Heart failure and octreotide in acromegaly

Sellar Lesions/Pathology

The sellar region is a tiny anatomic compartment in which many lesions and developmental diseases can be found. If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another. A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty. This article provides an overview of sellar diseases with emphasis on their most useful characteristics for clinical practice.

Safety of Subcutaneous Octreotide in Patients with Sulfonylurea-Induced Hypoglycemia and Congestive Heart Failure

Objective:

To report the safe use of subcutaneous octreotide in the treatment of sulfonylurea-induced hypoglycemia in 2 patients with severe congestive heart failure.

Case Summary:

Two patients with congestive heart failure with systolic dysfunction presented with severe hypoglycemia (blood glucose level: patient 1, 31 mg/dL; patient 2, 36 mg/dL) secondary to sulfonylurea agents. The mechanism of hypoglycemia was poor oral intake and prolonged half-life of the drugs due to renal failure. Hypoglycemia was refractory to glucose supplementation. Patient 1 received 2 doses of octreotide 50 μg subcutaneously 12 hours apart, with resolution of hypoglycemia (blood glucose level: <33 mg/dL before administration of octreotide, 62 mg/dL after first dose, 121 mg/dL after second dose). Patient 2 received an initial dose of octreotide 25 μg subcutaneously; hypoglycemia persisted after this dose, and the patient was given 2 doses of 50 μg subcutaneously 12 hours apart, leading to resolution of hypoglycemia (blood glucose level: 57 mg/dL before administration of octreotide, 80 mg/dL after first dose, 85 mg/dL after second dose, 146 mg/dL after third dose). Resolution of hypoglycemia with octreotide treatment obviated the need for prolonged intravenous dextrose infusions. No local or systemic adverse effects, especially cardiac adverse events, were noted during the course of treatment.

Discussion:

Octreotide is considered the antidote for sulfonylurea-induced hypoglycemia. It may be especially useful in patients with congestive heart failure who may not tolerate intravenous infusions of dextrose. The package insert cautions of the occurrence of cardiac adverse effects such as bradycardia, heart block, and worsening heart failure. Patients with heart failure may theoretically be at a higher risk of these adverse effects due to the concurrent use of atrioventricular blocking agents. However, a review of current literature reveals that the adverse effect profile depends on the route, dose, and formulation of the octreotide used along with the clinical indication. These adverse effects may not be clinically significant with the doses used for treatment of sulfonylurea-induced hypoglycemia and the benefits of the drug may outweigh the risks.

Conclusions:

In these cases, octreotide was safely and effectively used in the treatment of sulfonylurea-induced hypoglycemia in patients with congestive heart failure by adhering to dosing guidelines and close monitoring.

Resolution of acromegalic cardiomyopathy in mild acromegalic physical abnormality after short-term octreotide therapy

Congestive heart failure developed in a 42-year-old man who had very mild acromegalic features. Echocardiography showed a marked dilatation of the left ventricle and decreased systolic function. Laboratory examinations revealed the elevated levels of growth hormone and insulin-like growth factor-1 and pituitary microadenoma was demonstrated by magnetic resonance imaging. Although the extensive conventional medical treatment was ineffective, short-term addition of somatostatin analog, octreotide, rapidly improved his cardiac function. After discontinuation of octreotide, further improvement was observed with minimal residual diastolic dysfunction. All medical treatment could be stopped after successful trans-sphenoidal surgery. Early diagnosis and effective treatment is important to reverse the acromegalic cardiomyopathy.

Improvement of cardiac function after treatment with octreotide followed by trans-sphenoidal surgery in an acromegalic patient who presented with congestive heart failure

Cardiovascular disease is a major cause of mortality and morbidity in patients with acromegaly. We describe the case of a 43-year-old man with acromegaly who presented with severe congestive heart failure. Treatment with the somatostatin analog octreotide improved cardiac function with an increase in left ventricular ejection fraction (LVEF) from 11% to 27%. LVEF further increased to 43% after trans-sphenoidal surgery. Recovery was uneventful. We emphasize the need for early diagnosis and effective treatment of acromegaly to prevent cardiovascular complications. Octreotide therapy or trans-sphenoidal surgery, if possible, should be considered to control cardiac function even in acromegalic patients with severe congestive heart failure.