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MacFarlane J, Korbonits M. Growth hormone receptor antagonist pegvisomant and its role in the medical therapy of growth hormone excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101910. [PMID: 38981769 DOI: 10.1016/j.beem.2024.101910] [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] [Indexed: 07/11/2024]
Abstract
Pegvisomant is a growth-hormone (GH) receptor antagonist that prevents the formation of the active heterotrimer of the dimerised GH receptor and the GH molecule necessary for downstream signal transduction. Over the past 20 years, it has become a key therapeutic option for physicians treating syndromes of GH/IGF-1 excess. Sufficient longitudinal follow-up data suggest that it can be deemed both safe and effective. It is the drug with the greatest potential for achieving an amelioration of the biochemical effects of GH excess with a corresponding normalisation of IGF-1 levels; however, insufficient dose titration has lessened real-world therapeutic outcomes. Theoretical concerns about stimulating tumour growth have been resolved as this has not been observed, while derangement of liver enzymes and local skin-related adverse reactions may occur in a minority of the patients. It may be a particularly impactful medication for the treatment of children, young people, and those with inherited disorders of GH excess, where other treatment modalities often fail. Combination therapy of pegvisomant with first- and second-generation somatostatin receptor ligands or with dopamine agonists remains an ongoing area of interest and research. High cost remains a barrier to the use of pegvisomant in many settings.
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Affiliation(s)
- James MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| | - Márta Korbonits
- Centre for Endocrinology, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
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Haberbosch L, Strasburger CJ. Efficacy and Safety of Pegvisomant in the Treatment of Acromegaly. Arch Med Res 2023; 54:102884. [PMID: 37659952 DOI: 10.1016/j.arcmed.2023.102884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/04/2023]
Abstract
Pegvisomant, the first and currently only clinically available growth hormone receptor antagonist, is an effective therapeutic option for the medical treatment of acromegaly, a rare disorder characterized by excessive growth hormone secretion. With now over 20 years of real world experience, its safety and efficacy is well-established. However, several aspects of its clinical use are still controversially discussed. The high cost of pegvisomant has limited its use in several countries, and recent studies have reported a lower efficacy than the initial clinical trials. A reported increase in tumor volume under therapy varies between studies and has been attributed to either actual growth or re-expansion after cessation of somatostatin receptor ligand therapy. Furthermore, different combinations of pegvisomant and other therapeutic agents aiming at reduction of acromegaly disease activity have been proposed to increase or retain effectiveness while lowering side effects and cost. This review aims to assess current clinical data on the safety and efficacy of pegvisomant while also addressing controversies surrounding its use.
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Affiliation(s)
- Linus Haberbosch
- Department of Endocrinology and Metabolism, Charité Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Berlin, Germany
| | - Christian J Strasburger
- Department of Endocrinology and Metabolism, Charité Universitätsmedizin Berlin, Berlin, Germany.
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Oxley M, Francis H, Sato K. Growth Hormone Signaling in Liver Diseases: Therapeutic Potentials and Controversies. Semin Liver Dis 2023; 43:24-30. [PMID: 36652958 DOI: 10.1055/a-2015-1359] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Growth hormone (GH) and downstream insulin-like growth factor 1 (IGF1) signaling mediate growth and metabolism. GH deficiency causes short stature or dwarfism, and excess GH causes acromegaly. Although the association of GH/IGF1 signaling with liver diseases has been suggested previously, current studies are controversial and the functional roles of GH/IGF1 signaling are still undefined. GH supplementation therapy showed promising therapeutic effects in some patients, such as non-alcoholic fatty liver disease, but inhibition of GH signaling may be beneficial for other liver diseases, such as hepatocellular carcinoma. The functional roles of GH/IGF1 signaling and the effects of agonists/antagonists targeting this signaling may differ depending on the liver injury or animal models. This review summarizes current controversial studies of GH/IGF1 signaling in liver diseases and discusses therapeutic potentials of GH therapy.
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Affiliation(s)
- Madisyn Oxley
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather Francis
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Research, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Keisaku Sato
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Caulley L, Krijkamp E, Doyle MA, Thavorn K, Alkherayf F, Sahlollbey N, Dong SX, Quinn J, Johnson-Obaseki S, Schramm D, Kilty SJ, Hunink MGM. Cost-effectiveness of direct surgery versus preoperative octreotide therapy for growth-hormone secreting pituitary adenomas. Pituitary 2022; 25:868-881. [PMID: 36030360 PMCID: PMC9675692 DOI: 10.1007/s11102-022-01270-8] [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] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE The objective of this study was to compare the cost-effectiveness of preoperative octreotide therapy followed by surgery versus the standard treatment modality for growth-hormone secreting pituitary adenomas, direct surgery (that is, surgery without preoperative treatment) from a public third-party payer perspective. METHODS We developed an individual-level state-transition microsimulation model to simulate costs and outcomes associated with preoperative octreotide therapy followed by surgery and direct surgery for patients with growth-hormone secreting pituitary adenomas. Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually over a lifetime time horizon. Model outcomes included lifetime costs [2020 United States (US) Dollars], quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). RESULTS Under base case assumptions, direct surgery was found to be the dominant strategy as it yielded lower costs and greater health effects (QALYs) compared to preoperative octreotide strategy in the second-order Monte Carlo microsimulation. The ICER was most sensitive to probability of remission following primary therapy and duration of preoperative octreotide therapy. Accounting for joint parameter uncertainty, direct surgery had a higher probability of demonstrating a cost-effective profile compared to preoperative octreotide treatment at 77% compared to 23%, respectively. CONCLUSIONS Using standard benchmarks for cost-effectiveness in the US ($100,000/QALY), preoperative octreotide therapy followed by surgery may not be cost-effective compared to direct surgery for patients with growth-hormone secreting pituitary adenomas but the result is highly sensitive to initial treatment failure and duration of preoperative treatment.
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Affiliation(s)
- Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada.
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
- Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Eline Krijkamp
- Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mary-Anne Doyle
- Department of Medicine, Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fahad Alkherayf
- The Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Neurosurgery, University of Ottawa, Ottawa, Canada
| | - Nick Sahlollbey
- Department of Undergraduate Medicine, University of Ottawa, Ottawa, Canada
| | - Selina X Dong
- Department of Undergraduate Medicine, University of Ottawa, Ottawa, Canada
| | - Jason Quinn
- Department of Pathology, Dalhousie University, Halifax, Canada
| | - Stephanie Johnson-Obaseki
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - David Schramm
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Shaun J Kilty
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Myriam G M Hunink
- Department of Epidemiology and Biostatistics and Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
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Graffeo CS, Yagnik KJ, Carlstrom LP, Lakomkin N, Bancos I, Davidge-Pitts C, Erickson D, Choby G, Pollock BE, Chamberlain AM, Van Gompel JJ. Pituitary Adenoma Incidence, Management Trends, and Long-term Outcomes: A 30-Year Population-Based Analysis. Mayo Clin Proc 2022; 97:1861-1871. [PMID: 35753823 PMCID: PMC9981281 DOI: 10.1016/j.mayocp.2022.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/05/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To perform a population-based study of pituitary adenoma epidemiology, including longitudinal trends in disease incidence, treatment patterns, and outcomes. PATIENTS AND METHODS In this study of incident pituitary adenomas in Olmsted County, Minnesota, from January 1, 1989, through December 31, 2019, we identified 785 patients who underwent primary screening, 435 of whom were confirmed as harboring incident pituitary adenomas and were included. Primary outcomes of interest included demographic characteristics, presenting features, and disease outcomes (tumor control, biochemical control, and complications). RESULTS Among our 435 study patients, 438 unique pituitary adenomas were diagnosed at a median patient age of 39 years (interquartile range [IQR], 27 to 58 years). Adenomas were incidentally identified in 164 of the 438 tumors (37%). Common symptomatic presentations included hyperprolactinemia (188 of 438 [43%]) and visual field deficit (47 of 438 [11%]). Laboratory tests confirmed pituitary hormone hypersecretion in 238 of the 435 patients (55%), which was symptomatic in 222. The median tumor diameter was 8 mm (IQR, 5 to 17 mm). Primary management strategies were observation (156 of 438 tumors [36%]), medication (162 of 438 tumors [37%]), and transsphenoidal resection (120 of 438 tumors [27%]). Tumor and biochemical control were achieved in 398 (95%) and 216 (91%) secreting tumors, respectively. New posttreatment pituitary or visual deficits were noted in 43 (11%) and 8 (2%); apoplexy occurred in 28 (6%). Median clinical follow-up was 98 months (IQR, 47 to 189 months). Standardized incidence rates were 3.77 to 16.87 per 100,000 population, demonstrating linear expansion over time (R2=0.67). The mean overall standardized incidence rate was 10.1 per 100,000 population; final point prevalence was 175.1 per 100,000 population. CONCLUSION Pituitary adenoma is a highly incident disease, with prolactin-secreting and incidental lesions representing the majority of tumors. Incidence rates and asymptomatic detection appear to be increasing over time. Presenting symptoms and treatment pathways are variable; however, most patients achieve favorable outcomes with observation or a single treatment modality.
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Affiliation(s)
| | - Karan J Yagnik
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN
| | | | | | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester MN
| | - Garret Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN; Department of Radiation Oncology, Mayo Clinic, Rochester MN
| | | | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester MN; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester MN.
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Brue T, Chanson P, Rodien P, Delemer B, Drui D, Marié L, Juban L, Salvi L, Henocque R, Raverot G. Cost-Utility of Acromegaly Pharmacological Treatments in a French Context. Front Endocrinol (Lausanne) 2021; 12:745843. [PMID: 34690933 PMCID: PMC8531881 DOI: 10.3389/fendo.2021.745843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/08/2021] [Indexed: 12/17/2022] Open
Abstract
Objective Efficacy of pharmacological treatments for acromegaly has been assessed in many clinical or real-world studies but no study was interested in economics evaluation of these treatments in France. Therefore, the objective of this study was to estimate the cost-utility of second-line pharmacological treatments in acromegaly patients. Methods A Markov model was developed to follow a cohort of 1,000 patients for a lifetime horizon. First-generation somatostatin analogues (FGSA), pegvisomant, pasireotide and pegvisomant combined with FGSA (off label) were compared. Efficacy was defined as the normalization of insulin-like growth factor-1 (IGF-1) concentration and was obtained from pivotal trials and adjusted by a network meta-analysis. Costs data were obtained from French databases and literature. Utilities from the literature were used to estimate quality-adjusted life year (QALY). Results The incremental cost-utility ratios (ICUR) of treatments compared to FGSA were estimated to be 562,463 € per QALY gained for pasireotide, 171,332 € per QALY gained for pegvisomant, and 186,242 € per QALY gained for pegvisomant + FGSA. Pasireotide seems to be the least cost-efficient treatment. Sensitivity analyses showed the robustness of the results. Conclusion FGSA, pegvisomant and pegvisomant + FGSA were on the cost-effective frontier, therefore, depending on the willingness-to-pay for an additional QALY, they are the most cost-effective treatments. This medico-economic analysis highlighted the consistency of the efficiency results with the efficacy results assessed in the pivotal trials. However, most recent treatment guidelines recommend an individualized treatment strategy based on the patient and disease profile.
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Affiliation(s)
- Thierry Brue
- Assistance Publique-Hôpitaux de Marseille (AP-HM), Department of Endocrinology, Hôpital de la Conception, Centre de Référence des Maladies Rares de l’hypophyse HYPO, Marseille, France
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Marseille Medical Genetics (MMG), Institut Marseille Maladies Rares (MarMaRa), Marseille, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l’Hypophyse, Le Kremlin-Bicêtre, France
| | - Patrice Rodien
- Université d’Angers, CHU d’Angers, service d’Endocrinologie-Diabétologie-Nutrition, Centre de Référence des Maladies Rares de l’Hypophyse, Angers, France
| | - Brigitte Delemer
- CHU de Reims - Hôpital Robert Debré, Service d’Endocrinologie – Diabète – Nutrition, Reims Cedex, France
| | - Delphine Drui
- Endocrinology Department, L’institut du thorax, University Hospital of Nantes, Nantes Cedex, France
| | | | | | - Lara Salvi
- Rare Disease, Pfizer France, Paris Cedex, France
| | | | - Gérald Raverot
- Endocrinology Department, “Groupement Hospitalier Est” Hospices Civils de Lyon, Bron, France
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Leonart LP, Riveros BS, Krahn MD, Pontarolo R. Pharmacological Acromegaly Treatment: Cost-Utility and Value of Information Analysis. Neuroendocrinology 2021; 111:388-402. [PMID: 32299084 DOI: 10.1159/000507890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/14/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To conduct a cost-utility analysis comparing drug strategies involving octreotide, lanreotide, pasireotide, and pegvisomant for the treatment of patients with acromegaly who have failed surgery, from a Brazilian public payer perspective. METHODS A probabilistic cohort Markov model was developed. One-year cycles were employed. The patients started at 45 years of age and were followed lifelong. Costs, efficacy, and quality of life parameters were retrieved from the literature. A discount rate (5%) was applied to both costs and efficacy. The results were reported as costs per quality-adjusted life year (QALY), and incremental cost-effectiveness ratios (ICERs) were calculated when applicable. Scenario analyses considered alternative dosages, discount rate, tax exemption, and continued use of treatment despite lack of response. Value of information (VOI) analysis was conducted to explore uncertainty and to estimate the costs to be spent in future research. RESULTS Only lanreotide showed an ICER reasonable for having its use considered in clinical practice (R$ 112,138/US$ 28,389 per QALY compared to no treatment). Scenario analyses corroborated the base-case result. VOI analysis showed that much uncertainty surrounds the parameters, and future clinical research should cost less than R$ 43,230,000/US$ 10,944,304 per year. VOI also showed that almost all uncertainty that precludes an optimal strategy choice involves quality of life. CONCLUSIONS With current information, the only strategy that can be considered cost-effective in Brazil is lanreotide treatment. No second-line treatment is recommended. Significant uncertainty of parameters impairs optimal decision-making, and this conclusion can be generalized to other countries. Future research should focus on acquiring utility data.
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Affiliation(s)
- Leticia P Leonart
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Brazil
| | - Bruno S Riveros
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Brazil
| | - Murray D Krahn
- Toronto Health Economics and Technology Assessment Collaborative (THETA), Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Pontarolo
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Brazil,
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Tamshen K, Wang Y, Jamieson SM, Perry JK, Maynard HD. Genetic Code Expansion Enables Site-Specific PEGylation of a Human Growth Hormone Receptor Antagonist through Click Chemistry. Bioconjug Chem 2020; 31:2179-2190. [PMID: 32786367 PMCID: PMC8291075 DOI: 10.1021/acs.bioconjchem.0c00365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Regulation of human growth hormone (GH) signaling has important applications in the remediation of several diseases including acromegaly and cancer. Growth hormone receptor (GHR) antagonists currently provide the most effective means for suppression of GH signaling. However, these small 22 kDa recombinantly engineered GH analogues exhibit short plasma circulation times. To improve clinical viability, between four and six molecules of 5 kDa poly(ethylene glycol) (PEG) are nonspecifically conjugated to the nine amines of the GHR antagonist designated as B2036 in the FDA-approved therapeutic pegvisomant. PEGylation increases the molecular weight of B2036 and considerably extends its circulation time, but also dramatically reduces its bioactivity, contributing to high dosing requirements and increased cost. As an alternative to nonspecific PEGylation, we report the use of genetic code expansion technology to site-specifically incorporate the unnatural amino acid propargyl tyrosine (pglY) into B2036 with the goal of producing site-specific protein-polymer conjugates. Substitution of tyrosine 35 with pglY yielded a B2036 variant containing an alkyne functional group without compromising bioactivity, as verified by a cellular assay. Subsequent conjugation of 5, 10, and 20 kDa azide-containing PEGs via the copper-catalyzed click reaction yielded high purity, site-specific conjugates with >89% conjugation efficiencies. Site-specific attachment of PEG to B2036 is associated with substantially improved in vitro bioactivity values compared to pegvisomant, with an inverse relationship between polymer size and activity observed. Notably, the B2036-20 kDa PEG conjugate has a molecular weight comparable to pegvisomant, while exhibiting a 12.5 fold improvement in half-maximal inhibitory concentration in GHR-expressing Ba/F3 cells (103.3 nM vs 1289 nM). We expect that this straightforward route to achieve site-specific GHR antagonists will be useful for GH signal regulation.
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Affiliation(s)
- Kyle Tamshen
- Department of Chemistry and Biochemistry, University of California, Los Angeles, California 90095-1569, United States
| | - Yue Wang
- Liggins Institute, University of Auckland, Auckland 1203, New Zealand
| | - Stephen M.F. Jamieson
- Maurice Wilkins Centre for Molecular Biodiscovery, Auckland 1023, New Zealand
- Auckland Cancer Society Research Centre, School of Medical Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Jo K. Perry
- Liggins Institute, University of Auckland, Auckland 1203, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, Auckland 1023, New Zealand
| | - Heather D. Maynard
- Department of Chemistry and Biochemistry, University of California, Los Angeles, California 90095-1569, United States
- California NanoSystems Institute, University of California, Los Angeles, California 90095-1569, United States
- Department of Bioengineering, University of California, Los Angeles, California 90095-1569, United States
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Mohammed N, Ding D, Hung YC, Xu Z, Lee CC, Kano H, Martínez-Álvarez R, Martínez-Moreno N, Mathieu D, Kosak M, Cifarelli CP, Katsevman GA, Lunsford LD, Vance ML, Sheehan JP. Primary versus postoperative stereotactic radiosurgery for acromegaly: a multicenter matched cohort study. J Neurosurg 2020; 132:1507-1516. [PMID: 31026829 PMCID: PMC7418066 DOI: 10.3171/2019.1.jns183398] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The role of primary stereotactic radiosurgery (SRS) in patients with medically refractory acromegaly who are not operative candidates or who refuse resection is poorly understood. The aim of this multicenter, matched cohort study was to compare the outcomes of primary versus postoperative SRS for acromegaly. METHODS The authors reviewed an International Radiosurgery Research Foundation database of 398 patients with acromegaly who underwent SRS and categorized them into primary or postoperative cohorts. Patients in the primary SRS cohort were matched, in a 1:2 ratio, to those in the postoperative SRS cohort, and the outcomes of the 2 matched cohorts were compared. RESULTS The study cohort comprised 78 patients (median follow-up 66.4 months), including 26 and 52 in the matched primary and postoperative SRS cohorts, respectively. In the primary SRS cohort, the actuarial endocrine remission rates at 2 and 5 years were 20% and 42%, respectively. The Cox proportional hazards model showed that a lower pre-SRS insulin-like growth factor-1 level was predictive of initial endocrine remission (p = 0.03), whereas a lower SRS margin dose was predictive of biochemical recurrence after initial remission (p = 0.01). There were no differences in the rates of radiological tumor control (p = 0.34), initial endocrine remission (p = 0.23), biochemical recurrence after initial remission (p = 0.33), recurrence-free survival (p = 0.32), or hypopituitarism (p = 0.67) between the 2 matched cohorts. CONCLUSIONS Primary SRS has a reasonable benefit-to-risk profile for patients with acromegaly in whom resection is not possible, and it has similar outcomes to endocrinologically comparable patients who undergo postoperative SRS. SRS with medical therapy in the latent period can be used as an alternative to surgery in selected patients who cannot or do not wish to undergo resection.
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Affiliation(s)
- Nasser Mohammed
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | | | - David Mathieu
- Department of Neurological Surgery, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Mikulas Kosak
- 3rd Department of Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Gennadiy A. Katsevman
- Department of Neurological Surgery, West Virginia University, Morgantown, West Virginia
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Polat Korkmaz O, Gurcan M, Nuhoglu Kantarci FE, Haliloglu O, Ozkaya HM, Sahin S, Oren MM, Tanriover N, Gazioglu N, Kadioglu P. The effects of pre-operative somatostatin analogue therapy on treatment cost and remission in acromegaly. Pituitary 2019; 22:387-396. [PMID: 31098838 DOI: 10.1007/s11102-019-00968-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the effects of preoperative somatostatin analogue (SSA) treatment on the annual cost of all acromegaly treatment modalities and on remission rates. METHODS The medical records of 135 patients with acromegaly who were followed at endocrinology clinic of Cerrahpasa Medical Faculty for at least 2 years after surgery between 2009 and 2016 were reviewed. RESULTS The mean follow-up time was 50.9 ± 25.7 months. Early remission was defined according to 3rd month values in patients who didn't achieve remission, and 6th month values in patients who achieved remission at the 3rd month after surgery. The early and late remission rates of the entire study population were 40% and 80.7%, respectively. The early remission of the preoperative SSA-treated group (61.5%) was significantly higher than SSA-untreated group (31.2%) (p = 0.002). The early remission of the preoperative SSA-treated patients with macroadenomas (52.2%) was also significantly higher than the SSA-untreated group (23.5%) (p = 0.02). In the subgroup analysis; this difference was much more pronounced in invasive macroadenomas (p = 0.002). There were no differences between the groups in terms of late remission.The median annual cost of all acromegaly treatment modalities in study population was €3788.4; the cost for macroadenomas was significantly higher than for microadenomas (€4125.0 vs. €3226.5, respectively; p = 0.03). Preoperative SSA use in both microadenomas and macroadenomas didn't alter the cost of treatment. The increase in the duration of preoperative medical treatment had no effect on early or late remissions (p = 0.09; p = 0.8). CONCLUSIONS Preoperative medical treatment had no effect on the costs of acromegaly treatment. There was a benefical effect of pre-operative SSA use on early remission in patients with macroadenomas; however, this effect didn't persist long term.
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Affiliation(s)
- Ozge Polat Korkmaz
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Mert Gurcan
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Ozlem Haliloglu
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Serdar Sahin
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | | | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nurperi Gazioglu
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey.
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11
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Kamusheva M, Rusenova Y, Vandeva S, Elenkova A, Zaharieva S, Doneva M, Mitkova Z, Petrova G. Economic and pharmaco-economic analysis of acromegaly treatment: a systematic review. BIOTECHNOL BIOTEC EQ 2019. [DOI: 10.1080/13102818.2019.1680317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Maria Kamusheva
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Yanitsa Rusenova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Silvia Vandeva
- Department of Endocrinology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Atanaska Elenkova
- Department of Endocrinology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Sabina Zaharieva
- Department of Endocrinology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Miglena Doneva
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Zornitsa Mitkova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Guenka Petrova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
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Leonart LP, Tonin FS, Ferreira VL, Fernandez-Llimos F, Pontarolo R. Effectiveness and safety of pegvisomant: a systematic review and meta-analysis of observational longitudinal studies. Endocrine 2019; 63:18-26. [PMID: 30145746 DOI: 10.1007/s12020-018-1729-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/16/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE Acromegaly is a rare disease that often requires drug treatment to achieve control, with pegvisomant being one of the most widely used therapies. In the present paper, we aimed to obtain evidence regarding the effectiveness and safety of pegvisomant by reviewing real-world observational longitudinal studies. METHODS A systematic review was performed with a meta-analysis of event rates (95% confidence interval (CI)) using a random effects model. Sensitivity and subgroup analyses were performed (comprehensive meta-analysis 2.0). The systematic review was performed in accordance to preferred reporting items for systematic reviews and meta-analyses, meta-analysis of observational studies in epidemiology, and Cochrane recommendations (PROSPERO register CRD 42017059880). PubMed, Scopus, Web of Science, and SciELO were used to search for literature. Observational studies in patients using pegvisomant for the treatment of acromegaly were included. RESULTS Initially, 552 papers were retrieved from the databases; and 31 articles were included in the qualitative analysis and 14 in the quantitative analysis. Eight primary meta-analyses were performed. The overall rate of patients with disease control was of 60.9% (51.8-69.3%; 95% CI). When considering patients under monotherapy, the control rate was 71.7% (64.0-78.4%; 95% CI). Tumor growth was estimated in 7.3% (4.7-11.1%; 95% CI) and elevation of transaminases in 3.0% (1.7-5.2%; 95% CI). CONCLUSIONS The real-world data showed that the effectiveness of pegvisomant is not as high as reported in interventional studies. Acromegaly appears to be better controlled when pegvisomant is used as a monotherapy. No serious adverse events were associated with the use of pegvisomant; however, given the high cost of this drug, further studies are required.
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Affiliation(s)
- Letícia P Leonart
- Universidade Federal do Paraná, Graduate Program in Pharmaceutical Sciences, Curitiba, Paraná, Brazil
| | - Fernanda S Tonin
- Universidade Federal do Paraná, Graduate Program in Pharmaceutical Sciences, Curitiba, Paraná, Brazil
| | - Vinicius L Ferreira
- Universidade Federal do Paraná, Graduate Program in Pharmaceutical Sciences, Curitiba, Paraná, Brazil
| | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Department of Social Pharmacy, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Roberto Pontarolo
- Universidade Federal do Paraná, Graduate Program in Pharmaceutical Sciences, Curitiba, Paraná, Brazil.
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Leonart LP, Borba HHL, Ferreira VL, Riveros BS, Pontarolo R. Cost-effectiveness of acromegaly treatments: a systematic review. Pituitary 2018; 21:642-652. [PMID: 30159696 DOI: 10.1007/s11102-018-0908-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE Acromegaly is a rare disease that results in the enlargement of body extremities and in organomegaly. Treatments include surgery, drugs, and radiotherapy, which are all onerous. Therefore, well-conducted cost-analyses are crucial in the decision-making process. METHODS A systematic review of cost-effectiveness studies on acromegaly therapies was performed following PRISMA and Cochrane recommendations. The search for records was conducted in PubMed, Scopus, and Web of Science (May 2018). The quality of the included studies was assessed using the Joana Briggs Institute Tool. RESULTS From initial 547 records, 16 studies were included in the review. The studies could present more than one economic evaluation, and encompassed cost-effectiveness (n = 13), cost-utility (n = 5), and cost-consequence (n = 1) analyses. All studies were model-based and evaluated only direct medical costs. Eleven records did not mention discounting and only 10 performed sensitivity analyses. The characteristic of the studies, the cost-effectiveness results and the studies' conclusions are described and commented upon. The main limitation of the studies was discussed and aspects to improve in future studies were pointed out. CONCLUSIONS Cost-effectiveness studies on acromegaly have been performed in several scenarios, evaluating different phases of treatment. However, the studies present limitations and, overall, were considered of moderate quality. Further economic models should be developed following health economics guidelines recommendations, and must improve transparency.
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Affiliation(s)
- Letícia P Leonart
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Helena H L Borba
- Department of Pharmacy, Universidade Federal do Paraná, Street Pref. Lothário Meissner, 632, Curitiba, Paraná, 80210-170, Brazil
| | - Vinicius L Ferreira
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Bruno S Riveros
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Roberto Pontarolo
- Graduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Paraná, Brazil.
- Department of Pharmacy, Universidade Federal do Paraná, Street Pref. Lothário Meissner, 632, Curitiba, Paraná, 80210-170, Brazil.
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Bernabeu I, Cámara R, Marazuela M, Puig Domingo M. Documento de expertos sobre el manejo de la acromegalia. ENDOCRINOL DIAB NUTR 2018; 65:428-437. [DOI: 10.1016/j.endinu.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 11/26/2022]
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15
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Orlewska E, Stępień R, Orlewska K. Cost-effectiveness of somatostatin analogues in the treatment of acromegaly. Expert Rev Pharmacoecon Outcomes Res 2018; 19:15-25. [PMID: 30122081 DOI: 10.1080/14737167.2018.1513330] [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: 10/28/2022]
Abstract
INTRODUCTION Somatostatin analogues (SSAs) are the largest contributor to the direct medical cost of acromegaly management worldwide. The aim of this review was to identify and report available evidence on the cost-effectiveness of SSAs in the treatment of acromegaly. AREAS COVERED A literature search on relevant papers published up to April 2018 was performed. A total of 22 eligible studies (10 full-text articles and 12 conference abstracts) conducted in 14 countries were included in the analysis. In majority of studies, modelling technique was the principal research method. EXPERT COMMENTARY The results of cost-effectiveness analyses: 1) support published recommendations where SSAs are indicated as first-line medical treatment for patients with persistent disease after surgery or who are not eligible for surgery; 2) suggest that preoperative medical therapy with SSAs may be highly cost-effective in acromegalic patients with macroadenoma, in centres without optimal surgical results 3) indicate that in some countries pasireotide and pegvisomant appeared to be cost-effective or even dominant strategies in comparison to first-generation SSAs. The main limitation of economic evaluations was the lack of high-quality studies designed to directly compare various treatment strategies in acromegaly.
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Affiliation(s)
- Ewa Orlewska
- a Faculty of Medicine and Health Sciences , The Jan Kochanowski University , Kielce , Poland
| | - Renata Stępień
- a Faculty of Medicine and Health Sciences , The Jan Kochanowski University , Kielce , Poland
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16
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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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Wilkinson IR, Pradhananga SL, Speak R, Artymiuk PJ, Sayers JR, Ross RJ. A long-acting GH receptor antagonist through fusion to GH binding protein. Sci Rep 2016; 6:35072. [PMID: 27731358 PMCID: PMC5059632 DOI: 10.1038/srep35072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/23/2016] [Indexed: 12/14/2022] Open
Abstract
Acromegaly is a human disease of growth hormone (GH) excess with considerable morbidity and increased mortality. Somatostatin analogues are first line medical treatment but the disease remains uncontrolled in up to 40% of patients. GH receptor (GHR) antagonist therapy is more effective but requires frequent high-dose injections. We have developed an alternative technology for generating a long acting potent GHR antagonist through translational fusion of a mutated GH linked to GH binding protein and tested three candidate molecules. All molecules had the amino acid change (G120R), creating a competitive GHR antagonist and we tested the hypothesis that an amino acid change in the GH binding domain (W104A) would increase biological activity. All were antagonists in bioassays. In rats all antagonists had terminal half-lives >20 hours. After subcutaneous administration in rabbits one variant displayed a terminal half-life of 40.5 hours. A single subcutaneous injection of the same variant in rabbits resulted in a 14% fall in IGF-I over 7 days. IN CONCLUSION we provide proof of concept that a fusion of GHR antagonist to its binding protein generates a long acting GHR antagonist and we confirmed that introducing the W104A amino acid change in the GH binding domain enhances antagonist activity.
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Ramos-Leví AM, Bernabeu I, Sampedro-Núñez M, Marazuela M. Genetic Predictors of Response to Different Medical Therapies in Acromegaly. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2016; 138:85-114. [PMID: 26940388 DOI: 10.1016/bs.pmbts.2015.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the era of predictive medicine, management of diseases is evolving into a more personal and individualized approach, as more data are available regarding clinical, biochemical, radiological, molecular, histopathological, and genetic aspects. In the particular setting of acromegaly, which is a rare, chronic, debilitating, and disfiguring disease, an optimized approach deems even more necessary, especially because of an associated increased morbidity and mortality, the impact on patients' quality of life, and the increased cost of frequently necessary life-long treatments. In this paper, we review the available studies that address potential genetic influences on acromegaly, their role in the outcome, and response to treatments, as well as their contribution to the risk of developing side effects. We focus mainly on pharmacogenetic factors involved during treatment with dopamine agonists, somatostatin analogs, and pegvisomant. Specifically, mutations in dopamine receptors, somatostatin receptors, growth hormone receptors, and metabolic pathways involved in growth hormone action; polymorphisms in the insulin-like growth factor and the insulin-like growth factor binding proteins; and polymorphisms in other genes that may determine differences in the frequency of developing adverse events.
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Affiliation(s)
- Ana M Ramos-Leví
- Department of Endocrinology and Nutrition, Hospital Universitario la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ignacio Bernabeu
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Santiago de Compostela, Servicio Gallego de Salud (SERGAS); Universidad de Santiago de Compostela, La Coruña, Spain
| | - Miguel Sampedro-Núñez
- Department of Endocrinology and Nutrition, Hospital Universitario la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario la Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
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Margusino-Framiñán L, Pertega-Diaz S, Pena-Bello L, Sangiao-Alvarellos S, Outeiriño-Blanco E, Pita-Gutierrez F, Pita-Fernandez S, Cordido F. Cost-effectiveness analysis of preoperative treatment of acromegaly with somatostatin analogue on surgical outcome. Eur J Intern Med 2015; 26:736-41. [PMID: 26300269 DOI: 10.1016/j.ejim.2015.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/19/2015] [Accepted: 07/29/2015] [Indexed: 01/28/2023]
Abstract
CONTEXT There is no uniform standard of care for acromegaly. Due to the high costs involved, steps must be taken to ensure the cost-effective delivery of treatment. OBJECTIVE Taking the results of an earlier meta-analysis as a starting point, this study aims to determine whether treatment with long-acting somatostatin analogue (SSA) prior to surgery improves the cost-effectiveness of the treatment of acromegaly. METHODS The results are presented as an Incremental Cost Effectiveness Ratio (ICER) immediately after surgery, for the following year and over the next four decades. The cure rates percentage (95% CI) for the three randomized prospective controlled trials were 44.4% (34.2-54.7) and 18.2% (10.1-26.3) for preoperative treated and untreated patients respectively. The cost of pharmacological treatments was based on the number of units prescribed, dose and length of treatment. RESULTS The mean (95% CI) ICER immediately after surgery was €17,548 (12,007-33,250). In terms of the postoperative SSA treatment, the ICER changes from positive to negative before two years after surgery. One decade after surgery the ICER per patient/year was €-9973 (-18,798; -6752) for postoperative SSA treatment and €-31,733 (-59,812; -21,483) in the case of postoperative pegvisomant treatment. CONCLUSIONS In centres without optimal surgical results, preoperative treatment of GH-secreting pituitary macroadenomas with SSA not only shows a significant improvement in the surgical results, but is also highly cost-effective, with an ICER per patient/year one decade after surgery, of between €-9973 (-18,798; -6752) and €-31,733 (-59,812; -21,483) for SSA and pegvisomant respectively.
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Affiliation(s)
| | - Sonia Pertega-Diaz
- Clinical Epidemiology and Biostatistics Unit, University Hospital A Coruña, A Coruña, Spain
| | - Lara Pena-Bello
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain; Department of Medicine, Faculty of Health Sciences, University of A Coruña, A Coruña, Spain
| | | | | | | | - Fernando Cordido
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain; Department of Medicine, Faculty of Health Sciences, University of A Coruña, A Coruña, Spain; Department of Endocrinology, University Hospital A Coruña, A Coruña, Spain.
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Ingram DK, Roth GS. Calorie restriction mimetics: can you have your cake and eat it, too? Ageing Res Rev 2015; 20:46-62. [PMID: 25530568 DOI: 10.1016/j.arr.2014.11.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 11/25/2014] [Accepted: 11/25/2014] [Indexed: 12/31/2022]
Abstract
Strong consensus exists regarding the most robust environmental intervention for attenuating aging processes and increasing healthspan and lifespan: calorie restriction (CR). Over several decades, this paradigm has been replicated in numerous nonhuman models, and has been expanded over the last decade to formal, controlled human studies of CR. Given that long-term CR can create heavy challenges to compliance in human diets, the concept of a calorie restriction mimetic (CRM) has emerged as an active research area within gerontology. In past presentations on this subject, we have proposed that a CRM is a compound that mimics metabolic, hormonal, and physiological effects of CR, activates stress response pathways observed in CR and enhances stress protection, produces CR-like effects on longevity, reduces age-related disease, and maintains more youthful function, all without significantly reducing food intake, at least initially. Over 16 years ago, we proposed that glycolytic inhibition could be an effective strategy for developing CRM. The main argument here is that inhibiting energy utilization as far upstream as possible provides the highest chance of generating a broad spectrum of CR-like effects when compared to targeting a singular molecular target downstream. As an initial candidate CRM, 2-deoxyglucose, a known anti-glycolytic, was shown to produce a remarkable phenotype of CR, but further investigation found that this compound produced cardiotoxicity in rats at the doses we had been using. There remains interest in 2DG as a CRM but at lower doses. Beyond the proposal of 2DG as a candidate CRM, the field has grown steadily with many investigators proposing other strategies, including novel anti-glycolytics. Within the realm of upstream targeting at the level of the digestive system, research has included bariatric surgery, inhibitors of fat digestion/absorption, and inhibitors of carbohydrate digestion. Research focused on downstream sites has included insulin receptors, IGF-1 receptors, sirtuin activators, inhibitors of mTOR, and polyamines. In the current review we discuss progress made involving these various strategies and comment on the status and future for each within this exciting research field.
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Affiliation(s)
- Donald K Ingram
- Nutritional Neuroscience and Aging Laboratory, Pennington Biomedical Research Center, Louisiana State University System, 6400 Perkins Road, Baton Rouge, LA 70809, United States.
| | - George S Roth
- GeroScience, Inc., Pylesville, MD 21132, United States.
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21
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Giustina A. Optimal use of pegvisomant in acromegaly: are we getting there? Endocrine 2015; 48:3-8. [PMID: 25348149 DOI: 10.1007/s12020-014-0462-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 10/20/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Andrea Giustina
- Chair of Endocrinology, University of Brescia, A.O. Spedali Civili, Via Biseo 17, 25123, Brescia, Italy,
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22
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Ferreri L, Auriemma RS, Grasso LFS, Pivonello R, Colao A. Efficacy and tolerability of treatment with pegvisomant in acromegaly: an overview of literature. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.970171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Giustina A, Ambrosio MR, Beck Peccoz P, Bogazzi F, Cannavo' S, De Marinis L, De Menis E, Grottoli S, Pivonello R. Use of Pegvisomant in acromegaly. An Italian Society of Endocrinology guideline. J Endocrinol Invest 2014; 37:1017-30. [PMID: 25245336 PMCID: PMC4182612 DOI: 10.1007/s40618-014-0146-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/04/2014] [Indexed: 11/07/2022]
Affiliation(s)
- A Giustina
- Struttura Ambulatoriale di Endocrinologia, A.O. Spedali Civili di Brescia, University of Brescia, Via Biseo 17, 25100, Brescia, Italy,
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Stone JC, Clark J, Cuneo R, Russell AW, Doi SAR. Estrogen and selective estrogen receptor modulators (SERMs) for the treatment of acromegaly: a meta-analysis of published observational studies. Pituitary 2014; 17:284-95. [PMID: 23925896 DOI: 10.1007/s11102-013-0504-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Estrogen and selective estrogen receptor modulator (SERM) treatments for acromegaly have received limited attention since the development of newer pharmacologic therapies. There has been ongoing research evidence suggesting their utility in the biochemical control of acromegaly. Therefore, the aim of this meta-analysis was to synthesise current evidence with a view to determining to what extent and in which acromegalic patient subsets do estrogen and SERMs reduce IGF-1 levels. A literature search was conducted (finished December 2012), which included all studies pertaining to estrogen or SERM treatment and IGF-1. Seven patient subsets were identified from six published observational studies, and were pooled using meta-analytic methods. Overall, the pooled mean loss in IGF-1 was -29.09 nmol/L (95 % CI -37.23 to -20.95). A sensitivity analysis indicated that women receiving estrogen had a substantially greater reduction in IGF-1 levels compared with women receiving SERMs, with a weighted mean loss in IGF-1 of -38.12 nmol/L (95 % CI -46.78 to -29.45) compared with -22.91 nmol/L (95 % CI -32.73 to -13.09). There was a trend that did not reach statistical significance for men receiving SERM treatment at -11.41 nmol/L (95 % CI -30.14 to 7.31). It was concluded that estrogen and SERMs are a low cost and effective treatment to achieve control of IGF-1 levels in acromegalic women either as concomitant treatment for refractory disease, or where access to conventional therapy is restricted. Their use in men requires further study.
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Affiliation(s)
- Jennifer C Stone
- Clinical Epidemiology Unit, School of Population Health, University of Queensland, Brisbane, QLD, Australia
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25
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Vilar L, Valenzuela A, Ribeiro-Oliveira A, Gómez Giraldo CM, Pantoja D, Bronstein MD. Multiple facets in the control of acromegaly. Pituitary 2014; 17 Suppl 1:S11-7. [PMID: 24272033 PMCID: PMC3906559 DOI: 10.1007/s11102-013-0536-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
AIMS The current article provides a brief overview of the criteria for defining disease control in acromegaly. METHODS This was a retrospective, narrative review of previously published evidence chosen at the author's discretion along with an illustrative case study from Latin America. FINDINGS AND CONCLUSIONS In the strictest sense, "cure" in acromegaly is defined as complete restoration of normal pulsatile growth hormone secretion, although this is rarely achieved. Rather than "cure", as such, it is more appropriate to refer to disease control and remission, which is defined mainly in terms of specific biochemical targets (for growth hormone and insulin-like growth factor-1) that predict or correlate with symptoms, comorbidities and mortality. However, optimal management of acromegaly goes beyond biochemical control to include control of tumour growth (which may be independent of biochemical control) and comprehensive management of the symptoms and comorbidities typically associated with the disease, as these may not be adequately managed with acromegaly-specific therapy alone.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology and Metabolism, Hospital das Clinicas, Federal University Medical School, Recife, Pernambuco Brazil
| | - Alex Valenzuela
- Department of Internal Medicine, Fundación Cardio-Infantil, Instituto de Cardiología, Universidad del Rosario, Bogotá, Colombia
| | - Antônio Ribeiro-Oliveira
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais Brazil
| | - Claudia M. Gómez Giraldo
- Hospital Universitario de San Ignacio and Organización Colsánitas Internacional, Bogotá, Colombia
| | | | - Marcello D. Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho, 255, 7ºandar, sala 7037, São Paulo, CEP 05403-000 Brazil
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Abstract
INTRODUCTION Acromegaly is a rare disease that severely impacts patients' health all the while, being a slowly progressing illness. In the past decades, advancements in treatment modalities, especially development of new drugs, as well as focused guidelines has improved management of acromegaly. Still, many patients are considered not sufficiently treated and there remains an ongoing need for further development. AREAS COVERED This article reviews new medical treatments currently under clinical investigation (such as pasireotide, oral octreotide and somatoprim) and under experimental development (such as octreotide implants, CAM2029 and ATL-1103). EXPERT OPINION As it seems unlikely that one single agent may achieve cure in 100% of cases, there is an urgent need for new agents that help patients where current medication fails. Imperatively, this means we have to improve our understanding of the underlying pathogenetic and molecular mechanisms.
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Affiliation(s)
- Sylvère Störmann
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , Ziemssenstr. 1, 80336 München , Germany +49 0 89 5160 2111 ; +49 0 89 5160 2194 ;
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Sowiński J, Sawicka N, Piątek K, Zybek A, Ruchała M. Pharmacoeconomic aspects of the treatment of pituitary gland tumours. Contemp Oncol (Pozn) 2013; 17:137-43. [PMID: 23788980 PMCID: PMC3685378 DOI: 10.5114/wo.2013.34616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/14/2013] [Accepted: 04/18/2013] [Indexed: 12/17/2022] Open
Abstract
Nowadays physicians are under economic pressure; therefore therapeutic decisions based on safety, efficacy, and the effectiveness of the medication also require economic analysis. The aim of this review is to discuss data concerning the cost-effectiveness of drug therapy in patients with hormonally active pituitary adenomas, namely growth hormone, adrenocorticotropic hormone, thyroid-stimulating hormone-secreting pituitary adenomas, prolactinoma and pituitary incidentaloma. In acromegalic patients using lanreotide is cheaper for health care payers and more convenient for physicians and patients because of the opportunity for self/partner injections, lower clogging risk and possibility of longer intervals between injections, while the efficacy is comparable with octreotide. Patients with prolactinomas should be treated with novel dopamine agonists, such as cabergoline or quinagolide, however, bromocriptine still remains a cheaper and almost as effective alternative. There are no easy methods or algorithms, but in general, extracting the maximum value from the investment in treatment is essential.
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Affiliation(s)
- Jerzy Sowiński
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poland
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Bernabeu I, Alvarez-Escolá C, Paniagua AE, Lucas T, Pavón I, Cabezas-Agrícola JM, Casanueva FF, Marazuela M. Pegvisomant and cabergoline combination therapy in acromegaly. Pituitary 2013; 16:101-8. [PMID: 22396133 DOI: 10.1007/s11102-012-0382-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Combination with cabergoline may offer additional benefits to acromegalic patients on pegvisomant monotherapy. We evaluated the safety and efficacy profile of this combination and investigated the determinants of response. An observational, retrospective, cross-sectional study. Fourteen acromegalic patients (9 females), who were partially resistant to somatostatin analogs and on pegvisomant monotherapy. Cabergoline was added because of the presence of persistent mildly increased IGF-I. The mean follow-up time was 18.3 ± 10.4 months. The efficacy and safety profile was assessed. The influence of clinical and biochemical characteristics on treatment efficacy was studied. IGF-I levels returned to normal in 4 patients (28%) at the end of the study. In addition, some decline in IGF-I levels was observed in a further 5 patients. The % IGF-I decreased from 158 ± 64% to 124 ± 44% (p = 0.001). The average change in IGF-I was -18 ± 27% (range -67 to +24%). Lower baseline IGF-I (p = 0.007), female gender (p = 0.013), lower body weight (p = 0.031), and higher prolactin (PRL) levels (p = 0.007) were associated with a better response to combination therapy. There were no significant severe adverse events. Significant tumour shrinkage was observed in 1 patient. Combination therapy with pegvisomant and cabergoline could provide better control of IGF-I in some patients with acromegaly. Baseline IGF-I levels, female gender, body weight, and PRL levels affect the response to this combination therapy.
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Affiliation(s)
- I Bernabeu
- Endocrinology Department, Complejo Hospitalario Universitario de Santiago de Compostela (SERGAS), Travesía de la Choupana s/n, 15706, Santiago de Compostela, Spain.
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Roset M, Merino-Montero S, Luque-Ramírez M, Webb SM, López-Mondéjar P, Salinas I, Soto A, Bernal C, Villabona C, De Luis D, Donnay S, Pascual H, Pérez-Luis J. Cost of clinical management of acromegaly in Spain. Clin Drug Investig 2012; 32:235-45. [PMID: 22397307 DOI: 10.2165/11599680-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION AND BACKGROUND The cost of the therapeutic management of acromegaly depends on the selection of resources used, surgery and/or pharmacological treatment, by the specialist responsible for treatment, related to the characteristics of the patient and tumour. The objective of this work is to evaluate these costs for an illness that is rare but that is associated with a high morbidity in the context of routine clinical practice. METHODS This was an epidemiological, prospective, naturalistic, multicentre study in Spain, in which 38 endocrinologists participated. Adult patients with acromegaly and a pituitary microadenoma or macroadenoma were included in the study. Patients were assigned, according to first-line treatment, to the following two groups: surgery first-line group (surgery in the 6 months before inclusion or during the follow-up period) and pharmaceutical first-line group (treatment with somatostatin analogues [SAs] for at least 6 months and with or without surgery after starting treatment with SAs). Data were collected during routine visits made during a follow-up period of 2 years. All resources were estimated at 2009 prices (€) and adjusted according to the Spanish consumer price index in 2010. RESULTS Seventy-four patients were included, the majority of them with macroadenoma (70%). Eighty-eight percent of patients were treated surgically (76% as a first-line treatment), while 12% of patients received only SAs. Treatment with SAs was used at some point in the study by 85% of patients. The mean annual total cost of acromegaly is €9668 per patient (€9223 for the surgery group and €11,054 for the pharmaceutical group). Seventy-one percent of the direct cost of the disease corresponds to treatment with SAs. The cost of a patient treated only with surgery is €2501 on an annual basis, versus €9745 for a patient receiving only pharmacological treatment. In cases where a combination of both types of treatment is required, the annual total cost ranges from €10,866 to €12,364. CONCLUSION The annual direct cost per patients of acromegaly in Spain is €9668. Even though surgery is the preferred option for treatment for a great number of patients, SAs must be added to the treatment regimen of the majority of such patients. The costs associated with this treatment are greater than the cost of treatment with SAs alone.
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Marko NF, LaSota E, Hamrahian AH, Weil RJ. Comparative effectiveness review of treatment options for pituitary microadenomas in acromegaly. J Neurosurg 2012; 117:522-38. [PMID: 22725987 DOI: 10.3171/2012.4.jns11739] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Acromegaly, a syndrome of excess growth hormone (GH) secretion typically caused by a GH-secreting pituitary adenoma, reduces life expectancy by approximately 10 years when left untreated. Treatment of acromegaly involves combinations of one or more discrete therapeutic modalities to achieve biochemical control. Unfortunately, data capable of informing decisions among alternate management strategies are presently lacking. METHODS The authors performed a comparative effectiveness research (CER) review integrating efficacy, cost, and quality of life (QOL) analysis for treatment strategies comprising various combinations of surgery, radiotherapy, stereotactic radiosurgery, and pharmacotherapy in patients with acromegaly caused by a pituitary microadenoma. A management decision tree was used to identify 5 treatment strategies, each with up to 4 potential treatment steps. Efficacy was assessed using recent literature reports of biochemical control rates for each modality. Cost estimations were derived from wholesale drug prices and from the Healthcare Cost and Utility Project. Quality of life data were obtained from studies utilizing the Acromegaly Quality of Life Questionnaire. RESULTS Individual treatment modalities were analyzed and ranked in each of 3 domains: highest rate of success, lowest cost, and highest QOL, and these scores were combined to facilitate comparison of overall effectiveness of each of the management strategies. These aggregate effectiveness scores were used to compare the 5 strategies from the decision tree, and a novel strategy was also proposed. CONCLUSIONS The choice of management strategy must be individualized for each patient with acromegaly. This CER analysis provides a comprehensive framework to inform clinical decisions among alternate management strategies in patients with GH-secreting pituitary microadenomas.
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Chanson P, Kamenický P. [Treatment of acromegaly: a critical analysis of the last ten years]. ANNALES D'ENDOCRINOLOGIE 2012; 73:99-106. [PMID: 22521857 DOI: 10.1016/j.ando.2012.03.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The ten previous years in terms of acromegaly treatment were essentially characterized by the experience accumulated with new formulations of somatostatin analogues or new drugs such GH-receptor antagonists recently available. Surgery remains the first-line treatment and its results did not change despite the generalization of endoscopy, which mainly seems to decrease local side-effects. The setting of radiotherapy was essentially modified by the increasing use of gamma-knife or stereotactic radiotherapy; however, their results are essentially the same as the classic fractionated, conventional radiotherapy and nobody knows if it will decrease the side-effects of this therapeutic modality. Nevertheless, thanks to a multistep therapeutic strategy, combining the different therapeutic modalities, it has become very rare for acromegaly not to be controlled in a patient.
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Affiliation(s)
- Philippe Chanson
- Service d'endocrinologie et des maladies de la reproduction, faculté de médecine Paris-Sud, université Paris XI, hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
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Morin E, Berthelet F, Weisnagel J, Bidlingmaier M, Serri O. Failure of temozolomide and conventional doses of pegvisomant to attain biochemical control in a severe case of acromegaly. Pituitary 2012; 15:97-100. [PMID: 20407837 DOI: 10.1007/s11102-010-0232-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
It has been suggested that treatment with adequate dose titration of pegvisomant, a GH antagonist, up to a maximum of 40 mg daily, can achieve IGF-1 normalisation in virtually all patients with acromegaly. On the other hand, temozolomide (TMZ), an alkylating cytostatic agent, has been reported to reduce pituitary tumour size and hormone hypersecretion in a small number of aggressive pituitary macroadenomas. In this paper we report the case of a patient resistant to very high doses of pegvisomant used in combination with somatostatin analogs (SSA) and to TMZ therapy. The patient, initially a 22 year-old man with an invasive GH-secreting pituitary macroadenoma (IGF-1, 371% upper limit of normal), had active acromegaly despite a repeat transsphenoidal surgery followed by radiotherapy and SSA (octreotide 800 μg sc daily) (IGF-1, 262% ULN). In combination with SSA, pegvisomant was started at 20 mg daily and doses were titrated up to 60 mg daily. IGF-1 was moderately reduced and stabilized at 200% ULN after 1 year of treatment. Serum pegvisomant level was 30,500 ng/l, the denaturalized GHBP concentration 1,120 pM and the endogenous GH level was 220 μg/l. Pegvisomant was stopped and TMZ therapy was given for 5 cycles. However, the patient reported an increase of acromegaly symptoms and the serum IGF-1 was raised to the same level prior to pegvisomant therapy. Consequently, pegvisomant was tried again with doses up to 100 mg daily finally resulting in normalisation of serum IGF-1 level and improvement of acromegaly symptoms and patient well-being. We conclude that in some patients with severe acromegaly refractory to multimodal therapy, biochemical control may be difficult to attain with conventional doses of pegvisomant or TMZ therapy.
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Affiliation(s)
- Emilie Morin
- Department of Endocrinolgy, CHUM Research Centre, Notre-Dame Hospital, 1560, rue Sherbrooke East, Montreal, QC, H2L 4M1, Canada
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Katznelson L, Atkinson JLD, Cook DM, Ezzat SZ, Hamrahian AH, Miller KK. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly--2011 update. Endocr Pract 2011; 17 Suppl 4:1-44. [PMID: 21846616 DOI: 10.4158/ep.17.s4.1] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Laurence Katznelson
- Departments of Medicine and Neurosurgery, Stanford University, Stanford, California, USA
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Abstract
The high morbidity and mortality associated with acromegaly can be addressed with multiple treatment modalities, including surgery, medicines, and radiation therapy. Radiation was initially delivered through conventional fractionated radiotherapy, which targets a wide area over many treatment sessions and has been shown to induce remission in 50%–60% of patients with acromegaly. However, conventional fractionated radiotherapy takes several years to achieve remission in patients with acromegaly and carries a risk of hypopituitarism that may limit its use. Stereotactic radiosurgery, of which there are several forms, including Gamma Knife surgery, CyberKnife therapy, and proton beam therapy, offers slightly attenuated efficacy but achieves remission in less time and provides more precise targeting of the adenoma with better control of the dose of radiation received by adjacent structures such as the pituitary stalk, pituitary gland, optic chiasm, and cranial nerves in the cavernous sinus. Of the forms of stereotactic radiosurgery, Gamma Knife surgery is the most widely used and, because of its long-term follow-up in clinical studies, is the most likely to compete with medical therapy for first-line adjuvant use after resection. In this review, the authors outline the major modes of radiation therapies in clinical use today, and they critically assess the feasibility of these modalities for acromegaly treatment. Acromegaly is a multisystem disorder that demands highly specialized treatment protocols including neurosurgical and endocrinological intervention. As more efficient forms of pituitary radiation develop, acromegaly treatment options may continue to change with radiation therapies playing a more prominent role.
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Affiliation(s)
- Nathan C Rowland
- Department of Neurological Surgery, California Center for Pituitary Disorders, University of California, San Francisco, California 94143-0112, USA
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Abstract
The approach to a patient with acromegaly and persistent disease after surgery requires a complex diagnostic assessment. Acromegaly is a chronic and insidious disease that is associated with multisystem comorbidities, including cardiovascular disease, hypertension, sleep apnea syndrome, colon polyposis, arthropathy, and metabolic complications including glucose intolerance and type 2 diabetes mellitus. Patients also have a variety of signs and symptoms, including headache, arthralgias, carpal tunnel syndrome, sweating, fatigue, and psychological issues that impact significantly on quality of life. The recommended approach to the evaluation of the postoperative patient includes a biochemical assessment, with measurement of serum IGF-I along with a glucose-suppressed GH value, radiological assessment to determine location of residual tumor and presence of mass effects, a physical examination for evidence of skeletal and soft tissue overgrowth and related signs of acromegaly, and a thorough clinical assessment for the presence of comorbidities. Repeat surgery is indicated if there is residual tumor that is surgically accessible and there may be a chance for surgical cure, or if there are persistent mass effects upon the optic chiasm. Otherwise, medical therapy is indicated, utilizing somatostatin analogs, dopamine agonists, and pegvisomant, a GH receptor antagonist. Radiation therapy is usually relegated to situations where medical therapy is ineffective or poorly tolerated or where patients would prefer not to sustain the cost of long-term medical therapy. The choice of therapy requires close dialog among endocrinologists, neurosurgeons, radiation therapists, and neuroophthalmologists for optimal care of patients.
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Affiliation(s)
- Laurence Katznelson
- Departments of Medicine and Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA.
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