.00358] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/13/2018] [Indexed: 12/18/2022] Open
Abstract
Acromegaly is a rare disease due to chronic GH excess and to the consequent increase in IGF-1 levels. Both GH and IGF-1 play a role in intermediate metabolism affecting glucose homeostasis. Indeed, chronic GH excess impairs insulin sensitivity, increases gluconeogenesis, reduces the glucose uptake in adipose tissue and muscle and alters pancreatic β cells function. As a consequence, glucose metabolism alterations are a very frequent complication in acromegaly patients, further contributing to the increased cardiovascular risk and mortality. Treatment modalities of acromegaly differently impact on glucose tolerance. Successful surgical treatment of acromegaly ameliorates glucose metabolism abnormalities. Drugs used to treat acromegaly patients may per se affect glucose homeostasis, therefore influencing patients' management. Indeed pegvisomant has been shown to positively impact on glucose metabolism, while somatostatin analogs, especially pasireotide, can cause hyperglycaemia. On the other hand, robust data on the effect of dopamine agonists on glycaemic profile are still lacking. This review summarizes the available data on diabetes mellitus in acromegaly patients, with a focus on the potential effects of the medical treatment of the disease on glucose homeostasis, providing an overview of the current state of the art.
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Affiliation(s)
- Francesco Ferraù
- Department of Human Pathology of Adulthood and Childhood ‘G. Barresi', University of Messina, Messina, Italy
- *Correspondence: Francesco Ferraù
| | - Adriana Albani
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Ciresi
- Section of Endocrinology, Diabetology and Metabolism, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolism, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - Salvatore Cannavò
- Department of Human Pathology of Adulthood and Childhood ‘G. Barresi', University of Messina, Messina, Italy
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169
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Paragliola RM, Salvatori R. Novel Somatostatin Receptor Ligands Therapies for Acromegaly. Front Endocrinol (Lausanne) 2018; 9:78. [PMID: 29563895 PMCID: PMC5845985 DOI: 10.3389/fendo.2018.00078] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/20/2018] [Indexed: 12/21/2022] Open
Abstract
Surgery is considered the treatment of choice in acromegaly, but patients with persistent disease after surgery or in whom surgery cannot be considered require medical therapy. Somatostatin receptor ligands (SRLs) octreotide (OCT), lanreotide, and the more recently approved pasireotide, characterized by a broader receptor ligand binding profile, are considered the mainstay in the medical management of acromegaly. However, in the attempt to offer a more efficacious and better tolerated medical approach, recent research has been aimed to override some limitations related to the use of currently approved drugs and novel SRLs therapies, with potential attractive features, have been proposed. These include both new formulation of older molecules and new molecules. Novel OCT formulations are aimed in particular to improve patients' compliance and to reduce injection discomfort. They include an investigational ready-to-use subcutaneous depot OCT formulation (CAM2029), delivered via prefilled syringes and oral OCT that uses a "transient permeability enhancer" technology, which allows for OCT oral absorption. Another new delivery system is a long-lasting OCT implant (VP-003), which provide stable doses of OCT throughout a period of several months. Finally, a new SRL DG3173 (somatoprim) seems to be more selective for GH secretion, suggesting possible advantages in the presence of hyperglycemia or diabetes. How much these innovations will actually be beneficial to acromegaly patients in real clinical practice remains to be seen.
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Affiliation(s)
| | - Roberto Salvatori
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, Pituitary Center Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Roberto Salvatori,
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170
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Weiss J, Wood AJ, Zajac JD, Grossmann M, Andrikopoulos S, Ekinci EI. Diabetic ketoacidosis in acromegaly; a rare complication precipitated by corticosteroid use. Diabetes Res Clin Pract 2017; 134:29-37. [PMID: 28951345 DOI: 10.1016/j.diabres.2017.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/16/2017] [Accepted: 08/30/2017] [Indexed: 11/29/2022]
Abstract
Diabetic ketoacidosis has been described in the literature as a rare possible initial presentation of acromegaly before a diagnosis of acromegaly is eventually made. Indeed, diabetic ketoacidosis is a recognised complication of acromegaly. There are a number of factors that can predispose patients with acromegaly to diabetes as well as to diabetic ketoacidosis. These include high levels of growth hormone and insulin-like growth factor 1 in acromegaly and the effect on glycaemia by medications used in the management of acromegaly. Ketoacidosis has been described in patients with acromegaly even without the presence of an underlying autoimmune diabetes. Patients with acromegaly and ketoacidosis often respond to treatment and may not require long-term insulin.
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Affiliation(s)
- Jeremy Weiss
- Department of Endocrinology, Austin Health, Level 2 Centaur Building, Repatriation Campus Heidelberg West, Victoria 3084, Australia
| | - Anna J Wood
- Department of Endocrinology, Austin Health, Level 2 Centaur Building, Repatriation Campus Heidelberg West, Victoria 3084, Australia
| | - Jeffrey D Zajac
- Department of Endocrinology, Austin Health, Level 2 Centaur Building, Repatriation Campus Heidelberg West, Victoria 3084, Australia; Department of Medicine, Austin Health and the University of Melbourne (Austin Campus), Parkville, VIC 3010, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Level 2 Centaur Building, Repatriation Campus Heidelberg West, Victoria 3084, Australia
| | - Sofianos Andrikopoulos
- Department of Medicine, Austin Health and the University of Melbourne (Austin Campus), Parkville, VIC 3010, Australia
| | - Elif I Ekinci
- Department of Endocrinology, Austin Health, Level 2 Centaur Building, Repatriation Campus Heidelberg West, Victoria 3084, Australia; Department of Medicine, Austin Health and the University of Melbourne (Austin Campus), Parkville, VIC 3010, Australia.
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171
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Salvatori R, Gordon MB, Woodmansee WW, Ioachimescu AG, Carver DW, Mirakhur B, Cox D, Molitch ME. A multicenter, observational study of lanreotide depot/autogel (LAN) in patients with acromegaly in the United States: 2-year experience from the SODA registry. Pituitary 2017; 20:605-618. [PMID: 28741071 DOI: 10.1007/s11102-017-0821-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE This analysis evaluates the 2-year effectiveness and safety of lanreotide depot/autogel (LAN), as well as treatment convenience and acromegaly symptom relief, from the Somatuline® Depot for Acromegaly (SODA) registry, a post-marketing, open-label, observational, multicenter, United States registry study. METHODS Patients with acromegaly treated with LAN were eligible for enrollment. Demographics, LAN dose, extended dosing interval (EDI) (interval of injections ≥42 days), insulin-like growth factor 1 (IGF-1), growth hormone (GH), glycated hemoglobin, adverse events (AEs), injection convenience, and symptom data were collected. RESULTS As of September 29, 2014, 241 patients were enrolled in SODA. IGF-1 levels below age- and gender-adjusted upper normal limit (ULN) were achieved in 71.2% at month (M) 12 and 74.4% at M24; GH ≤2.5 µg/L in 83.3% at M12 and 80.0% at M24; GH <1.0 µg/L in 61.7% at M12 and 61.4% at M24. Both IGF-1 < ULN and GH ≤2.5 µg/L were achieved in 65.0% at M12 and 54.8% at M24; both IGF-1 < ULN and GH < 1.0 µg/L were achieved in 51.7 and 42.9% at M12 and M24, respectively. EDI regimen was 5.0% at baseline and 12.0% at M24. At M24, acromegaly symptoms appeared stable or improved. The most common AE was arthralgia (25.7%). Among 106 serious AEs reported by 42 patients, 10 were deemed related to therapy in 9 patients. At M24, 73.1% of patients rated LAN as convenient. CONCLUSIONS SODA indicates 2-year biochemical control with majority of patients achieving both IGF-1 < ULN and GH ≤2.5 µg/L. LAN was generally well tolerated with no new or unexpected safety signals reported during the observation period. clinicaltrials.gov Clinical Trial Identifier: NCT00686348.
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Affiliation(s)
- Roberto Salvatori
- Division of Endocrinology, Diabetes and Metabolism, and Pituitary Center, Johns Hopkins University, 1830 East Monument Street #333, Baltimore, MD, 21287, USA.
| | - Murray B Gordon
- Allegheny Neuroendocrinology Center, Division of Endocrinology, Allegheny General Hospital, 420 E North Avenue, Suite 205, Pittsburgh, PA, 15212, USA
| | - Whitney W Woodmansee
- Division of Endocrinology, Diabetes and Hypertension, Brigham's and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Adriana G Ioachimescu
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Department of Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road, NE, B6209, Atlanta, GA, 30322, USA
| | - Don W Carver
- Ipsen Biopharmaceuticals, Inc. Statistician Consultant, 106 Allen Road, Basking Ridge, NJ, 07920, USA
| | - Beloo Mirakhur
- Medical Affairs, Ipsen Biopharmaceuticals, Inc., 106 Allen Road, Basking Ridge, NJ, 07920, USA
| | - David Cox
- Medical Affairs, Ipsen Biopharmaceuticals, Inc., 106 Allen Road, Basking Ridge, NJ, 07920, USA
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, IL, 60611, USA
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Tritos NA. Recent advances in medical therapies for pituitary adenomas. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017. [DOI: 10.2217/ije-2017-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Nicholas A Tritos
- Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
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173
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Farb TB, Adeva M, Beauchamp TJ, Cabrera O, Coates DA, Meredith TD, Droz BA, Efanov A, Ficorilli JV, Gackenheimer SL, Martinez-Grau MA, Molero V, Ruano G, Statnick MA, Suter TM, Syed SK, Toledo MA, Willard FS, Zhou X, Bokvist KB, Barrett DG. Regulation of Endogenous (Male) Rodent GLP-1 Secretion and Human Islet Insulin Secretion by Antagonism of Somatostatin Receptor 5. Endocrinology 2017; 158:3859-3873. [PMID: 28938487 DOI: 10.1210/en.2017-00639] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/06/2017] [Indexed: 12/25/2022]
Abstract
Incretin and insulin responses to nutrient loads are suppressed in persons with diabetes, resulting in decreased glycemic control. Agents including sulfonylureas and dipeptidyl peptidase-4 inhibitors (DPP4i) partially reverse these effects and provide therapeutic benefit; however, their modes of action limit efficacy. Because somatostatin (SST) has been shown to suppress insulin and glucagonlike peptide-1 (GLP-1) secretion through the Gi-coupled SST receptor 5 (SSTR5) isoform in vitro, antagonism of SSTR5 may improve glycemic control via intervention in both pathways. Here, we show that a potent and selective SSTR5 antagonist reverses the blunting effects of SST on insulin secretion from isolated human islets, and demonstrate that SSTR5 antagonism affords increased levels of systemic GLP-1 in vivo. Knocking out Sstr5 in mice provided a similar increase in systemic GLP-1 levels, which were not increased further by treatment with the antagonist. Treatment of mice with the SSTR5 antagonist in combination with a DPP4i resulted in increases in systemic GLP-1 levels that were more than additive and resulted in greater glycemic control compared with either agent alone. In isolated human islets, the SSTR5 antagonist completely reversed the inhibitory effect of exogenous SST-14 on insulin secretion. Taken together, these data suggest that SSTR5 antagonism should increase circulating GLP-1 levels and stimulate insulin secretion (directly and via GLP-1) in humans, improving glycemic control in patients with diabetes.
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Affiliation(s)
- Thomas B Farb
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Marta Adeva
- Centro de Investigacion Lilly, Eli Lilly and Company, 28108-Alcobendas, Madrid, Spain
| | - Thomas J Beauchamp
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Over Cabrera
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - David A Coates
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | | | - Brian A Droz
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Alexander Efanov
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - James V Ficorilli
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | | | - Maria A Martinez-Grau
- Centro de Investigacion Lilly, Eli Lilly and Company, 28108-Alcobendas, Madrid, Spain
| | - Victoriano Molero
- Centro de Investigacion Lilly, Eli Lilly and Company, 28108-Alcobendas, Madrid, Spain
| | - Gema Ruano
- Centro de Investigacion Lilly, Eli Lilly and Company, 28108-Alcobendas, Madrid, Spain
| | - Michael A Statnick
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Todd M Suter
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Samreen K Syed
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Miguel A Toledo
- Centro de Investigacion Lilly, Eli Lilly and Company, 28108-Alcobendas, Madrid, Spain
| | - Francis S Willard
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Xin Zhou
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - Krister B Bokvist
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
| | - David G Barrett
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285
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174
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Mazziotti G, Mosca A, Frara S, Vitale G, Giustina A. Somatostatin analogs in the treatment of neuroendocrine tumors: current and emerging aspects. Expert Opin Pharmacother 2017; 18:1679-1689. [PMID: 29067877 DOI: 10.1080/14656566.2017.1391217] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neuroendocrine tumors (NETs) harbor somatostatin receptors and there is a strong rationale for using somatostatin analogs (SSAs) for treatment of NETs. Areas covered: This article discusses i) pharmacology of somatostatin and its analogs; ii) antisecretory and anti-proliferative effects of SSAs in NETs; iii) efficacy and safety of emerging therapeutic regimens with first generation SSAs administered at either high doses or in combination with antineoplastic drugs; iv) efficacy and safety of pasireotide and chimeric molecules; v) efficacy of radionuclide therapy of NETs using SSAs. Expert opinion: SSAs are the first-line medical therapy for functioning and non-functioning well-differentiated NETs. In patients not responder to first generation SSAs, the increase of drug dose over the conventional regimens, the combination of SSAs with other biotherapies or molecular targeted therapies, the switch to pasireotide or the use of SSAs in radionuclide therapy may improve the therapeutic success.
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Affiliation(s)
| | - Alessandra Mosca
- b Medical Oncology , 'Maggiore della Carità' University Hospital , Novara , Italy
| | - Stefano Frara
- c Chair of Endocrinology , San Raffaele Vita-Salute University , Milan , Italy
| | - Giovanni Vitale
- d Department of Clinical Sciences and Community Health (DISCCO) , University of Milan , Milan , Italy.,e Laboratory of Geriatric and Oncologic Neuroendocrinology Research , Istituto Auxologico Italiano IRCCS , Milan , Italy
| | - Andrea Giustina
- c Chair of Endocrinology , San Raffaele Vita-Salute University , Milan , Italy
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175
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Petersenn S, Christ-Crain M, Droste M, Finke R, Flitsch J, Kreitschmann-Andermahr I, Luger A, Schopohl J, Stalla G. [Diagnostics and treatment of acromegaly : Necessity for targeted monitoring of comorbidities]. Internist (Berl) 2017; 58:1171-1182. [PMID: 29027568 DOI: 10.1007/s00108-017-0331-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acromegaly is a rare and severe condition, presenting with typical signs and symptoms. The diagnosis is often initially made years after the first manifestations of the disease. In more than 99% of patients the disease is caused by a benign pituitary tumor that secretes growth hormone (GH). The diagnosis is based on the presence of increased insulin-like growth factor 1 (IGF-1) levels and a lack of GH suppression in the oral glucose tolerance test. The standard imaging procedure for tumor detection is magnetic resonance imaging in the region of the sella turcica. Treatment includes surgical, drug and radiation therapy. Important factors are an intensive aftercare of the patient, controls for detection of tumor recurrence and pituitary insufficiency as well as assessment of various organ functions and risk constellations. Patient care should involve close cooperation between endocrinologists, neurosurgeons and general practitioners as well as other specialist disciplines.
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Affiliation(s)
- S Petersenn
- ENDOC Praxis für Endokrinologie, Andrologie und medikamentöse Tumortherapie, Erik-Blumenfeld-Platz 27A, 22587, Hamburg, Deutschland.
| | - M Christ-Crain
- Endokrinologie, Diabetologie & Metabolismus, Universitätsspital Basel, Basel, Schweiz
| | - M Droste
- Endokrinologie, Diabetologie, Hormonanalytik, Medicover MVZ, Oldenburg, Deutschland
| | - R Finke
- Innere Medizin, Endokrinologie/Diabetologie & Allgemeinmedizin, Praxisgemeinschaft an der Kaisereiche, Berlin, Deutschland
| | - J Flitsch
- Klinik und Poliklinik für Neurochirurgie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - I Kreitschmann-Andermahr
- Neurochirurgische Klinik, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - A Luger
- Klinische Abteilung für Endokrinologie & Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - J Schopohl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Deutschland
| | - G Stalla
- Innere Medizin, Endokrinologie und Klinische Chemie, Max-Planck-Institut für Psychiatrie, München, Deutschland
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176
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Tarasco E, Seebeck P, Pfundstein S, Daly AF, Eugster PJ, Harris AG, Grouzmann E, Lutz TA, Boyle CN. Effect of AP102, a subtype 2 and 5 specific somatostatin analog, on glucose metabolism in rats. Endocrine 2017; 58:124-133. [PMID: 28822091 DOI: 10.1007/s12020-017-1386-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/26/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Somatostatin analogs are widely used to treat conditions associated with hormonal hypersecretion such as acromegaly and metastatic neuroendocrine tumors. First generation somatostatin analogs, such as octreotide and lanreotide, have high affinity for somatostatin receptor subtype 2 (SSTR2), but have incomplete efficacy in many patients. Pasireotide targets multiple SSTRs, having the highest affinity for SSTR5, but causes hyperglycemia and diabetes mellitus in preclinical and clinical studies. AP102 is a new somatostatin analogs with high affinity at both SSTR2 and SSTR5. We aimed to characterize the effects of AP102 vs. pasireotide on random and dynamic glucose levels, glucoregulatory hormone concentrations and growth axis measures in healthy Sprague-Dawley rats. METHODS Three doses of each compound were evaluated under acute conditions (1, 10, and 30 µg/kg s.c.), and two doses during a chronic (4-week) infusion (3 and 10 µg/kg/h s.c.). RESULTS Neither acute nor chronic AP102 administration altered blood glucose concentrations or dynamic responses following an intraperitoneal glucose tolerance test. In contrast, acute and chronic pasireotide dosing increased random and post-intraperitoneal glucose tolerance test blood glucose measures, compared to vehicle-treated controls. Both AP102 and pasireotide acutely suppressed growth hormone levels, although insulin-like growth factor-1 and somatic growth was suppressed to a greater extent with pasireotide. CONCLUSIONS AP102 is a new dual SSTR2/SSTR5-specific somatostatin analog that acutely reduces growth hormone but does not cause hyperglycemia during acute or chronic administration in a healthy rat model. Further studies in diabetic animals and in humans are necessary to determine the potential utility of AP102 in the clinical setting.
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Affiliation(s)
- Erika Tarasco
- Institute of Veterinary Physiology, Vetsuisse Faculty, University of Zurich, 8057, Zurich, Switzerland
- Zurich Centre for Integrative Human Physiology, University of Zurich, 8057, Zurich, Switzerland
| | - Petra Seebeck
- Zurich Integrative Rodent Physiology (ZIRP), University of Zurich, 8057, Zurich, Switzerland
| | - Svende Pfundstein
- Zurich Integrative Rodent Physiology (ZIRP), University of Zurich, 8057, Zurich, Switzerland
| | - Adrian F Daly
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium
| | - Philippe J Eugster
- Laboratoire des Catecholamines et Peptides, Service de Biomédecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Alan G Harris
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, Liège, Belgium
| | - Eric Grouzmann
- Laboratoire des Catecholamines et Peptides, Service de Biomédecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thomas A Lutz
- Institute of Veterinary Physiology, Vetsuisse Faculty, University of Zurich, 8057, Zurich, Switzerland
- Zurich Centre for Integrative Human Physiology, University of Zurich, 8057, Zurich, Switzerland
| | - Christina N Boyle
- Institute of Veterinary Physiology, Vetsuisse Faculty, University of Zurich, 8057, Zurich, Switzerland.
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177
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Drugs and hyperglycemia: A practical guide. Maturitas 2017; 104:80-83. [PMID: 28923179 DOI: 10.1016/j.maturitas.2017.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/02/2017] [Accepted: 08/04/2017] [Indexed: 12/30/2022]
Abstract
Drug-induced diabetes is one of the factors contributing to the increasing incidence of diabetes worldwide. This review considers the frequency, pathogenesis and treatment of drug-induced diabetes. Drugs that induce diabetes include hormonal therapy, especially glucocorticoids and androgen blockers, cardiovascular drugs, especially statins, beta-blockers and diuretics, antipsychotics, especially clozapine, olanzapine and quetiapine, antiretrovirals (protease inhibitors and non-reverse transcriptase inhibitors - NRTIs) and other drugs (mechanistic target of rapamycin inhibitors -mTORs, post organ transplantation drugs, tyrosine kinase inhibitors and interferon-alpha). Abnormalities of the distal gluco-regulatory pathways of hyperglycemia involve decreased insulin secretion and frequent insulin resistance, whereas the proximal defects are unknown, thus limiting targeted treatment. Drug-induced diabetes is potentially reversible and the risk is underestimated. There is little information on its long-term effects on microvascular complications as clinical trials have not been long enough and neither have they focused on these factors. Overall management includes awareness of a drug's diabetogenic potential, underlying diabetes risk, benefits and risks of continuing vs discontinuing the drug, plus a consideration of drug duration and dose. While diabetes and its severity can be identified and controlled, the likelihood of future diabetes complications frequently cannot. This, balanced against the predicted benefit of the drug, results in clinical uncertainty. Empirical approaches to drug-related hyperglycemia include decreasing the dose or selecting an alternative treatment, if possible. In the absence of drug-specific evidence, treatment of drug-induced hyperglycemia and diabetes is similar to comprehensive standard diabetes care, including lifestyle modifications, oral/injectable antidiabetic agents and insulin. Important clinical considerations include surveillance of glucose before and during treatment and, in some cases, institution of diabetes preventive measures like lifestyle modification and early treatment. Future research is needed to elucidate pathophysiology and optimal targeted treatment for drug-induced diabetes and its long-term complications.
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178
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Tahara S, Murakami M, Kaneko T, Shimatsu A. Efficacy and safety of long-acting pasireotide in Japanese patients with acromegaly or pituitary gigantism: results from a multicenter, open-label, randomized, phase 2 study. Endocr J 2017; 64:735-747. [PMID: 28592706 DOI: 10.1507/endocrj.ej16-0624] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A multicenter, open-label, phase 2 study was conducted to investigate the efficacy and safety of long-acting pasireotide formulation in Japanese patients with acromegaly or pituitary gigantism. Medically naïve or inadequately controlled patients (on somatostatin analogues or dopamine agonists) were included. Primary end point was the proportion of all patients who achieved biochemical control (mean growth hormone [GH] levels<2.5μg/L and normalized insulin-like growth factor-1 [IGF-1]) at month 3. Thirty-three patients (acromegaly, n=32; pituitary gigantism, n=1) were enrolled and randomized 1:1:1 to receive open-label pasireotide 20mg, 40mg, or 60mg. The median age was 52 years (range, 31-79) and 20 patients were males. At month 3, 18.2% of patients (6/33; 90% confidence interval: 8.2%, 32.8%) had biochemical control (21.2% [7/33] when including a patient with mean GH<2.5μg/L and IGF-1< lower limit of normal). Reductions in the median GH and IGF-1 levels observed at month 3 were maintained up to month 12; the median percent change from baseline to month 12 in GH and IGF-1 levels were -74.71% and -59.33%, respectively. Twenty-nine patients completed the 12-month core phase, 1 withdrew consent, and 3 discontinued treatment due to adverse events (AEs; diabetes mellitus, hyperglycemia, liver function abnormality, n=1 each). Almost all patients (97%; 32/33) experienced AEs; the most common AEs were nasopharyngitis (48.5%), hyperglycemia (42.4%), diabetes mellitus (24.2%), constipation (18.2%), and hypoglycemia (15.2%). Serious AEs were reported in 7 patients with the most common being hyperglycemia (n=2). Long-acting pasireotide demonstrated clinically relevant efficacy and was well tolerated in Japanese patients with acromegaly or pituitary gigantism.
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Affiliation(s)
- Shigeyuki Tahara
- Department of Neurosurgery, Nippon Medical School, Tokyo 113-8602, Japan
| | - Mami Murakami
- Oncology development & Medical affairs, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Tomomi Kaneko
- Oncology development & Medical affairs, Novartis Pharma K.K., Tokyo 105-6333, Japan
| | - Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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179
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Amarawardena WKMG, Liyanarachchi KD, Newell-Price JDC, Ross RJM, Iacovazzo D, Debono M. Pasireotide: successful treatment of a sparsely granulated tumour in a resistant case of acromegaly. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170067. [PMID: 28721221 PMCID: PMC5510455 DOI: 10.1530/edm-17-0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/22/2017] [Indexed: 02/03/2023] Open
Abstract
The granulation pattern of somatotroph adenomas is well known to be associated with differing clinical and biochemical characteristics, and it has been shown that sparsely granulated tumours respond poorly to commonly used somatostatin receptor ligands (SRLs). We report a challenging case of acromegaly with a sparsely granulated tumour resistant to multiple modalities of treatment, ultimately achieving biochemical control with pasireotide. A 26-year-old lady presented with classical features of acromegaly, which was confirmed by an oral glucose tolerance test. Insulin-like growth factor 1 (IGF1) was 1710 µg/L (103–310 µg/L) and mean growth hormone (GH) was >600 U/L. MRI scan showed a 4 cm pituitary macroadenoma with suprasellar extension and right-sided cavernous sinus invasion. She underwent trans-sphenoidal pituitary surgery. Histology displayed moderate amounts of sparsely granular eosinophilic cytoplasm, staining only for GH. Postoperative investigations showed uncontrolled disease (IGF1:1474 µg/L, mean GH:228 U/L) and residual tumour in the cavernous sinus. She received external beam fractionated radiation. Over the years, she received octreotide LAR (up to 30 mg), lanreotide (up to 120 mg) two weekly, cabergoline, pegvisomant and stereotactic radiosurgery to no avail. Only pegvisomant resulted in an element of disease control; however, this had to be stopped due to abnormal liver function tests. Fifteen years after the diagnosis, she was started on pasireotide 40 mg monthly. Within a month, her IGF1 dropped and has remained within the normal range (103–310 µg/L). Pasireotide has been well tolerated, and there has been significant clinical improvement. Somatostatin receptor subtyping revealed a positivity score of two for both sst5 and sst2a subtypes.
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Affiliation(s)
- W K M G Amarawardena
- Department of Oncology and Metabolism, University of Sheffield, SheffieldUK.,Department of Endocrinology, Royal Hallamshire Hospital, University of Sheffield, SheffieldUK
| | - K D Liyanarachchi
- Department of Oncology and Metabolism, University of Sheffield, SheffieldUK.,Department of Endocrinology, Royal Hallamshire Hospital, University of Sheffield, SheffieldUK
| | - J D C Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, SheffieldUK.,Department of Endocrinology, Royal Hallamshire Hospital, University of Sheffield, SheffieldUK
| | - R J M Ross
- Department of Oncology and Metabolism, University of Sheffield, SheffieldUK
| | - D Iacovazzo
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, LondonUK
| | - M Debono
- Department of Endocrinology, Royal Hallamshire Hospital, University of Sheffield, SheffieldUK
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180
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Giustina A, Mazziotti G, Cannavò S, Castello R, Arnaldi G, Bugari G, Cozzi R, Ferone D, Formenti AM, Gatti E, Grottoli S, Maffei P, Maffezzoni F, Montini M, Terzolo M, Ghigo E. High-Dose and High-Frequency Lanreotide Autogel in Acromegaly: A Randomized, Multicenter Study. J Clin Endocrinol Metab 2017; 102:2454-2464. [PMID: 28419317 DOI: 10.1210/jc.2017-00142] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 04/12/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT Increase in drug frequency or dose is recommended for acromegaly patients with partial response to long-acting somatostatin receptor ligands (SRLs). However, the efficacy and safety data with lanreotide (LAN) Autogel (LAN-ATG) at high dose (HD) or high frequency (HF) are still scanty. OBJECTIVE To evaluate the biochemical efficacy and safety of HF and HD LAN-ATG in patients with active acromegaly. DESIGN Twenty-four-week prospective, multicenter, randomized, open-label trial. PATIENTS AND INTERVENTIONS Thirty patients with active acromegaly, partial responders to SRLs, were randomized to HF (120 mg/21 days; 15 patients) or HD (180 mg/28 days; 15 patients) LAN-ATG. OUTCOMES Normalization of serum insulin-like growth factor-I (IGF-I) and reduction in random growth hormone (GH) values < 1.0 µg/L, reduction in serum IGF-I and GH from baseline, differences in biochemical response between HF and HD LAN-ATG, adverse events. RESULTS IGF-I decreased significantly (P = 0.007) during the 24-week treatment, with greater decrease in HD (P = 0.03) vs HF group (P = 0.08). Normalization in IGF-I values occurred in 27.6% of patients (P = 0.016 vs baseline), without a significant difference between HF and HD groups (P = 0.59). The decrease in serum IGF-I significantly correlated with serum LAN values (P = 0.04), and normalization of IGF-I was predicted by baseline IGF-I values (P = 0.02). Serum GH values did not change significantly (P = 0.22). Overall, 19 patients (63.3%) experienced adverse events, all being mild to moderate and transient, without differences between the two therapeutic arms. CONCLUSION HF and HD LAN-ATG regimens are effective in normalizing IGF-I values in about one-third of patients with active acromegaly inadequately controlled by long-term conventional SRLs therapy.
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Affiliation(s)
- Andrea Giustina
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Gherardo Mazziotti
- Endocrinology Unit, Azienda Socio Sanitaria Territoriale Carlo Poma, 46100 Mantova, Italy
| | | | - Roberto Castello
- Division of General Medicine, Azienda Ospedaliera Universitaria Integrata, 37126 Verona, Italy
| | - Giorgio Arnaldi
- Division of Endocrinology, Azienda Ospedaliera Universitaria Ospedali Riuniti, 60126 Ancona, Italy
| | - Giovanna Bugari
- Laboratory of Chemical Analysis, Azienda Socio Sanitaria Territoriale Spedali Civili, 25126 Brescia, Italy
| | - Renato Cozzi
- Division of Endocrinology, Ospedale Niguarda, 20162 Milan, Italy
| | - Diego Ferone
- Endocrinology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliera Universitaria San Martino-Istituto dei Tumori, University of Genoa, 16132 Genoa, Italy
| | - Anna Maria Formenti
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Enza Gatti
- Neuroradiology, University of Brescia, 25123 Brescia, Italy
| | - Silvia Grottoli
- Division of Endocrinology and Metabolism, University of Turin, 10126 Turin, Italy
| | - Pietro Maffei
- Department of Medicine, Padua University Hospital, 35121 Padua, Italy
| | - Filippo Maffezzoni
- Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | | | | | - Ezio Ghigo
- Division of Endocrinology and Metabolism, University of Turin, 10126 Turin, Italy
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181
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Christiansen Arlien-Søborg M, Trolle C, Alvarson E, Bæk A, Dal J, Otto Lunde Jørgensen J. Biochemical assessment of disease control in acromegaly: reappraisal of the glucose suppression test in somatostatin analogue (SA) treated patients. Endocrine 2017; 56:589-594. [PMID: 28260207 DOI: 10.1007/s12020-017-1258-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is recommended not to measure growth hormone during oral glucose suppression (oral glucose tolerance test) during somatostatin analog treatment in acromegaly. However, we have observed that failure to suppress growth hormone in response to oral glucose tolerance test during somatostatin analog unmasks insufficient disease control and hypothesize that somatostatin analog also induces insufficient growth hormone suppression to mixed meals. METHODS We therefore compared serum growth hormone levels during two mixed meals in patients with controlled insulin-like growth factor-I levels after either surgery alone (n = 9) or somatostatin analog treatment (n = 9). The patients were unbiasedly matched for gender and insulin-like growth factor-I and studied twice in the following order: (1) during a 6 h growth hormone day curve including two mixed meals and (2) during a 3 h growth hormone profile including 60 min fasting followed by a 2-h oral glucose tolerance test. RESULTS During the day curve growth hormone levels were elevated in the somatostatin analog group (P = 0.008) and growth hormone levels 1 h after each meal declined significantly only in the surgery group (P = 0.02). During the oral glucose tolerance test the two groups had similar growth hormone levels prior to the glucose load (P = 0.6), whereas a significant 66% suppression was observed after glucose only in the surgery group (P = 0.001). CONCLUSIONS (1) Patients controlled by somatostatin analog fail to suppress growth hormone in response to both mixed meals and oral glucose tolerance test (2) This phenomenon is likely to result in elevated serum growth hormone levels during everyday life in somatostatin analog-treated patients, (3) We postulate that measuring growth hormone levels during oral glucose tolerance test is useful to unmask potential somatostatin analog under-treatment in the presence of 'safe' insulin-like growth factor-I levels.
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Affiliation(s)
- Mai Christiansen Arlien-Søborg
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark.
| | - Christian Trolle
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark
| | - Elin Alvarson
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark
| | - Amanda Bæk
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark
| | - Jakob Dal
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark
| | - Jens Otto Lunde Jørgensen
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, Aarhus C, 8000, Denmark
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182
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Langlois F, McCartney S, Fleseriu M. Recent Progress in the Medical Therapy of Pituitary Tumors. Endocrinol Metab (Seoul) 2017; 32:162-170. [PMID: 28685507 PMCID: PMC5503860 DOI: 10.3803/enm.2017.32.2.162] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 12/11/2022] Open
Abstract
Management of pituitary tumors is multidisciplinary, with medical therapy playing an increasingly important role. With the exception of prolactin-secreting tumors, surgery is still considered the first-line treatment for the majority of pituitary adenomas. However, medical/pharmacological therapy plays an important role in controlling hormone-producing pituitary adenomas, especially for patients with acromegaly and Cushing disease (CD). In the case of non-functioning pituitary adenomas (NFAs), pharmacological therapy plays a minor role, the main objective of which is to reduce tumor growth, but this role requires further studies. For pituitary carcinomas and atypical adenomas, medical therapy, including chemotherapy, acts as an adjuvant to surgery and radiation therapy, which is often required to control these aggressive tumors. In the last decade, knowledge about the pathophysiological mechanisms of various pituitary adenomas has increased, thus novel medical therapies that target specific pathways implicated in tumor synthesis and hormonal over secretion are now available. Advancement in patient selection and determination of prognostic factors has also helped to individualize therapy for patients with pituitary tumors. Improvements in biochemical and "tumor mass" disease control can positively affect patient quality of life, comorbidities and overall survival. In this review, the medical armamentarium for treating CD, acromegaly, prolactinomas, NFA, and carcinomas/aggressive atypical adenomas will be presented. Pharmacological therapies, including doses, mode of administration, efficacy, adverse effects, and use in special circumstances are provided. Medical therapies currently under clinical investigation are also briefly discussed.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Endocrinology and Metabolism, University of Sherbrooke, Sherbrooke, QC, Canada
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Shirley McCartney
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
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183
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Vergès B. Effects of anti-somatostatin agents on glucose metabolism. DIABETES & METABOLISM 2017; 43:411-415. [PMID: 28579289 DOI: 10.1016/j.diabet.2017.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/05/2017] [Accepted: 05/09/2017] [Indexed: 12/26/2022]
Abstract
The anti-somatostatin agents used to treat acromegaly, Cushing's disease and neuroendocrine tumours also have hyperglycaemic effects. This is particularly true for pasireotide. Hyperglycaemic events are seen in 57-73% of patients with Cushing's treated with pasireotide, with a need to initiate antidiabetic treatment in about 50% of these patients. In acromegaly, treatment with pasireotide induces hyperglycaemia in 29-61% of patients. Pasireotide-induced hyperglycemia occurs early, within the first 3 months of treatment, due to a decrease in insulin secretion secondary to a fall in secretion of GLP-1 and GIP, and potentially also due to a direct inhibitory effect of pasireotide on beta cells. Close monitoring of blood glucose is mandatory in all patients during the first 3 months of treatment with pasireotide. Where necessary, antidiabetic treatment should be initiated, preferably with a DPP-4 inhibitor or a GLP-1 receptor agonist, both of which have proven efficacy in the control of hyperglycaemia induced by pasireotide.
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Affiliation(s)
- B Vergès
- Service d'endocrinologie, diabétologie et maladies métaboliques, hôpital du Bocage, CHU de Dijon, 21000 Dijon, France; Inserm LNC, UMR1231, 21000 Dijon, France.
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Giustina A, Arnaldi G, Bogazzi F, Cannavò S, Colao A, De Marinis L, De Menis E, Degli Uberti E, Giorgino F, Grottoli S, Lania AG, Maffei P, Pivonello R, Ghigo E. Pegvisomant in acromegaly: an update. J Endocrinol Invest 2017; 40:577-589. [PMID: 28176221 PMCID: PMC5443862 DOI: 10.1007/s40618-017-0614-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND In 2007, we published an opinion document to review the role of pegvisomant (PEG) in the treatment of acromegaly. Since then, new evidence emerged on the biochemical and clinical effects of PEG and on its long-term efficacy and safety. AIM We here reviewed the emerging aspects of the use of PEG in clinical practice in the light of the most recent literature. RESULTS The clinical use of PEG is still suboptimal, considering that it remains the most powerful tool to control IGF-I in acromegaly allowing to obtain, with a pharmacological treatment, the most important clinical effects in terms of signs and symptoms, quality of life and comorbidities. The number of patients with acromegaly exposed to PEG worldwide has become quite elevated and the prolonged follow-up allows now to deal quite satisfactorily with many clinical issues including major safety issues, such as the concerns about possible tumour (re)growth under PEG. The positive or neutral impact of PEG on glucose metabolism has been highlighted, and the clinical experience, although limited, with sleep apnoea and pregnancy has been reviewed. Finally, the current concept of somatostatin receptor ligands (SRL) resistance has been addressed, in order to better define the acromegaly patients to whom the PEG option may be offered. CONCLUSIONS PEG increasingly appears to be an effective and safe medical option for many patients not controlled by SRL but its use still needs to be optimized.
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Affiliation(s)
- A Giustina
- Chair of Endocrinology, Vita-Salute San Raffaele University, Milano, Italy.
| | - G Arnaldi
- Clinic of Endocrinology and Metabolism Disease, Ospedali Riuniti di Ancona, Ancona, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - S Cannavò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - A Colao
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - L De Marinis
- Pituitary Unit, Catholic University School of Medicine, Rome, Italy
| | - E De Menis
- Department of Internal Medicine, General Hospital, Montebelluna (TV), Italy
| | - E Degli Uberti
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - F Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - S Grottoli
- Endocrinology, Diabetology and Metabolism, AOU Città della Salute e della Scienza of Turin, Turin, Italy
| | - A G Lania
- Endocrinology Unit, Department of Biomedical Sciences, Humanitas University and Humanitas Research Hospital, Rozzano, Italy
| | - P Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Azienda Ospedaliera Padova, Padova, Italy
| | - R Pivonello
- Department of Clinical and Surgery Medicine, Endocrinology and Metabolism, University of Naples, Naples, Italy
| | - E Ghigo
- Department of Medical Sciences, School of Medicine, University of Turin, Turin, Italy
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185
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Mende KC, Matschke J, Burkhardt T, Saeger W, Buslei R, Buchfelder M, Fahlbusch R, Westphal M, Flitsch J. Pituicytoma-An outlook on possible targeted therapies. CNS Neurosci Ther 2017; 23:620-626. [PMID: 28556544 DOI: 10.1111/cns.12709] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/30/2017] [Accepted: 05/03/2017] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Pituicytoma is a rare neoplasm of the sella region. Tumor resection is the primary treatment option, but remains subtotal due to excessive bleeding in many cases. The search for alternative or additional treatment regimens is necessary. AIMS We aimed to determine the receptor expression of pituicytoma to find alternatives or supplements to surgical therapy in the use of targeted therapies. METHODS Pituicytoma samples were collected from three institutions between 2006 and 2015 and were stained for vascular endothelial growth factors (VEGF), thyroid transcription factor (TTF1), and somatostatin receptors (SSTR 2/3/5). The stains were classified from 0=no staining to +++=strong staining. A complementary retrospective analysis of the patient charts regarding sex, age, and primary symptoms, pituitary function, and perioperative complications was performed. RESULTS Ten samples were analyzed; mean patient age was 57.8 years SD 16.3 years. Seven samples were acquired from male patients (one relapse) and three from female. All tumors stained strongly positive (+++) for VEGF-R. Six samples stained positive for TTF1. As for somatostatin receptors, three samples were slightly positive for SSTR 2; seven were negative. SSTR 3 was + in one, three were ++, three were +++, and three were 0. SSTR 5 stained +++ in 1, ++ in 5, + in 1, and 0 in three patients. CONCLUSIONS Pituicytomas were generally positive for VEGFR and showed regular expression of SSTR 3 and 5 indicating a possible treatment option through targeted therapies in cases where resection remains insufficient. Further research is necessary as to whether tumor growth can be inhibited using these pathways.
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Affiliation(s)
| | - Jakob Matschke
- Institute of Neuropathology, Hamburg University Medical Center, Hamburg, Germany
| | - Till Burkhardt
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, Hamburg University Medical Center, Hamburg, Germany
| | - Rolf Buslei
- Department of Neuropathology, University of Erlangen, Erlangen, Germany
| | | | - Rudolf Fahlbusch
- International Neuroscience Institute Hannover GmbH, Hannover, Germany
| | - Manfred Westphal
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
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186
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Gordon MB, Spiller KL. Pasireotide in an insulin-requiring diabetic acromegalic patient without worsening of hyperglycemia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170003. [PMID: 28567297 PMCID: PMC5445444 DOI: 10.1530/edm-17-0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/18/2017] [Indexed: 11/25/2022] Open
Abstract
Long-acting pasireotide is an effective treatment option for acromegaly, but it is associated with hyperglycemia, which could impact its use in patients with diabetes. We present a case of a 53-year-old man with acromegaly and type 2 diabetes mellitus (glycated hemoglobin (HbA1c): 7.5%), who refused surgery to remove a pituitary macroadenoma and enrolled in a Phase 3 clinical trial comparing long-acting pasireotide and long-acting octreotide in acromegalic patients. The patient initially received octreotide, but insulin-like growth factor 1 (IGF-1) levels remained elevated after 12 months (383.9 ng/mL; 193.0 ng/mL; reference range: 86.5–223.8 ng/mL), indicating uncontrolled acromegaly. He switched to pasireotide 40 mg and subsequently increased to 60 mg. Within 6 months, IGF-1 levels normalized (193.0 ng/mL), and they were mostly normal for the next 62 months of treatment with pasireotide (median IGF-1: 190.7 ng/mL). Additionally, HbA1c levels remained similar to or lower than baseline levels (range, 6.7% to 7.8%) during treatment with pasireotide despite major changes to the patient’s antidiabetic regimen, which included insulin and metformin. Uncontrolled acromegaly can result in hyperglycemia due to an increase in insulin resistance. Despite having insulin-requiring type 2 diabetes, the patient presented here did not experience a long-term increase in HbA1c levels upon initiating pasireotide, likely because long-term control of acromegaly resulted in increased insulin sensitivity. This case highlights the utility of long-acting pasireotide to treat acromegaly in patients whose levels were uncontrolled after long-acting octreotide and who manage diabetes with insulin.
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Affiliation(s)
- Murray B Gordon
- Allegheny Neuroendocrinology Center, Departments of Medicine and Neurosurgery, Allegheny General Hospital, Pittsburgh, PennsylvaniaUSA
| | - Kellie L Spiller
- Allegheny Neuroendocrinology Center, Departments of Medicine and Neurosurgery, Allegheny General Hospital, Pittsburgh, PennsylvaniaUSA
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187
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Treppiedi D, Peverelli E, Giardino E, Ferrante E, Calebiro D, Spada A, Mantovani G. Somatostatin Receptor Type 2 (SSTR2) Internalization and Intracellular Trafficking in Pituitary GH-Secreting Adenomas: Role of Scaffold Proteins and Implications for Pharmacological Resistance. Horm Metab Res 2017; 49:259-268. [PMID: 27632151 DOI: 10.1055/s-0042-116025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractSomatostatin receptor type 2 (SSTR2), together with SSTR5, represents the main
target of medical treatment for growth hormone (GH)-secreting pituitary tumors,
since it is expressed in most of these tumors and exerts both antiproliferative
and cytostatic effects, and reduces hormone secretion, as well. However,
clinical practice indicates a great variability in the frequency and entity of
favorable responses of acromegalic patients to long-acting somatostatin
analogues (SSAs), but the molecular mechanisms regulating this pharmacological
resistance are not completely understood. So far, several potentially implied
mechanisms have been suggested, including impaired expression of SSTRs, or
post-receptor signal transduction alterations. More recently, new studies
exploited the molecular factors involved in SSTRs intracellular trafficking
regulation, this being a critical point for the modulation of the available
active G-coupled receptors (GPCRs) amount at the cell surface. In this respect,
the role of the scaffold proteins such as β-arrestins, and the cytoskeleton
protein Filamin A (FLNA), have become of relevant importance for GH-secreting
pituitary tumors. In fact, β-arrestins are linked to SSTR2 desensitization and
internalization, and FLNA is able to regulate SSTR2 trafficking and stability at
the plasma membrane. Therefore, the present review will summarize emerging
evidence highlighting the role of β-arrestins and FLNA, as possible novel
players in the modulation of agonist activated-SSTR2 receptor trafficking and
response in GH-secreting pituitary tumors.
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Affiliation(s)
- D Treppiedi
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Peverelli
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Giardino
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Ferrante
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - D Calebiro
- Institute of Pharmacology and Toxicology, University of Würzburg, and Rudolf Virchow Center, Bio-Imaging Center, Würzburg, Germany
| | - A Spada
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Mantovani
- Endocrine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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188
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Caron PJ, Petersenn S, Houchard A, Sert C, Bevan JS. Glucose and lipid levels with lanreotide autogel 120 mg in treatment-naïve patients with acromegaly: data from the PRIMARYS study. Clin Endocrinol (Oxf) 2017; 86:541-551. [PMID: 27874199 DOI: 10.1111/cen.13285] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/28/2016] [Accepted: 11/18/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Impaired glycaemic control, characteristic of acromegaly, can be exacerbated by treatment with somatostatin analogues (SSAs), particularly those with multireceptor activity. We present data from the PRIMARYS study on the impact of the SSA lanreotide, associated with tumour volume and hormonal improvements, on glucose and other metabolic parameters in acromegaly. DESIGN PRIMARYS was a 48-week open-label single-arm phase 3b study of lanreotide autogel 120 mg/4 weeks. A priori and post hoc metabolic profile data are reported for the overall population, patients with/without diabetes and patients achieving/not achieving hormonal control. PATIENTS Treatment-naïve adults with pituitary macroadenoma, mean growth hormone >1 μg/l and elevated insulin-like growth factor-1 levels (n = 90). MEASUREMENTS Glycaemic parameters [glycated haemoglobin (HbA1c ) and fasting plasma glucose (FPG) levels] assessed at baseline and weeks 12, 24 and 48. Lipid-profile data (triglycerides, total cholesterol, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol) collected at baseline and study end. RESULTS In patients with diabetes (n = 24), HbA1c showed a clinically relevant decrease during treatment [mean change from baseline to week 48, -1·44% (95% CI: -2·52, -0·36)]. In the overall population, in patients without diabetes, or in patients with/without hormonal control, HbA1c did not significantly change by week 48. Mean FPG levels showed no significant change by week 48 in all populations. Individually, increases and decreases in glycaemic parameters affected some patients in all populations. Glycaemic status as a composite measure of HbA1c and FPG (classification as normal, mild or diabetic) was stable from baseline to study end in most patients (overall, 70%; patients with diabetes, 50%; patients without diabetes, 76%), but worsened by week 48 in nine (15%) patients [seven (50%) with diabetes at baseline] and improved in nine (15%) patients (none with diabetes). Changes in lipid profiles were not considered clinically meaningful. CONCLUSIONS Glucose and lipid levels were not detrimentally affected in most patients, while only a relatively small proportion showed deterioration in glucose control.
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Affiliation(s)
- Philippe J Caron
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, Toulouse, France
| | | | | | | | - John S Bevan
- JJR Macleod Centre for Diabetes, Endocrinology & Metabolism (Mac-DEM), Aberdeen Royal Infirmary, Aberdeen, UK
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189
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Pivonello R, Auriemma RS, Grasso LFS, Pivonello C, Simeoli C, Patalano R, Galdiero M, Colao A. Complications of acromegaly: cardiovascular, respiratory and metabolic comorbidities. Pituitary 2017; 20:46-62. [PMID: 28224405 DOI: 10.1007/s11102-017-0797-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Acromegaly is associated with an enhanced mortality, with cardiovascular and respiratory complications representing not only the most frequent comorbidities but also two of the main causes of deaths, whereas a minor role is played by metabolic complications, and particularly diabetes mellitus. The most prevalent cardiovascular complications of acromegaly include a cardiomyopathy, characterized by cardiac hypertrophy and diastolic and systolic dysfunction together with arterial hypertension, cardiac rhythm disorders and valve diseases, as well as vascular endothelial dysfunction. Biochemical control of acromegaly significantly improves cardiovascular disease, albeit completely recovering to normal mainly in young patients with short disease duration. Respiratory complications, represented mainly by sleep-breathing disorders, particularly sleep apnea, and respiratory insufficiency, frequently occur at the early stage of the disease and, although their severity decreases with disease control, this improvement does not often change the indication for a specific therapy directed to improve respiratory function. Metabolic complications, including glucose and lipid disorders, are variably reported in acromegaly. Treatments of acromegaly may influence glucose metabolism, and the presence of diabetes mellitus in acromegaly may affect the choice of treatments, so that glucose homeostasis is worth being monitored during the entire course of the disease. Early diagnosis and prompt treatment of acromegaly, aimed at obtaining a strict control of hormone excess, are the best strategy to limit the development or reverse the complications and prevent the premature mortality.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy.
| | - Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Ludovica F S Grasso
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Roberta Patalano
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Mariano Galdiero
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, via S. Pansini 5, 80131, Naples, Italy
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190
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Ramos-Leví AM, Marazuela M. Cardiovascular comorbidities in acromegaly: an update on their diagnosis and management. Endocrine 2017; 55:346-359. [PMID: 28042644 DOI: 10.1007/s12020-016-1191-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/25/2016] [Indexed: 01/11/2023]
Abstract
Comorbidities related to the cardiovascular system are one of the most prevalent in patients with acromegaly, and contribute to an increased risk of morbidity and all-cause mortality. Specifically, hypertension, cardiomyopathy, heart valve disease, arrhythmias, atherosclerosis, coronary artery disease, and cardiac dysfunction may be frequent findings. Although the underlying physiopathology for each comorbidity may not be fully elucidated, uncontrolled growth hormone/insulin-like growth factor 1 excess, age, prolonged disease duration, and coexistence of other cardio-vascular risk factors are significant influencing variables. A simple diagnostic approach to screen for the presence of these comorbidities may allow prompt treatment and arrest the progression of cardiac abnormalities. In this article, we revise the most prevalent cardiovascular comorbidities and their pathophysiology in acromegalic patients, and we address some recommendations for their prompt diagnosis, management and treatment. Strengths and pitfalls of different diagnostic techniques that are currently being used and how different treatments can affect these complications will be further discussed.
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Affiliation(s)
- Ana M Ramos-Leví
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain
| | - Mónica Marazuela
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain.
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191
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Abstract
Acromegaly is a clinical syndrome which results from growth hormone excess. Uncontrolled acromegaly is associated with cardiovascular mortality, due to an excess of risk factors including diabetes mellitus, hypertension and cardiomegaly. Diabetes mellitus is a frequent complication of acromegaly with a prevalence of 12-37%. This review will provide an overview of a number of aspects of diabetes mellitus and glucose intolerance in acromegaly including the following: 1. Epidemiology and pathophysiology of abnormalities of glucose homeostasis 2. The impact of different management options for acromegaly on glucose homeostasis 3. The management options for diabetes mellitus in patients with acromegaly RECENT FINDINGS: Growth hormone and IGF-1 have complex effects on glucose metabolism. Insulin resistance, hyperinsulinaemia and increased gluconeogenesis combine to produce a metabolic milieu which leads to the development of diabetes in acromegaly. Treatment of acromegaly should ameliorate abnormalities of glucose metabolism, due to reversal of insulin resistance and a reduction in gluconeogenesis. Recent advances in medical therapy of acromegaly have varying impacts on glucose homeostasis. These adverse effects influence management choices in patients with acromegaly who also have diabetes mellitus or glucose intolerance. The underlying mechanisms of disorders of glucose metabolism in patients with acromegaly are complex. The aim of treatment of acromegaly is normalisation of GH/IGF-1 with reduction of co-morbidities. The choice of therapy for acromegaly should consider the impact of therapy on several factors including glucose metabolism.
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Affiliation(s)
- A M Hannon
- Department of Endocrinology, Beaumont Hospital and RCSI Medical School, Beaumont, Dublin 9, Ireland
| | - C J Thompson
- Department of Endocrinology, Beaumont Hospital and RCSI Medical School, Beaumont, Dublin 9, Ireland
| | - M Sherlock
- Department of Endocrinology, Adelaide and Meath Hospitals incorporating the National Children's Hospital and Trinity College Dublin, Tallaght, Dublin 24, Ireland.
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192
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Abstract
PURPOSE Uncontrolled acromegaly results in approximately 2-fold excess mortality. Pituitary surgery is first-line therapy, and medical treatment is indicated for persistent disease. While cabergoline and pegvisomant are used in select patients, somatostatin receptor ligands (SRLs) remain the cornerstone of medical treatment. Management of patients poorly responsive to SRLs is therefore, challenging. The purpose of this review is to highlight the options for combination medical therapy in the treatment of acromegaly, with an emphasis on efficacy and safety. METHODS All original articles/abstracts detailing combination medical therapy in acromegaly were identified from a PubMed search. RESULTS Studies reviewed included retrospective and open-label prospective studies. While the combination of SRL and cabergoline was generally well tolerated, a lower baseline insulin-like growth factor-1 (IGF-1) level was the best predictor of efficacy; this combination may be most effective in patients with mildly elevated IGF-1. SRL-pegvisomant combination normalized IGF-1 in the majority of patients; continued efficacy despite individual drug dosing reduction was also reported. The risk of significant liver enzyme elevation was, however, higher than that reported with SRL monotherapy; close monitoring is recommended. Data on pegvisomant-cabergoline combination is limited, but this may be an option in the setting of SRL intolerance. Reports on temozolomide used in combination with other medical therapies in patients with aggressive GH-secreting tumors are also summarized. CONCLUSION While more prospective, randomized controlled trials on long-term efficacy and safety are needed, combination medical therapy remains a treatment strategy that should be considered for acromegaly patients poorly responsive to SRLs.
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Affiliation(s)
- Dawn Shao Ting Lim
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, 97239, USA
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR, 97239, USA.
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193
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Gostelow R, Scudder C, Keyte S, Forcada Y, Fowkes RC, Schmid HA, Church DB, Niessen SJM. Pasireotide Long-Acting Release Treatment for Diabetic Cats with Underlying Hypersomatotropism. J Vet Intern Med 2017; 31:355-364. [PMID: 28145031 PMCID: PMC5354018 DOI: 10.1111/jvim.14662] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/16/2016] [Accepted: 01/03/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Long-term medical management of hypersomatotropism (HS) in cats has proved unrewarding. Pasireotide, a novel somatostatin analogue, decreases serum insulin-like growth factor 1 (IGF-1) and improves insulin sensitivity in cats with HS when administered as a short-acting preparation. OBJECTIVES Assess once-monthly administration of long-acting pasireotide (pasireotide LAR) for treatment of cats with HS. ANIMALS Fourteen cats with HS, diagnosed based on diabetes mellitus, pituitary enlargement, and serum IGF-1 > 1000 ng/mL. METHODS Uncontrolled, prospective cohort study. Cats received pasireotide LAR (6-8 mg/kg SC) once monthly for 6 months. Fructosamine and IGF-1 concentrations, and 12-hour blood glucose curves (BGCs) were assessed at baseline and then monthly. Product of fructosamine concentration and insulin dose was calculated as an indicator of insulin resistance (Insulin Resistance Index). Linear mixed-effects modeling assessed for significant change in fructosamine, IGF-1, mean blood glucose (MBG) of BGCs, insulin dose (U/kg) and Insulin Resistance Index. RESULTS Eight cats completed the trial. Three cats entered diabetic remission. Median IGF-1 (baseline: 1962 ng/mL [range 1051-2000 ng/mL]; month 6: 1253 ng/mL [524-1987 ng/mL]; P < .001) and median Insulin Resistance Index (baseline: 812 μmolU/L kg [173-3565 μmolU/L kg]; month 6: 135 μmolU/L kg [0-443 μmolU/L kg]; P = .001) decreased significantly. No significant change was found in mean fructosamine (baseline: 494 ± 127 μmol/L; month 6: 319 ± 113.3 μmol/L; P = .07) or MBG (baseline: 347.7 ± 111.0 mg/dL; month 6: 319.5 ± 113.3 mg/dL; P = .11), despite a significant decrease in median insulin dose (baseline: 1.5 [0.4-5.2] U/kg; 6 months: 0.3 [0.0-1.4] U/kg; P < .001). Adverse events included diarrhea (n = 11), hypoglycemia (n = 5), and worsening polyphagia (n = 2). CONCLUSIONS AND CLINICAL IMPORTANCE Pasireotide LAR is the first drug to show potential as a long-term management option for cats with HS.
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Affiliation(s)
- R Gostelow
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK
| | - C Scudder
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK
| | - S Keyte
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK
| | - Y Forcada
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK
| | - R C Fowkes
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London, UK
| | - H A Schmid
- Novartis Institutes for Biomedical Research, Oncology Research, Novartis Pharma AG, Basel, Switzerland
| | - D B Church
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK
| | - S J M Niessen
- Diabetic Remission Clinic, Department of Clinical Science and Services, Royal Veterinary College, Hertfordshire, UK.,Newcastle Medical School, Newcastle upon Tyne, UK
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194
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Abstract
Somatostatin and dopamine receptors are expressed in normal and tumoral somatotroph cells. Upon receptor stimulation, somatostatin and the somatostatin receptor ligands octreotide, lanreotide, and pasireotide, and to a lesser extent, dopamine and the dopamine analogs bromocriptine and cabergoline, suppress growth hormone (GH) secretion from a GH-secreting pituitary somatotroph adenoma. Somatostatin and dopamine receptors are Gαi-protein coupled that inhibit adenylate cyclase activity and cAMP production and reduce intracellular calcium concentration and calcium flux oscillations. Although their main action on somatotroph cells is acute inhibition of GH secretion, they also may inhibit GH production and possibly somatotroph proliferation. These receptors have been reported to create complexes that exhibit functions distinct from that of receptor monomers. Somatostatin suppression of GH is mediated mainly by somatostatin receptor subtype 2 and to a lesser extent by SST5. Human somatostatin receptor subtype 5 has also been shown to harbor mutations associated with GH levels, somatotroph tumor behavior, and somatostatin receptor ligand (SRL) responsiveness. Reviewing current knowledge of somatostatin and dopamine receptor expression and signaling in normal and tumoral somatotroph cells offers insights into mechanisms underlying SRL and dopamine agonist effectiveness in patients with acromegaly.
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Affiliation(s)
- Anat Ben-Shlomo
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Davis Building, Room 3021, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - Ning-Ai Liu
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Davis Building, Room 3021, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Shlomo Melmed
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Davis Building, Room 3021, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
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195
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Abstract
First-generation somatostatin receptors ligands (SRL) are the mainstay in the medical treatment of acromegaly, however the percentage of patients controlled with these drugs significantly varies in the different studies. Many factors are involved in the resistance to SRL. In this review, we update the physiology of somatostatin and its receptors (sst), the use of SRL in the treatment of acromegaly and the factors involved in the response to these drugs. The SRL act through interaction with the sst, which up to now have been characterized as five subtypes. The first-generation SRL, octreotide and lanreotide, are considered sst2 specific and have biochemical response rates varying from 20 to 70%. Tumor volume reduction can be found in 36-75% of patients. Several factors may determine the response to these drugs, such as sst, AIP, E-cadherin, ZAC1, filamin A and β-arrestin expression in the somatotropinomas. In patients resistant to first-generation SRL, alternative medical treatment options include: SRL high dose regimens, SRL in combination with cabergoline or pegvisomant, or the use of pasireotide. Pasireotide is a next-generation SRL with a broader pattern of interaction with sst. In the light of the recent increase of treatment options in acromegaly and the deeper knowledge of the determinants of response to the current first-line therapy, a shift from a trial-and-error treatment to a personalized one could be possible.
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Affiliation(s)
- Monica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 9th floor, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil.
- Neuroendocrinology Section and Molecular Genetics Laboratory, Secretaria Estadual de Saúde do Rio de Janeiro, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 9th floor, Ilha do Fundão, Rio de Janeiro, 21941-913, Brazil
- Neuroendocrinology Section and Molecular Genetics Laboratory, Secretaria Estadual de Saúde do Rio de Janeiro, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- IRCCS AOU San Martino-IST Genoa, Genoa, Italy
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196
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Hutchinson JA, Burholt S, Hamley IW. Peptide hormones and lipopeptides: from self-assembly to therapeutic applications. J Pept Sci 2017; 23:82-94. [PMID: 28127868 PMCID: PMC5324658 DOI: 10.1002/psc.2954] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/24/2016] [Accepted: 11/27/2016] [Indexed: 12/18/2022]
Abstract
This review describes the properties and activities of lipopeptides and peptide hormones and how the lipidation of peptide hormones could potentially produce therapeutic agents combating some of the most prevalent diseases and conditions. The self‐assembly of these types of molecules is outlined, and how this can impact on bioactivity. Peptide hormones specific to the uptake of food and produced in the gastrointestinal tract are discussed in detail. The advantages of lipidated peptide hormones over natural peptide hormones are summarised, in terms of stability and renal clearance, with potential application as therapeutic agents. © 2017 The Authors Journal of Peptide Science published by European Peptide Society and John Wiley & Sons Ltd.
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Affiliation(s)
- J A Hutchinson
- Department of Chemistry, University of Reading, Whiteknights, Reading, RG6 6AD, UK
| | - S Burholt
- Department of Chemistry, University of Reading, Whiteknights, Reading, RG6 6AD, UK
| | - I W Hamley
- Department of Chemistry, University of Reading, Whiteknights, Reading, RG6 6AD, UK
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197
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Grasso LFS, Auriemma RS, Pivonello R, Colao A. Somatostatin analogs, cabergoline and pegvisomant: comparing the efficacy of medical treatment for acromegaly. Expert Rev Endocrinol Metab 2017; 12:73-85. [PMID: 30058878 DOI: 10.1080/17446651.2016.1222899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Therapies for acromegaly aim at normalizing hormonal excess and controlling tumor growth . Therapeutic approaches are surgery, pharmacotherapy and radiotherapy. Area covered: This review focuses on the role of medical therapy of acromegaly, comparing the efficacy of somatostatin analogues (SSA), dopamine-agonists (DA) and pegvisomant (PEG), the three available drug classes for treating acromegaly. To clarify the difference in response rates reported in the literature for these therapies, we performed a search for original articles published in PubMed. SSA represent the first-line approach to medical treatment. This therapy is effective in controlling acromegaly in about 40% of patients, however there are great differences in the reported hormonal efficacy of SSA in the different series. In patients partially resistant to SSA, cabergoline can be added when hormonal levels are close to normalization, resulting effective in control IGF-I levels in 43% of patients. In patients with higher hormonal levels PEG is indicated, normalizing IGF-I levels in 79.8% and 80.6% of cases when used in monotherapy or in combination with SSA. Pasireotide, the newly developed SSA multi-ligand receptor, represents a new option in SSA resistant patients. Expert commentary: Medical therapy represents an important therapeutic option resulting safe and effective in controlling acromegaly in a high percentage of patients. The best treatment should be individually tailored for each patient, taking into account sex, age, comorbidities, tumor characteristics and hormonal levels.
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Affiliation(s)
- Ludovica F S Grasso
- a Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia , 'Federico II' University of Naples , Naples , Italy
| | - Renata S Auriemma
- a Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia , 'Federico II' University of Naples , Naples , Italy
| | - Rosario Pivonello
- a Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia , 'Federico II' University of Naples , Naples , Italy
| | - Annamaria Colao
- a Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia , 'Federico II' University of Naples , Naples , Italy
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198
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Fleseriu M, Rusch E, Geer EB. Safety and tolerability of pasireotide long-acting release in acromegaly-results from the acromegaly, open-label, multicenter, safety monitoring program for treating patients who have a need to receive medical therapy (ACCESS) study. Endocrine 2017; 55:247-255. [PMID: 27896545 PMCID: PMC5225222 DOI: 10.1007/s12020-016-1182-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/14/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Pasireotide long-acting release is a somatostatin analog that is indicated for treatment of patients with acromegaly. This analysis documents the safety of pasireotide long-acting release in patients with acromegaly enrolled in the ACCESS trial (ClinicalTrials.gov identifier: NCT01995734). METHODS ACCESS is an open-label, multicenter, single-arm, expanded-treatment protocol designed to provide patients access to pasireotide long-acting release pending regulatory approval. Patients received pasireotide long-acting release 40 mg administered intramuscularly every 28 days. The primary outcome was the proportion of patients having a treatment-emergent grade ≥3 or serious adverse event. Efficacy data were not collected. RESULTS Forty-four adult patients with active acromegaly were enrolled in the study for an average of 37.6 weeks (range, 4-70 weeks). Twenty-five grade ≥3 treatment-emergent adverse events were reported in 11 patients (25.0 %), 3 of whom (27.3 %) experienced grade ≥3 hyperglycemia. In patients treated with pasireotide long-acting release for ≥3 months (n = 42), mean glycated hemoglobin and fasting plasma glucose levels increased significantly from 5.9 % and 100.4 mg/dL at baseline to 6.8 % and 135.9 mg/dL at 3 months, respectively. Ten patients (22.7 %) were treated with pasireotide long-acting release for ≥15 months, after which mean glycated hemoglobin and fasting plasma glucose levels were 6.3 % and 123 mg/dL, respectively. Twenty-one patients (48 %) initiated antidiabetic medication. CONCLUSIONS Grade ≥3 adverse events (primary outcome) were reported in 25.0 % of acromegaly patients treated with pasireotide long-acting release in a clinical setting. Hyperglycemia-related adverse events were reported in 45.5 % of patients, but were typically manageable, supporting the role of pasireotide long-acting release as a safe treatment option for acromegaly patients.
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Affiliation(s)
| | - Elisha Rusch
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Eliza B Geer
- Division of Endocrinology, Mount Sinai Hospital, New York, NY, USA
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199
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Öberg K, Lamberts SWJ. Somatostatin analogues in acromegaly and gastroenteropancreatic neuroendocrine tumours: past, present and future. Endocr Relat Cancer 2016; 23:R551-R566. [PMID: 27697899 DOI: 10.1530/erc-16-0151] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/03/2016] [Indexed: 11/08/2022]
Abstract
Acromegaly is a hormonal disorder that arises when the pituitary gland secretes excess growth hormone (GH), which in turn stimulates a concomitant increase in serum insulin-like growth factor 1 (IGF-1) levels. Gastroenteropancreatic neuroendocrine tumours (GEP-NET) constitute a heterogeneous group of tumours that can secrete serotonin and a variety of peptide hormones that may cause characteristic symptoms known as carcinoid syndrome or other symptoms and hormonal hypersecretion syndromes depending on the tumour's site of origin. Current medical therapy for the treatment of acromegaly and GEP-NET involves the administration of somatostatin analogues that effectively suppress excess hormone secretion. After its discovery in 1979, octreotide became the first synthetic biologically stable somatostatin analogue with a short-acting formulation of octreotide introduced into clinical practice in the late 1980s. Lanreotide, another somatostatin analogue, became available in the mid-1990s initially as a prolonged-release formulation administered every 10 or 14 days. Long-acting release formulations of both octreotide (Sandostatin LAR and Novartis) and lanreotide (Somatuline Autogel, Ipsen), based on microparticle and nanoparticle drug-delivery technologies, respectively, were later developed, which allowed for once-monthly administration and improved convenience. First-generation somatostatin analogues remain one of the cornerstones of medical therapy in the management of pituitary and GEP-NET hormone hypersecretion, with octreotide having the longest established efficacy and safety profile of the somatostatin analogue class. More recently, pasireotide (Signifor), a next-generation multireceptor-targeted somatostatin analogue, has emerged as an alternative therapeutic option for the treatment of acromegaly. This review summarizes the development and clinical success of somatostatin analogues.
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200
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Ibáñez-Costa A, Rivero-Cortés E, Vázquez-Borrego MC, Gahete MD, Jiménez-Reina L, Venegas-Moreno E, de la Riva A, Arráez MÁ, González-Molero I, Schmid HA, Maraver-Selfa S, Gavilán-Villarejo I, García-Arnés JA, Japón MA, Soto-Moreno A, Gálvez MA, Luque RM, Castaño JP. Octreotide and pasireotide (dis)similarly inhibit pituitary tumor cells in vitro. J Endocrinol 2016; 231:135-145. [PMID: 27587848 DOI: 10.1530/joe-16-0332] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/01/2016] [Indexed: 02/01/2023]
Abstract
Somatostatin analogs (SSA) are the mainstay of pharmacological treatment for pituitary adenomas. However, some patients escape from therapy with octreotide, a somatostatin receptor 2 (sst2)-preferring SSA, and pasireotide, a novel multi-sst-preferring SSA, may help to overcome this problem. It has been proposed that correspondence between sst1-sst5 expression pattern and SSA-binding profile could predict patient's response. To explore the cellular/molecular features associated with octreotide/pasireotide response, we performed a parallel comparison of their in vitro effects, evaluating sst1-sst5 expression, intracellular Ca2+ signaling ([Ca2+]i), hormone secretion and cell viability, in a series of 85 pituitary samples. Somatotropinomas expressed sst5>sst2, yet octreotide reduced [Ca2+]i more efficiently than pasireotide, while both SSA similarly decreased growth hormone release/expression and viability. Corticotropinomas predominantly expressed sst5, but displayed limited response to pasireotide, while octreotide reduced functional endpoints. Non-functioning adenomas preferentially expressed sst3 but, surprisingly, both SSA increased cell viability. Prolactinomas mainly expressed sst1 but were virtually unresponsive to SSA. Finally, both SSA decreased [Ca2+]i in normal pituitaries. In conclusion, both SSA act in vitro on pituitary adenomas exerting both similar and distinct effects; however, no evident correspondence was found with the sst1-sst5 profile. Thus, it seems plausible that additional factors, besides the simple abundance of a given sst, critically influence the SSA response.
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Affiliation(s)
- Alejandro Ibáñez-Costa
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Esther Rivero-Cortés
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Mari C Vázquez-Borrego
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Manuel D Gahete
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Luis Jiménez-Reina
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Morphological SciencesUniversidad de Córdoba, Córdoba, Spain
| | - Eva Venegas-Moreno
- Metabolism and Nutrition UnitHospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Andrés de la Riva
- Service of NeurosurgeryHospital Universitario Reina Sofía, Córdoba, Spain
| | | | | | - Herbert A Schmid
- Novartis Pharma AGNovartis Institutes for Biomedical Research, Oncology, CH-4057 Basel, Switzerland
| | - Silvia Maraver-Selfa
- Service of Endocrinology and NutritionHospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | | | | | - Miguel A Japón
- Department of PathologyHospital Universitario Virgen del Rocío, Seville, Spain
| | - Alfonso Soto-Moreno
- Metabolism and Nutrition UnitHospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - María A Gálvez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Service of Endocrinology and NutritionHospital Universitario Reina Sofía, Córdoba, Spain
| | - Raúl M Luque
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
| | - Justo P Castaño
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)Córdoba, Spain
- Department of Cell BiologyPhysiology and Immunology, Universidad de Córdoba, Córdoba, Spain
- Hospital Universitario Reina SofíaCórdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERObn)Córdoba, Spain
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