Patient reported outcome data from acromegaly patients treated with injectable somatostatin receptor ligands (SRLs) in routine clinical practice

Oral octreotide capsules for acromegaly treatment: application of clinical trial insights to real-world use

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.

Preferences for different treatment options among people living with acromegaly in the US

OBJECTIVE

Acromegaly is a rare hormonal disorder that results in enlargement of the face, hands and feet. It is associated with comorbidities, increased mortality, reduced quality of life and economic burden. Adequate treatment is critical to alleviate symptoms; however, the treatment burden is substantial. To understand how different treatment aspects might ease the burden, this study investigated preferences for treatment options among people with acromegaly in the US, using a choice experiment (CE).

METHODS

An online CE was conducted based on a similar study among the US general population. Respondents were recruited through Acromegaly Community in the US, and all eligible respondents were included. The survey assessed six treatment options that varied according to administration, frequency, storage, treatment setting, needle type and injection pain.

RESULTS

109 adults with acromegaly completed the survey between October and December 2022. On average, the population had lived with symptoms for 15 years, while the average number of years with the diagnosis was eight. Respondents preferred subcutaneous injections every fourth week and preferred them at home rather than at the hospital. Most respondents preferred subcutaneous injections right under the skin administered once every fourth week with a pen at home over oral capsules administered twice daily at home.

CONCLUSION

The results indicate that new treatment options administered as subcutaneous injections right under the skin once every fourth week at home have the potential to lower the treatment burden among people with acromegaly, emphasizing the importance of taking each person's preference into consideration when choosing treatment.

Oral Octreotide Capsules and Paltusotine in Management of Acromegaly

Injectable somatostatin receptor ligands (iSRL) are the most frequently utilized medical therapy in patients with acromegaly; however, satisfaction rates are suboptimal. Injections can result in local erythema, discomfort and subcutaneous nodule formation, encompassed with the inconvenience of attending either primary or secondary care medical facilities for injections every 4 weeks. Some patients also note breakthrough of acromegaly-related symptoms towards the end of the injection cycle. To improve acceptance and ultimately improve wellbeing of these individuals, two oral SRLs, oral octreotide capsules (OOC) and paltusotine, have been developed. The OOC combines an enteric coating to allow delivery to the small intestines and a transient permeability enhancer to enable oral bioavailability. Comparable octreotide levels are obtained with twice-daily OOC and subcutaneous octreotide 100 µg. Phase III studies show OOC to maintain equivalent biochemical control in at least 60% of patients previously receiving a stable dose of iSRL. In longer-term studies, the response to OOC was durable up to 3 years. Paltusotine is a novel potent orally available non-peptidyl somatostatin receptor subtype-2 ligand. Studies in healthy volunteers show dose-dependent suppression of growth hormone-releasing hormone-induced growth hormone secretion and suppression of insulin-like growth factor-I (IGF-I) with repeat doses. In the recent phase II study, patients with acromegaly who were partial responders (IGF-I 1.0 - 2.5 x upper limit of normal) to monotherapy with iSRL when switched to once-daily paltusotine maintained control of IGF-I within 20% of baseline or lower in 87% after 13 weeks. Adverse events with both OOC and paltusotine were reflective of those recognized with iSRL and occurred at a similar frequency. OOC and paltusotine are well-received additions to the therapeutic armamentarium in medical therapy for the management of acromegaly; however, further data on efficacy, tumour control and shrinkage are required to allow positioning of this medication within the management algorithm for acromegaly.

New Treatments for Acromegaly in Development

Acromegaly treatment has greatly evolved in recent decades, but there are still patients whose acromegaly is not controlled with currently available treatments, and there is a need to improve the treatment burden. Fortunately, there are new treatments under development that may increase treatment efficacy and convenience.

Treatment of acromegaly with oral octreotide

Acromegaly is a rare disease caused by a growth hormone excess, usually due to a secreting pituitary adenoma. Somatostatin receptor ligands (SRL) are the mainstay of medical therapy for patients with acromegaly who fail to achieve biochemical control post-operatively or are not eligible for surgical treatment. SRLs are typically administered as monthly injections and have shown to be effective in maintaining biochemical and radiological control of acromegaly. However, these injections may cause local adverse events and are associated with increased psychological burden in some patients. Oral octreotide provides a new alternative for patients responding to injectable SRLs. This new formulation has shown to have similar safety and efficacy profiles compared to injectable SRLs and may be a preferable option for some patients with acromegaly. The aim of this review is to provide an overview of the role of oral octreotide in the management of acromegaly.

MPOWERED Trial Open-Label Extension: Long-term Efficacy and Safety Data for Oral Octreotide Capsules in Acromegaly

CONTEXT

The MPOWERED core trial (NCT02685709) and open-label extension (OLE) phase investigated long-term efficacy and safety of oral octreotide capsules (OOC) in patients with acromegaly. Core trial primary endpoint data demonstrated noninferiority to injectable somatostatin receptor ligands (iSRLs). Core trial completers were invited to participate in the OLE phase.

OBJECTIVE

To assess long-term efficacy and safety of OOC in patients with acromegaly who previously responded to and tolerated both OOC and injectable octreotide/lanreotide and completed the core phase.

METHODS

The unique study design of transitioning between OOC and iSRLs allowed within-patient evaluations. The proportion of biochemical responders (insulin-like growth factor I < 1.3 × upper limit of normal) at end of each extension year who entered that year as responders was the main outcome measure.

RESULTS

At year 1 extension end, 52/58 patients from both the monotherapy and the combination therapy groups were responders (89.7%; 95% CI 78.8-96.1), 36/41 (87.8%; 95% CI 73.8-95.9) in year 2, and 29/31 (93.5%; 95% CI 78.6-99.2) in year 3. No new or unexpected safety signals were detected; 1 patient withdrew owing to treatment failure. Patients who transitioned from iSRLs in the core trial to OOC in the OLE phase reported improved treatment convenience/satisfaction and symptom control.

CONCLUSION

Patient-reported outcome data support for the first time that transitioning patients randomized to iSRL (who previously responded to both OOC and iSRLs) back to OOC had a significant effect on patients' symptoms score in a prospective cohort. The MPOWERED OLE showed long-term maintenance of response and sustained safety with OOC.

Innovative therapeutics in acromegaly

Acromegaly is a systemic disease associated with increased morbidity and mortality that can be prevented with adequate disease control. Three modalities of treatment (surgery, medical treatment, and radiotherapy) are available; however, a significant proportion of patients still maintain disease activity despite treatment. Therefore, there is a need for innovations in the treatment of acromegaly that include changes in the current trial and error approach and the development of new drugs. In this review, we summarize the recent innovations in the treatment of acromegaly and address the future perspectives in this field.

Durable biochemical response and safety with oral octreotide capsules in acromegaly

OBJECTIVE

The objective of this study is to report results from the open-label extension (OLE) of the OPTIMAL trial of oral octreotide capsules (OOC) in adults with acromegaly, evaluating the long-term durability of therapeutic response.

DESIGN

The study design is an OLE of a double-blind placebo-controlled (DPC) trial.

METHODS

Patients completing the 36-week DPC period on the study drug (OOC or placebo) or meeting predefined withdrawal criteria were eligible for OLE enrollment at 60 mg/day OOC dose, with the option to titrate to 40 or 80 mg/day. The OLE is ongoing; week 48 results are reported.

RESULTS

Forty patients were enrolled in the OLE, 20 each having received OOC or placebo, with 14 and 5 patients completing the DPC period as responders, respectively. Ninety percent of patients completing the DPC period on OOC and 70% of those completing on placebo completed 48 weeks of the OLE. Maintenance of response in the OLE (i.e. insulin-like growth factor I (IGF1) ≤ 1.0 × upper limit of normal (ULN)) was achieved by 92.6% of patients who responded to OOC during the DPC period. Mean IGF1 levels were maintained between the end of the DPC period (0.91 × ULN; 95% CI: 0.784, 1.045) and week 48 of the OLE (0.90 × ULN; 95% CI: 0.750, 1.044) for those completing the DPC period on OOC. OOC safety was consistent with previous findings, with no increased adverse events (AEs) associated with the higher dose and improved gastrointestinal tolerability observed over time.

CONCLUSIONS

Patients with acromegaly maintained long-term biochemical response while receiving OOC, with no new AEs observed with prolonged OOC exposure.

ACROBAT Edge: Safety and efficacy of switching injected SRLs to oral paltusotine in patients with acromegaly

CONTEXT

Paltusotine is a once-daily, oral, non-peptide small-molecule somatostatin receptor type 2 (SST2) agonist in clinical development for treatment of acromegaly.

OBJECTIVE

To evaluate change in IGF-I levels in patients switched from octreotide LAR or lanreotide depot monotherapy to paltusotine.

DESIGN

Phase 2, open-label, prospective, multicenter, multinational, non-randomized, single-arm exploratory study in which dosage up-titrations were performed in a double-blinded manner.

SETTING

26 global sites.

PARTICIPANTS

Patients with acromegaly switched to paltusotine from injected SRL-based therapy.

INTERVENTIONS

Patients received 13-week treatment with once-daily oral paltusotine (10-40 mg/day).

MAIN OUTCOME MEASURES

Primary endpoint was change from baseline to week 13 in IGF-I for patients who switched from long-acting octreotide or lanreotide monotherapy to paltusotine (Group 1). All patients underwent a 4-week paltusotine washout at end of treatment period (weeks 13-17). IGF-I, GH, patient reported outcome, and safety data were collected.

RESULTS

Forty-seven patients enrolled. In Group 1 (n = 25), IGF-I and GH showed no significant change between SRL baseline and end of paltusotine treatment at week 13 (median change in IGF-I = -0.03×upper limit of normal [ULN], P = 0.6285; GH = -0.05 ng/mL, P = 0.6285). IGF-I and GH rose significantly in the 4 weeks after withdrawing paltusotine (median change in IGF-I = 0.55×ULN, P < 0.0001 [median increase 39%]; GH = 0.72 ng/mL, P < 0.0001 [109.1% increase]). No patients discontinued due to adverse events; no treatment-related serious adverse events were reported.

CONCLUSIONS

These results suggest once daily, oral paltusotine is effective in maintaining IGF-I values in patients with acromegaly who switched from injected SRLs. Paltusotine was well tolerated with a safety profile consistent with other SRLs.

Questionnaire and tools: clinical powerful instrument in acromegaly diagnosis and management

PURPOSE

Acromegaly is a rare chronic disease characterized by systemic comorbidity and reduced quality of life. Although achieving biochemical control has always been the primary goal of acromegaly therapy, recent evidence has shown that the traditional assessment does not adequately capture the complexity of symptoms and patients' perception. These findings result in the need to improve a fast decision-making process of the clinician, who should not only take into account biochemical-instrumental criteria, but also patients' symptoms. With the aim of supporting the clinician in the diagnostic and therapeutic decision-making process several disease-specific tools have been developed. The aim of this review is to provide a description of the acromegaly-specific tools, presenting their main features, their application in daily practice, and their efficacy and utility.

METHODS

A systematic search of Medline/PubMed, ISI-Web of Knowledge, and Google Scholar databases was done.

RESULTS

Specific instruments and questionnaires have recently been developed to assist clinicians in the assessment of acromegaly. These are either Patient-Reported Outcome tools, such as Acromegaly Quality of Life Questionnaire (AcroQoL) and Pain Assessment Acromegaly Symptom Questionnaire (PASQ), or Clinician-Reported Outcome tools, such as ACROSCORE, SAGIT^® and Acromegaly Disease Activity Tool (ACRODAT^®). Such tools are extremely flexible and, therefore, have been widely adopted by endocrinologists and other professionals, so much so that they have also been included as recommendations in the 2018 international guidelines.

CONCLUSION

Questionnaires and tools are useful in the management of acromegaly patients. They help clinicians evaluate patients' symptoms and could assist in the evaluation of disease activity.

Patient-reported outcomes in patients with acromegaly treated with pegvisomant in the ACROSTUDY extension: A real-world experience

PURPOSE

To report the effects of pegvisomant (PEGV) treatment on patient-reported outcomes in acromegaly patients.

METHODS

We conducted an extension study of an open-label, multinational, non-interventional study (ACROSTUDY) evaluating the long-term safety and efficacy of PEGV for acromegaly in routine clinical practice. Enrolled patients were rollover patients from ACROSTUDY, or treatment naïve/semi-naïve (NSN; no PEGV within 6 months of enrollment). Exploratory efficacy endpoints were changes in symptoms with the Patient-Assessed Acromegaly Symptom Questionnaire (PASQ) and quality of life with the Acromegaly Quality of Life questionnaire (AcroQoL) analyzed by controlled or uncontrolled IGF-I levels. Results were analyzed in all patients, in NSN patient subgroup, and by diabetes status.

RESULTS

A total of 544 patients with acromegaly were enrolled, including 434 rollover subjects from ACROSTUDY and 110 NSN patients. Mean PEGV treatment duration was 7.8 years (range, 0-19.6 years). Overall, the majority of PASQ scores improved over time, but there was no significant difference between IGF-I controlled or uncontrolled groups. In the NSN subgroup, most PASQ and AcroQoL scores remained similar to baseline up to 1 year, regardless of IGF-I control. Patients with diabetes reported better PASQ scores over time with PEGV treatment, regardless of IGF-I control. IGF-I normalization increased from 10% of patients at baseline to more than 78% at year 10, with a mean daily PEGV dose of 18.7 mg.

CONCLUSIONS

Overall, patients treated with PEGV had small improvements in PASQ. While IGF-I normalization increased with PEGV treatment, IGF-I control had no effects on PASQ and AcroQoL scores.

Oral Octreotide: A Review of Recent Clinical Trials and Practical Recommendations for Its Use in the Treatment of Patients With Acromegaly

OBJECTIVE

Acromegaly is characterized by chronic growth hormone (GH) and insulin-like growth factor-I (IGF-I) hypersecretion, often caused by a GH-secreting pituitary adenoma. Surgery remains first line, but medical therapy is essential if surgery is contraindicated, does not achieve remission, or does not prevent recurrence despite apparent surgical remission. Oral octreotide capsules (OOC) that combine octreotide with a transient permeability enhancer technology are the first oral somatostatin receptor ligand (SRL) approved in the US for acromegaly.

METHODS

We review the literature and clinical trial data of OOC for patients with acromegaly and discuss clinical assessment of OOC use, potential drug-drug interactions, drug initiation, dose titration, and monitoring of drug efficacy and tolerability.

RESULTS

Four pivotal clinical trials involving a total of 238 patients with acromegaly treated with OOC effective suppression of serum GH and IGF-I levels, maintenance of disease control, decreased breakthrough symptoms and symptomatic improvement with noninferiority of OOC to injectable SRLs (iSRLs) in maintaining biochemical response. Additionally, the safety profile of OOC is comparable to that of iSRLs. Most patients who completed the clinical trials of OOC have also expressed preference to oral compared to iSRL administration.

CONCLUSION

OOC is an effective treatment option for patients with acromegaly who previously responded to iSRLs, with the benefits of avoiding injection-related side effects. This article provides a review of the pharmacology, safety, and efficacy and offers practical recommendations on utilization of OOCs to treat iSRL-responsive patients with acromegaly.

Prevalence of comorbidities and concomitant medication use in acromegaly: analysis of real-world data from the United States

PURPOSE

Patients receiving treatment for acromegaly often experience significant associated comorbidities for which they are prescribed additional medications. We aimed to determine the real-world prevalence of comorbidities and concomitant medications in patients with acromegaly, and to investigate the association between frequency of comorbidities and number of concomitantly prescribed medications.

METHODS

Administrative claims data were obtained from the IBM® MarketScan® database for a cohort of patients with acromegaly, identified by relevant diagnosis codes and acromegaly treatments, and a matched control cohort of patients without acromegaly from January 2010 through April 2020. Comorbidities were identified based on relevant claims and assessed for both cohorts.

RESULTS

Overall, 1175 patients with acromegaly and 5875 matched patients without acromegaly were included. Patients with acromegaly had significantly more comorbidities and were prescribed concomitant medications more so than patients without acromegaly. In the acromegaly and control cohorts, respectively, 67.6% and 48.4% of patients had cardiovascular disorders, the most prevalent comorbidities, and 89.0% and 68.3% were prescribed > 3 concomitant medications (p < 0.0001). Hypopituitarism and hypothalamic disorders, sleep apnea, malignant neoplasms and cancer, and arthritis and musculoskeletal disorders were also highly prevalent in the acromegaly cohort. A moderate, positive correlation (Spearman correlation coefficient 0.60) was found between number of comorbidities and number of concomitant medications in the acromegaly cohort.

CONCLUSION

Compared with patients without acromegaly, patients with acromegaly have significantly more comorbidities and are prescribed significantly more concomitant medications. Physicians should consider the number and type of ongoing medications for individual patients before prescribing additional acromegaly treatments.

Maintenance of response to oral octreotide compared with injectable somatostatin receptor ligands in patients with acromegaly: a phase 3, multicentre, randomised controlled trial

BACKGROUND

Despite biochemically responding to injectable somatostatin receptor ligands (iSRLs), many patients with acromegaly experience treatment burdens. We aimed to assess maintenance of biochemical response and symptomatic control with oral octreotide capsules versus iSRLs in patients with acromegaly who previously tolerated and responded to both.

METHODS

This global, open-label, randomised controlled phase 3 trial was done in 29 clinical sites in Austria, France, Germany, Hungary, Italy, Lithuania, Russia, Serbia, Spain, and the USA. Eligible patients were adults aged 18-75 years with acromegaly who were receiving iSRLs (long-acting octreotide or lanreotide autogel) for at least 6 months before baseline with a stable dose for at least 4 months, and were deemed to be biochemically responding (insulin-like growth factor I [IGF-I] <1·3 × upper limit of normal [ULN] and mean integrated growth hormone <2·5 ng/mL). In the 26-week run-in phase, all patients received oral octreotide (40 mg a day, optional titration to 60 or 80 mg a day). Eligibility for the randomised treatment phase was completion of the run-in phase as a biochemical responder (IGF-I <1·3 × ULN and mean integrated growth hormone <2·5 ng/mL at week 24) and investigator assessment of acromegaly being adequately controlled. Patients were randomly assigned (3:2) to oral octreotide capsules or iSRL at the same dose and interval as before enrolment. Randomisation and drug dispensing were conducted through a qualified randomisation service provider (eg, interactive web or voice response system). The primary endpoint was a non-inferiority assessment (margin -20 percentage points) of proportion of participants maintaining biochemical response throughout the randomised treatment phase (IGF-I <1·3 × ULN using time-weighted average; assessed by comparing the lower bound of the 2-sided 95% CI for the difference in biochemical response between groups). IGF-I was assessed once a month during the run-in and randomised treatment phases (single sample). Efficacy and safety assessments were performed on the randomised population. This trial is registered with ClinicalTrials.gov, NCT02685709.

FINDINGS

Between Feb 11, 2016, and Aug 20, 2020, 218 patients were assessed for eligibility. 72 patients were excluded, and 146 participants were enrolled into the run-in phase. 116 patients completed the run-in phase and 30 participants discontinued treatment. 92 participants were randomly assigned to oral octreotide (n=55) or iSRL (n=37). 50 (91%) of 55 participants who received oral octreotide (95% CI 44-53) and 37 (100%) of 37 participants who received iSRLs (34-37) maintained biochemical response. The lower bound of the 2-sided 95% CI for the adjusted difference in proportions between the two treatment groups achieved the prespecified non-inferiority criterion of -20% (95% CI -19·9 to 0·5). 19 (35%) of 55 participants in the oral octreotide group and 15 (41%) of 37 participants in the iSRL group had treatment-related adverse events; the most common of which in both groups were gastrointestinal.

INTERPRETATION

Oral octreotide was non-inferior to iSRL treatment, and might be a favourable alternative to iSRLs for many patients with acromegaly.

FUNDING

Chiasma.

TRANSLATION

For the Russian translation of the abstract see Supplementary Materials section.

The Future of Somatostatin Receptor Ligands in Acromegaly

Currently, the first-generation somatostatin receptor ligands (fg-SRLs), octreotide LAR and lanreotide autogel, are the mainstays of acromegaly treatment and achieve biochemical control in approximately 40% of patients and tumor shrinkage in over 60% of patients. Pasireotide, a second-generation SRL, shows higher efficacy with respect to both biochemical control and tumor shrinkage but has a worse safety profile. In this review, we discuss the future perspectives of currently available SRLs, focusing on the use of biomarkers of response and precision medicine, new formulations of these SRLs and new drugs, which are under development. Precision medicine, which is based on biomarkers of response to treatment, will help guide the decision-making process by allowing physicians to choose the appropriate drug for each patient and improving response rates. New formulations of available SRLs, such as oral, subcutaneous depot, and nasal octreotide, may improve patients' adherence to treatment and quality of life since there will be more options available that better suit each patient. Finally, new drugs, such as paltusotine, somatropin, ONO-5788, and ONO-ST-468, may improve treatment adherence and present higher efficacy than currently available drugs.

Correlation Between Clinical and Biochemical Markers in Patients With Acromegaly on Different Modalities of Treatment

Background

Acromegaly is a disabling disease caused by growth hormone (GH) over-secretion, associated with increased morbidity and mortality through different metabolic and somatic consequences involving soft tissue, acral overgrowth, and skin thickening, which will lead to different clinical manifestations. The study aimed to assess the correlation between biochemical markers of acromegaly with different clinical findings and biochemical control with the clinical findings.

Methods

A cross-sectional study was done on 56 patients with acromegaly attending a tertiary center for diabetes, endocrine, and metabolism in Southern Iraq Basrah. They were 32 (57.1%) males. Fatigue, headache, excessive sweating, joint pain, backache, soft tissue swelling, numbness, snoring, and visual problems were assessed on a four-point Likert scale. In addition, biochemical dynamic GH testing was done using a five-point random GH curve and/or standard GH suppression under the oral glucose tolerance test (OGTT).

Results

No significant correlation was found between symptoms severity and five-point GH parameters in respect of mean, peak, and nadir. Only backache showed a significant correlation with GH under OGTT suppression parameters in respect to mean, peak, and nadir (P-values < 0.01, < 0.01, and < 0.01), respectively. No particular biochemical control cut-off value in the 9 am random GH, mean five-point GH curve, or nadir GH under OGTT was correlated with the degree of severity for any of the clinical symptoms, as there was no difference between the biochemically controlled and uncontrolled groups in respect to any of the clinical symptom’s severity scale.

Conclusion

Only backache correlated with the biochemical tests of disease activity in the form of GH under OGTT. It appears in this study that the severity of the clinical symptoms does not correlate with biochemical control so that thorough evaluation and treatment of clinical complaints besides biochemical control is an essential part of the management plan in patients with acromegaly.

Acromegaly: achieving timely diagnosis and improving outcomes by personalized care

PURPOSE OF REVIEW

Discuss recent literature regarding clinical manifestations and comorbidities in acromegaly, with focus on early diagnosis and customized care.

RECENT FINDINGS

The mean interval between onset of clinical manifestations and diagnosis is currently 3-5 years. Women, especially younger than 50 years of age, experience longer delays, have lower insulin-like growth factor 1 (IGF-1) levels and larger tumors than men. Development of comorbidities usually precedes the diagnosis and is influenced by age, sex, and biochemical disease activity. Comorbidities other than irreversible osteoarticular structural changes usually improve after acromegaly treatment. In patients with diabetes, the course of hyperglycemia not only depends on biochemical control but also on specific acromegaly therapies. Quality of life is influenced by sex, as well as by acromegaly symptoms, biochemical activity, and treatment. Quality of life remains lower than general population despite biochemical remission.

SUMMARY

Early diagnosis can be achieved by suspecting acromegaly based on suggestive clinical scenarios rather than obvious changes in appearance. Personalized care entails a proactive multidisciplinary approach to identify and treat comorbidities while carefully monitoring the effects of acromegaly treatment.

New and emerging pharmacological treatment options for acromegaly

Introduction: Transsphenoidal surgery is the first-line treatment for acromegaly, but even in referral centers, approximately 50% of patients are not cured, and adjuvant pharmacological treatment is necessary. Widely used therapies encompass different drug classes, such as injectable somatostatin receptor ligands (SRLs), oral dopamine agonists and injectable growth hormone receptor antagonists, but approximately 40% of patients still have disease activity in real-life practice. Therefore, there is a need for new medical therapies to allow disease control in a larger proportion of patients, increase quality of life, reduce morbidity and mortality and improve treatment adherence in acromegaly.Areas covered: In this review, the authors cover new and emerging drugs under development or drugs recently approved for the treatment of acromegaly.Expert opinion: Disease control is essential to reduce morbidity and mortality in acromegaly but is still not achieved in a significant proportion of patients or takes a long time to be achieved with currently available options and treatment algorithms. Therefore, the development of new drugs as well as the establishment of biomarkers of disease control to allow precision medicine will improve treatment and outcomes in acromegaly.

Disease and Treatment-Related Burden in Patients With Acromegaly Who Are Biochemically Controlled on Injectable Somatostatin Receptor Ligands

Medical treatment for acromegaly commonly involves receiving intramuscular or deep subcutaneous injections of somatostatin receptor ligands (SRLs) in most patients. In addition to side effects of treatment, acromegaly patients often still experience disease symptoms even when therapy is successful in controlling GH and IGF-1 levels. Symptoms and side effects can negatively impact patients' health-related quality of life. In this study, we examine the disease- and treatment-related burden associated with SRL injections as reported through the use of the Acromegaly Treatment Satisfaction Questionnaire (Acro-TSQ ^©) and clinician-reported symptom severity through the Acromegaly Index of Severity (AIS). Patients included in this analysis were enrolled in a randomized phase 3 study, were biochemically-controlled (an IGF-1 < 1.3 × the upper limit of normal [ULN] and average GH < 2.5 ng/ml) and receiving SRL injections for ≥6 months with a stable dose of either long-acting octreotide or lanreotide monotherapy for ≥4 months. The sample (N = 91) was 65% female, 91% Caucasian, with a mean [standard deviation (SD)] age of 53 (1) years. Two-thirds of patients reported that they still experience acromegaly symptoms; 82% of these said they experience symptoms all of the time. Three-fourths experienced gastrointestinal (GI) side effects after injections, and 77% experienced treatment-related injection site reactions (ISRs). Patients commonly reported that these interfered with their daily life, leisure, and work activities. Those with higher symptom severity, as measured by the AIS, scored significantly worse on several Acro-TSQ domains: Symptom Interference, GI Interference, Treatment Satisfaction, and Emotional Reaction. Despite being biochemically controlled with injectable SRLs, most patients reported experiencing acromegaly symptoms that interfere with daily life, leisure, and work. GI side effects and ISRs were also common. This study highlights the significant disease burden that still persists for patients with acromegaly that have achieved biochemical control with the use of injectable SRLs.