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Fleseriu M, Nachtigall LB, Samson SL, Melmed S. Oral octreotide capsules for acromegaly treatment: application of clinical trial insights to real-world use. Expert Rev Endocrinol Metab 2024; 19:367-375. [PMID: 38842362 DOI: 10.1080/17446651.2024.2363540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/30/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Acromegaly is a rare endocrine disorder usually caused by a benign growth hormone‒secreting pituitary adenoma. Surgical adenoma resection is typically the first line of treatment, and medical therapy is used for patients with persistent disease following surgery, for adenoma recurrence, or for patients ineligible for, or declining, surgery. Approved somatostatin receptor ligands (SRLs) have been limited to injectable options, until recently. Oral octreotide capsules (OOC) are the first approved oral SRL for patients with acromegaly. AREAS COVERED We review published reports and provide case study examples demonstrating practical considerations on the use of OOC. Using two hypothetical case scenarios, we discuss current treatment patterns, breakthrough symptoms and quality of life (QoL), efficacy of SRLs, OOC dose titration, evaluation of OOC treatment response, and incidence and management of adverse events. EXPERT OPINION OOC are an option for patients with acromegaly including those who experience breakthrough symptoms, who have preference for oral therapies, or other reasons for declining injectable SRLs. OOC have been associated with improved patient-reported QoL measures compared with those reported for lanreotide and octreotide. Continued real-world experience will determine whether OOC, alone or in combination with other therapies, provides further advantages over current injectable acromegaly treatments.
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Affiliation(s)
- Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Lisa B Nachtigall
- Neuroendocrine Clinical Center, Massachusetts General Hospital Neuroendocrine and Pituitary Center, Chestnut Hill, MA, USA
| | - Susan L Samson
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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2
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Varlamov EV, Fleseriu M. Acromegaly and COVID-19, lessons, and new opportunities. Pituitary 2024:10.1007/s11102-024-01404-0. [PMID: 38819618 DOI: 10.1007/s11102-024-01404-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/01/2024]
Abstract
The COVID-19 pandemic created challenges in effective management of patients with acromegaly. Specifically, with regards to timely diagnosis, delays in surgeries, and disruption(s) to routine patient care. A transition to telemedicine did help to overcome safety restrictions that were placed on in-person care. Creation of surgical safety protocols in conjunction with widespread testing for COVID-19 has also helped with the resumption of pituitary surgery cases. However, acromegaly related comorbidities including cardiovascular disease, diabetes mellitus, sleep apnea and respiratory disease, vertebral fractures, and hypopituitarism, may increase the risk of a more severe COVID-19 infection course. Of note and to date, no negative trends in COVID-19 related outcomes have been reported in patients with acromegaly. Nevertheless, anxiety and depression rates in patients with acromegaly are higher than those in the general population. More studies are needed to assess the true impact of the COVID-19 pandemic on morbidity, mortality, and neuropsychiatric health of patients with acromegaly.
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Affiliation(s)
- Elena V Varlamov
- Pituitary Center, Oregon Health & Science University, Portland, OR, 97239, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Pituitary Center, Oregon Health & Science University, Portland, OR, 97239, USA.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
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3
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Marques P, Sagarribay A, Tortosa F, Neto L, Tavares Ferreira J, Subtil J, Palha A, Dias D, Sapinho I. Multidisciplinary Team Care in Pituitary Tumours. Cancers (Basel) 2024; 16:950. [PMID: 38473312 DOI: 10.3390/cancers16050950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/05/2023] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
The optimal care for patients with pituitary tumours is best provided in a multidisciplinary and collaborative environment, which requires the contribution of multiple medical specialties working together. The benefits and advantages of the pituitary multidisciplinary team (MDT) are broad, and all relevant international consensus and guidelines in the field recommend that patients with pituitary tumours should always be managed in a MDT. Endocrinologists and neurosurgeons are normally the leading specialties within the pituitary MDT, supported by many other specialties with significant contributions to the diagnosis and management of pituitary tumours, including neuropathology, neuroradiology, neuro-ophthalmology, and otorhinolaryngology, among others. Here, we review the literature concerning the concepts of Pituitary MDT/Pituitary Tumour Centre of Excellence (PTCOE) in terms of their mission, goals, benefits, structure, proposed models of function, and barriers, and we also provide the views of different specialists involved in our Pituitary MDT.
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Affiliation(s)
- Pedro Marques
- Pituitary Tumor Unit, Endocrinology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
- Faculty of Medicine, Universidade Católica Portuguesa, 1649-023 Lisbon, Portugal
| | - Amets Sagarribay
- Pituitary Tumor Unit, Neurosurgery Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Francisco Tortosa
- Pituitary Tumor Unit, Pathology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Lia Neto
- Pituitary Tumor Unit, Radiology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Joana Tavares Ferreira
- Pituitary Tumor Unit, Ophthalmology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - João Subtil
- Pituitary Tumor Unit, Otorhinolaryngology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Ana Palha
- Pituitary Tumor Unit, Endocrinology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Daniela Dias
- Pituitary Tumor Unit, Endocrinology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
| | - Inês Sapinho
- Pituitary Tumor Unit, Endocrinology Department, Hospital CUF Descobertas, 1998-018 Lisbon, Portugal
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Yang F, Wu Y, Hockey R, Doust J, Mishra GD, Montgomery GW, Mortlock S. Evidence of shared genetic factors in the etiology of gastrointestinal disorders and endometriosis and clinical implications for disease management. Cell Rep Med 2023; 4:101250. [PMID: 37909040 PMCID: PMC10694629 DOI: 10.1016/j.xcrm.2023.101250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/26/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023]
Abstract
In clinical practice, the co-existence of endometriosis and gastrointestinal symptoms is often observed. Using large-scale datasets, we report a genetic correlation between endometriosis and irritable bowel syndrome (IBS), peptic ulcer disease (PUD), gastro-esophageal reflux disease (GORD), and a combined GORD/PUD medicated (GPM) phenotype. Mendelian randomization analyses support a causal relationship between genetic predisposition to endometriosis and IBS and GPM. Identification of shared risk loci highlights biological pathways that may contribute to the pathogenesis of both diseases, including estrogen regulation and inflammation, and potential therapeutic drug targets (CCKBR; PDE4B). Higher use of IBS, GORD, and PUD medications in women with endometriosis and higher use of hormone therapies in women with IBS, GORD, and PUD, support the co-occurrence of these conditions and highlight the potential for drug repositioning and drug contraindications. Our results provide evidence of shared disease etiology and have important clinical implications for diagnostic and treatment decisions for both diseases.
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Affiliation(s)
- Fei Yang
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Yeda Wu
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Richard Hockey
- The University of Queensland, NHMRC Centre for Research Excellence on Women and Non-communicable Diseases (CREWaND), School of Public Health, Herston Road, Herston, QLD, Australia
| | - Jenny Doust
- The University of Queensland, NHMRC Centre for Research Excellence on Women and Non-communicable Diseases (CREWaND), School of Public Health, Herston Road, Herston, QLD, Australia
| | - Gita D Mishra
- The University of Queensland, NHMRC Centre for Research Excellence on Women and Non-communicable Diseases (CREWaND), School of Public Health, Herston Road, Herston, QLD, Australia
| | - Grant W Montgomery
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Sally Mortlock
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD 4072, Australia.
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5
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Xiao T, Jiao R, Yang S, Wang Y, Bai X, Zhou J, Li R, Wang L, Yang H, Yao Y, Deng K, Gong F, Pan H, Duan L, Zhu H. Incidence and risk factors of cancers in acromegaly: a Chinese single-center retrospective study. Endocrine 2023; 82:368-378. [PMID: 37442901 PMCID: PMC10543525 DOI: 10.1007/s12020-023-03447-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE To evaluate the incidence of malignancies in acromegaly and to identify risk factors for newly-diagnostic cancers, especially the excessive growth hormone (GH) and insulin-like growth factor-1 (IGF-1). METHODS A retrospective cohort including 1738 consecutive hospitalized patients with acromegaly in a single referral center between 2012 and 2020 (mean follow-up 4.3 years). A gender- and age-matched case-control study (280 patients from the cohort) was performed for risk factor analysis. RESULTS One hundred thirteen malignancies (67 diagnosed after acromegaly) were observed. The overall newly-diagnostic cancer risk of acromegaly was higher than the general population (standardized incidence ratio (SIR) 2.81; 95% CI 2.18-3.57). The risk of thyroid cancer (n = 33, SIR 21.42; 95% CI 13.74-30.08) and colorectal cancer (n = 8, SIR 3.17; 95% CI 1.37-6.25) was elevated. In the overall cohort, IGF-1 (ULN: 1.27 vs. 0.94, p = 0.057), GH (1.30 vs. 1.00 ng/ml, p = 0.12), and disease-controlled rate (34.9% vs. 45.9%, p = 0.203) at the last visit did not reach significance between patients with and without post-diagnostic cancer. In the case-control study, GH (1.80 vs. 0.90 ng/ml, p = 0.018) and IGF-1 (ULN: 1.27 vs. 0.91, p = 0.003) at the last visit were higher in patients with post-diagnostic cancers, with a lower disease-controlled rate. Elder age was a risk factor for cancer. Other metabolic comorbidities and the size of pituitary tumors were similar. CONCLUSION The risk of malignancies, especially thyroid cancer, was increased in patients with acromegaly in our center. More cancer screening should be considered when managing acromegaly, especially in patients with higher posttreatment GH and IGF-1.
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Affiliation(s)
- Tongxin Xiao
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Jiao
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Eight-Year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengmin Yang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Wang
- Department of Medical Records, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Bai
- Department of Medical Records, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingya Zhou
- Department of Medical Records, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ran Li
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbo Yang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengying Gong
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lian Duan
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Elbaum M, Kałużny M, Jawiarczyk-Przybyłowska A, Wojtczak B, Zieliński G, Bolanowski M. The Relationship between the Burden of Acromegaly, Associated Comorbidities, Complications and Disease Status. J Clin Med 2023; 12:6309. [PMID: 37834952 PMCID: PMC10573270 DOI: 10.3390/jcm12196309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/18/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Uncontrolled acromegaly causes increased morbidity and mortality. The analysis of acromegaly comorbidities and complications is important when establishing a standard of care for the entire population of acromegaly patients. The aim of this study was to determine the frequency of comorbidities and complications of acromegaly and their dependence on the activity of the disease. A retrospective analysis of medical records from 124 patients with acromegaly was carried out, including 39 who were cured, 73 treated with somatostatin analogs and 12 newly diagnosed patients. The incidence of comorbidities and complications was very high, and those most frequently observed were arterial hypertension, multinodular goiter, lipid disorders, hypopituitarism and degenerative changes. At least one complication of acromegaly was observed in 92% of patients undergoing successful neurosurgery and in all pharmacologically treated patients. By contrast, two or more complications were observed in 77% of cured patients and in pharmacologically controlled and uncontrolled patients, 82% and 91%, respectively. Conclusions: Acromegaly is associated with a high prevalence of complications. Active acromegaly is associated with a higher incidence of complications than in treated groups. Untreated patients have more complications than treated patients. Successfully cured patients have significantly fewer complications than pharmacologically controlled patients and patients with active acromegaly.
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Affiliation(s)
- Michał Elbaum
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże L. Pasteura 4, 50-367 Wroclaw, Poland
| | - Marcin Kałużny
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże L. Pasteura 4, 50-367 Wroclaw, Poland
| | | | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Borowska Str. 213, 50-556 Wroclaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine—National Research Institute, 128 Szaserów Str., 04-141 Warsaw, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wybrzeże L. Pasteura 4, 50-367 Wroclaw, Poland
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Fleseriu M, Barkan A, Brue T, Duquesne E, Houchard A, del Pilar Schneider M, Ribeiro-Oliveira A, Melmed S. Treatment Patterns, Adherence, Persistence, and Health Care Resource Utilization in Acromegaly: A Real-World Analysis. J Endocr Soc 2023; 7:bvad104. [PMID: 37705695 PMCID: PMC10496868 DOI: 10.1210/jendso/bvad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 09/15/2023] Open
Abstract
Context Treatment of acromegaly is multimodal for many patients, and medical treatments include somatostatin receptor ligands (SRLs), dopamine agonists (DAs), and growth hormone receptor antagonists (GHRAs). However, recent real-world evidence on treatment patterns for patients with acromegaly is limited. Objective This study evaluated medication usage, treatment changes, adherence, persistence, comorbidities, and health care resource utilization using deidentified data from MarketScan, a US claims database. Methods Eligible patients (n = 882) were those receiving monotherapy or combination therapy for ≥90 days without treatment gaps. Results Mean age at diagnosis was 48.6 years; 50.1% of patients were female. Over half (59.4%) had 1 line of treatment (LOT); 23.1% had 2 LOTs; 17.5% had at least 3 LOTs. Most patients (94.6%) initiated treatment with monotherapies. The most common first-line monotherapy treatments were cabergoline (DA, 36.8%), octreotide long-acting release (first-generation SRL, 29.5%), and lanreotide depot (first-generation SRL, 22.5%). Adherence for first-line treatments (proportion of days covered) was higher for first-generation SRLs (lanreotide depot: 0.8) compared with DAs (0.7). Treatment persistence (time between the first treatment record and a change in LOT/censoring) in LOT 1 was higher for GHRAs (24.8 months) and first-generation SRLs (20.0 months) compared with DAs (14.4 months). Female patients and those diagnosed at a younger age were more likely to have shorter treatment persistence. The most prevalent comorbidities were hyperlipidemia, essential hypertension, and sleep apnea. Conclusion Patients with more comorbidities had more health care visits during the first year after diagnosis, suggesting increased disease burden. Real-world evidence on treatment patterns provides insights into recommendations for individualized therapy.
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Affiliation(s)
- Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Ariel Barkan
- A. Alfred Taubman Health Care Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Thierry Brue
- Faculté de Médecine, Aix-Marseille University, Marseille 13385, France
| | | | - Aude Houchard
- Ipsen, HEOR Oncology Department, Boulogne–Billancourt 92100, France
| | | | | | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Kim J, Hong N, Choi J, Moon JH, Kim EH, Hong JW, Lee EJ, Kim SG, Ku CR. Sex differences in mortality in patients with acromegaly: a nationwide cohort study in Korea. Eur J Endocrinol 2023; 189:225-234. [PMID: 37548222 DOI: 10.1093/ejendo/lvad106] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The results of previous studies on sex differences in mortality and comorbidities among patients with acromegaly are diverse. We assessed sex differences in mortality and the risk of complications in patients with acromegaly. METHODS We included 1884 patients with acromegaly with 1:50 age- and sex-matched 94 200 controls using the Korean nationwide claims database from 2009 to 2019. RESULTS During the median 5.51 years of follow-up, the acromegaly group had higher all-cause mortality than the control group (hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.38-2.19), with higher risk in women than men (HR 2.17 vs 1.36). The most common cause of death was malignancy. Women with acromegaly aged ≥50 years exhibited significantly higher mortality than men with acromegaly aged ≥50 years (HR 1.74 vs 0.96). In a treatment subgroup other than surgery alone, women had a higher risk of mortality than men (HR 2.82 vs 1.58). Sex differences in mortality among patients with acromegaly remained equal after adjustment for the Charlson Comorbidity Index (CCI), socioeconomic status (SES), body mass index (BMI), alcohol consumption, smoking, fasting plasma glucose, creatinine, and total cholesterol. Patients with acromegaly had elevated risks of developing major adverse cardiovascular events (MACE), atrial fibrillation, obstructive sleep apnea (OSA), diabetes mellitus (DM), end-stage renal disease (ESRD), Parkinson's disease (PD), depression, and malignancy than age- and sex-matched controls, with a higher risk of OSA and DM in women than men. CONCLUSIONS The risk of mortality and complications in patients with acromegaly compared to age- and sex-matched controls was higher in women than in men.
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Affiliation(s)
- Jiwon Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea, 10444
- Yonsei University Graduate School of Medicine, Seoul, Republic of Korea, 03722
| | - Namki Hong
- Endocrinology, Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea, 03722
| | - Jimi Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea, 02841
| | - Ju Hyung Moon
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea, 03722
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea, 03722
| | - Eui Hyun Kim
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea, 03722
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea, 03722
| | - Jae Won Hong
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea, 10380
| | - Eun Jig Lee
- Endocrinology, Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea, 03722
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea, 03722
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea, 02841
| | - Cheol Ryong Ku
- Endocrinology, Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea, 03722
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea, 03722
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9
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Voltan G, Mazzeo P, Regazzo D, Scaroni C, Ceccato F. Role of Estrogen and Estrogen Receptor in GH-Secreting Adenomas. Int J Mol Sci 2023; 24:9920. [PMID: 37373068 DOI: 10.3390/ijms24129920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/17/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Acromegaly is a rare disease with several systemic complications that may lead to increased overall morbidity and mortality. Despite several available treatments, ranging from transsphenoidal resection of GH-producing adenomas to different medical therapies, complete hormonal control is not achieved in some cases. Some decades ago, estrogens were first used to treat acromegaly, resulting in a significant decrease in IGF1 levels. However, due to the consequent side effects of the high dose utilized, this treatment was later abandoned. The evidence that estrogens are able to blunt GH activity also derives from the evidence that women with GH deficiency taking oral estro-progestins pills need higher doses of GH replacement therapy. In recent years, the role of estrogens and Selective Estrogens Receptor Modulators (SERMs) in acromegaly treatment has been re-evaluated, especially considering poor control of the disease under first- and second-line medical treatment. In this review, we analyze the state of the art concerning the impact of estrogen and SERMs on the GH/IGF1 axis, focusing on molecular pathways and the possible implications for acromegaly treatment.
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Affiliation(s)
- Giacomo Voltan
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Pierluigi Mazzeo
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Daniela Regazzo
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
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10
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Oguz SH, Firlatan B, Sendur SN, Dagdelen S, Erbas T. Follow, consider, and catch: second primary tumors in acromegaly patients. Endocrine 2023; 80:160-173. [PMID: 36517649 DOI: 10.1007/s12020-022-03282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM The risk of second primary tumors is increased in general cancer population, however, there is no data on acromegalic cancer patients in this regard. The aim of this study is to determine the prevalence of patients with two primary tumors among acromegalic cancer patients and to evaluate if patients with two primaries have distinct clinical characteristics or risk factors compared to those with one. METHODS This is a single-center retrospective cohort study. The study included 63 patients with at least one malignant tumor out of a total number of 394 acromegaly patients. Patients with multiple primary neoplasms were evaluated in detail. RESULTS This study revealed a 16% cancer prevalence in acromegaly patients, with 14% (9/63) having two primary neoplasms. Papillary thyroid carcinoma was the most prevalent tumor in the entire cancer cohort (41%, 26/63), and in the group of patients with two primaries (44%, 4/9). Patients with two primary tumors were older than those with one when diagnosed with acromegaly (48.3 ± 16.6 vs. 43.3 ± 10.7 years), which might be attributed to a longer diagnostic delay (median of 4.5 vs. 2 years). The period between the onset of acromegaly symptoms and diagnosis was not associated with earlier cancer diagnosis. No relationship between circulating GH or IGF-I levels and the number of neoplasms was found. CONCLUSION The development of second primary tumors in acromegalic patients with cancer diagnosis is not rare. Acromegalic cancer patients should be closely monitored for new symptoms or signs that could be associated with second primary tumors.
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Affiliation(s)
- Seda Hanife Oguz
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
- Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey.
| | - Busra Firlatan
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Suleyman Nahit Sendur
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selcuk Dagdelen
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tomris Erbas
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
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11
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Tönjes A, Quinkler M, Knappe U, Störmann S, Schöfl C, Schopohl J, Meyhöfer SM. [Treatment of acromegaly - data from the German Acromegaly Register]. Dtsch Med Wochenschr 2023; 148:380-385. [PMID: 36940688 DOI: 10.1055/a-1847-2553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Acromegaly is a rare disease in which chronic growth hormone overproduction (usually from an anterior pituitary adenoma) leads to various systemic complications. The management of acromegaly and the comorbidities of the disease is complex and requires a multidisciplinary approach. Early diagnosis is extremely important, as then the chances of a complete cure are significantly higher. The operation is the therapy of first choice and should be performed at a specialized center with an experienced neurosurgeon. With good patient information and guidance, the drug therapy of acromegaly patients in specialized practices and clinics can usually lead to biochemical control and thereby normalization of mortality risk. As with numerous rare diseases, care in specialized centers and recording and evaluation in registry studies can contribute to better patient care and the optimization of therapy and diagnostic guidelines. We assume that with the help of the German Acromegaly Registry, which currently includes more than 2500 patients with acromegaly, we will be able to present a realistic picture of the care situation in Germany in the coming years.
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12
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Birtolo MF, Antonini S, Lania AG, Mazziotti G. Looking at the spine in controlled Acromegaly. Endocrine 2023; 79:283-286. [PMID: 36574147 DOI: 10.1007/s12020-022-03258-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 12/28/2022]
Abstract
Skeletal fragility with high risk of vertebral fractures (VFs) is an emerging complication of growth hormone (GH) hypersecretion. VFs often coexist with spine arthropathy and both clinical conditions negatively impact on quality of life of acromegalic subjects. Management of spine osteopathy and arthropathy in acromegaly could be challenging since both complications can persist or even progress after biochemical control of disease. This article analyzes the latest evidence about possible pathophysiological links between VFs and spine arthropathy in active and controlled acromegaly, as well as the diagnostic and therapeutic aspects concerning the holistic management of acromegalic osteo-arthropathy.
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Affiliation(s)
- Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Simone Antonini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy.
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy.
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13
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Fleseriu M, Zhang Z, Hanman K, Haria K, Houchard A, Khawaja S, Ribeiro-Oliveira A, Gadelha M. A systematic literature review to evaluate extended dosing intervals in the pharmacological management of acromegaly. Pituitary 2023; 26:9-41. [PMID: 36447058 PMCID: PMC9708130 DOI: 10.1007/s11102-022-01285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE This systematic literature review investigated whether extended dosing intervals (EDIs) of pharmacological acromegaly treatments reduce patient burden and costs compared with standard dosing, while maintaining effectiveness. METHODS MEDLINE/Embase/the Cochrane Library (2001-June 2021) and key congresses (2018-2021) were searched and identified systematic literature review bibliographies reviewed. Included publications reported on efficacy/effectiveness, safety and tolerability, health-related quality of life (HRQoL), and patient-reported and economic outcomes in longitudinal/cross-sectional studies in adults with acromegaly. Interventions included EDIs of pegvisomant, cabergoline, and somatostatin receptor ligands (SRLs): lanreotide autogel/depot (LAN), octreotide long-acting release (OCT), pasireotide long-acting release (PAS), and oral octreotide; no comparator was required. RESULTS In total, 35 publications reported on 27 studies: 3 pegvisomant monotherapy, 11 pegvisomant combination therapy with SRLs, 9 LAN, and 4 OCT; no studies reported on cabergoline, PAS, or oral octreotide at EDIs. Maintenance of normal insulin-like growth factor I (IGF-I) was observed in ≥ 70% of patients with LAN (1 study), OCT (1 study), and pegvisomant monotherapy (1 study). Achievement of normal IGF-I was observed in ≥ 70% of patients with LAN (3 studies) and pegvisomant in combination with SRLs (4 studies). Safety profiles were similar across EDI and standard regimens. Patients preferred and were satisfied with EDIs. HRQoL was maintained and cost savings were provided with EDIs versus standard regimens. CONCLUSIONS Clinical efficacy/effectiveness, safety, and HRQoL outcomes in adults with acromegaly were similar and costs lower with EDIs versus standard regimens. Physicians may consider acromegaly treatment at EDIs, especially for patients with good disease control.
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Affiliation(s)
- M Fleseriu
- Pituitary Center at Oregon Health & Science University, Portland, OR, USA.
| | - Z Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - K Haria
- Costello Medical, London, UK
| | - A Houchard
- Ipsen Pharma, Boulogne-Billancourt, France
| | - S Khawaja
- World Alliance of Pituitary Organizations, Zeeland, The Netherlands
| | | | - M Gadelha
- Neuroendocrinology Research Center/Endocrinology Division, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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14
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Adherence to Acromegaly Treatment and Analysis of the Related Factors-A Real-World Study in Bulgaria. Pharmaceutics 2023; 15:pharmaceutics15020438. [PMID: 36839760 PMCID: PMC9963513 DOI: 10.3390/pharmaceutics15020438] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
The purpose was to assess the level of medication adherence (MA) and related factors among individuals with acromegaly. The secondary goal was to assess the quality of life of patients and whether and how it correlates with the level of adherence. A prospective one-year study was conducted among patients with acromegaly diagnosed, treated, and monitored in the reference center for rare endocrine diseases in Bulgaria in 2021. Clinical data, patients reported outcomes, and health economics data were collected to define the predictors of non-adherence to medicines. Medication adherence level was assessed through a free Morisky-Green 4-item questionnaire. A total of 179 patients with acromegaly were observed. Approximately 62% were female, 50% were between 41 and 60 years, and the mean age at diagnosis was 40.4 years. The response rate to the questionnaires was 53% (n = 95; mean age 53.5 years, 73% female and 26% male). Patients with high levels of MA reported higher median values for the 36-Item Short Form Health Survey (SF-36) in comparison with those with low levels: 65.5 vs. 48.5 (p = 0.017). Similar results for EQ-5D-3L (3-level EuroQol 5D version) values and the level of MA were found: 0.656 vs. 0.796 (p = 0.0123). A low level of adherence was revealed in 34.7% of the patients, with no difference among different age groups. A significant positive determinant for adherence was years lived with acromegaly (OR = 5.625, 95% CI 1.7401-18.1832, p = 0.0039), as shorter duration was related to higher odds for high level of adherence. The current study demonstrates the importance of MA assessment for patients with acromegaly in Bulgaria. The medication adherence to the prescribed therapy among the observed group of patients with acromegaly varied as the percentage of adherent patients was around 65%. Still, there are low-adherent patients, and the responsible factors should be further investigated.
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15
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Coopmans EC, Andela CD, Claessen KMJA, Biermasz NR. Evaluating the Impact of Acromegaly on Quality of Life. Endocrinol Metab Clin North Am 2022; 51:709-725. [PMID: 36244688 DOI: 10.1016/j.ecl.2022.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acromegaly has a substantial negative impact on quality of life (QoL). This review aims to discuss the impact of acromegaly on QoL from the clinical perspective as well as from the patient perspective. Furthermore, it aims to evaluate the use of patient-reported outcome measures (PROMs) in acromegaly and how PROMs aid decision-making. The recommendations presented in this review are based on recent clinical evidence on the impact of acromegaly on QoL combined with the authors' own clinical experience treating patients with acromegaly. We recommend that a patient-centered approach should be considered in treatment decisions, integrating conventional biochemical outcomes, tumor control, comorbidities, treatment complications, and PROMs, including QoL measures. This more integrated approach seems effective in treating comorbidities and improving patient-reported outcomes and is critical, as many patients do not achieve biochemical or tumor control and comorbidities, impairment in QoL may not remit even when full biochemical control is achieved.
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Affiliation(s)
- Eva C Coopmans
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands; Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZB Leiden, the Netherlands.
| | - Cornelie D Andela
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands; Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZB Leiden, the Netherlands; Basalt Rehabilitation Center, Vrederustlaan 180, 2543 SW Den Haag, the Netherlands
| | - Kim M J A Claessen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands; Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZB Leiden, the Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands; Center for Endocrine Tumors Leiden (CETL), Center for Pituitary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZB Leiden, the Netherlands.
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16
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Fleseriu M, Langlois F, Lim DST, Varlamov EV, Melmed S. Acromegaly: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2022; 10:804-826. [PMID: 36209758 DOI: 10.1016/s2213-8587(22)00244-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022]
Abstract
Growth hormone-secreting pituitary adenomas that cause acromegaly arise as monoclonal expansions of differentiated somatotroph cells and are usually sporadic. They are almost invariably benign, yet they can be locally invasive and show progressive growth despite treatment. Persistent excess of both growth hormone and its target hormone insulin-like growth factor 1 (IGF-1) results in a wide array of cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic comorbidities that might not be reversible with disease control. Normalisation of IGF-1 and growth hormone are the primary therapeutic aims; additional treatment goals include tumour shrinkage, relieving symptoms, managing complications, reducing excess morbidity, and improving quality of life. A multimodal approach with surgery, medical therapy, and (more rarely) radiation therapy is required to achieve these goals. In this Review, we examine the epidemiology, pathogenesis, diagnosis, complications, and treatment of acromegaly, with an emphasis on the importance of tailoring management strategies to each patient to optimise outcomes.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Elena V Varlamov
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Crisafulli S, Fontana A, L'Abbate L, Ientile V, Gianfrilli D, Cozzolino A, De Martino MC, Ragonese M, Sultana J, Barone-Adesi F, Trifirò G. Development and testing of diagnostic algorithms to identify patients with acromegaly in Southern Italian claims databases. Sci Rep 2022; 12:15843. [PMID: 36151305 PMCID: PMC9508179 DOI: 10.1038/s41598-022-20295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
Acromegaly is a rare disease characterized by an excessive production of growth-hormone and insulin-like growth factor 1, typically resulting from a GH-secreting pituitary adenoma. This study was aimed at comparing and measuring accuracy of newly and previously developed coding algorithms for the identification of acromegaly using Italian claims databases. This study was conducted between January 2015 and December 2018, using data from the claims databases of Caserta Local Health Unit (LHU) and Sicily Region in Southern Italy. To detect acromegaly cases from the general target population, four algorithms were developed using combinations of diagnostic, surgical procedure and co-payment exemption codes, pharmacy claims and specialist’s visits. Algorithm accuracy was assessed by measuring the Youden Index, sensitivity, specificity, positive and negative predictive values. The percentage of positive cases for each algorithm ranged from 7.9 (95% CI 6.4–9.8) to 13.8 (95% CI 11.7–16.2) per 100,000 inhabitants in Caserta LHU and from 7.8 (95% CI 7.1–8.6) to 16.4 (95% CI 15.3–17.5) in Sicily Region. Sensitivity of the different algorithms ranged from 71.1% (95% CI 54.1–84.6%) to 84.2% (95% CI 68.8–94.0%), while specificity was always higher than 99.9%. The algorithm based on the presence of claims suggestive of acromegaly in ≥ 2 different databases (i.e., hospital discharge records, copayment exemptions registry, pharmacy claims and specialist visits registry) achieved the highest Youden Index (84.2) and the highest positive predictive value (34.8; 95% CI 28.6–41.6). We tested four algorithms to identify acromegaly cases using claims databases with high sensitivity and Youden Index. Despite identifying rare diseases using real-world data is challenging, this study showed that robust validity testing may yield the identification of accurate coding algorithms.
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Affiliation(s)
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Luca L'Abbate
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Valentina Ientile
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Daniele Gianfrilli
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessia Cozzolino
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Marta Ragonese
- Department of Human Pathology of Adulthood and Childhood "G. Barresi" DETEV, University of Messina, Messina, Italy
| | - Janet Sultana
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Francesco Barone-Adesi
- Department of Translational Medicine, University Piemonte Orientale, Novara, Italy.,Research Center in Emergency and Disaster Medicine (CRIMEDIM), University Piemonte Orientale, Novara, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy.
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