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Grottoli S, Maffei P, Tresoldi AS, Granato S, Benedan L, Mariani P, Giustina A. Insights from an Italian Delphi panel: exploring resistance to first-generation somatostatin receptor ligands and guiding second-line medical therapies in acromegaly management. J Endocrinol Invest 2024:10.1007/s40618-024-02386-3. [PMID: 38809458 DOI: 10.1007/s40618-024-02386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE First-line medical therapy for acromegaly management includes first-generation somatostatin receptor ligands (fgSRLs), but resistance limits their use. Despite international guidelines, the choice of second-line therapy is debated. METHODS We aim to discuss resistance to fgSRLs, identify second-line therapy determinants and assess glycemia's impact to provide valuable insights for acromegaly management in clinical practice. A group of Italian endocrinologists expert in the pituitary field participated in a two-round Delphi panel between July and September 2023. The Delphi questionnaire encompassed a total of 75 statements categorized into three sections: resistance to fgSRLs therapy and predictors of response; determinants for the selection of second-line therapy; the role of glycemia in the therapeutic management. The statements were rated on a 6-point Likert scale. RESULTS Fifty-nine (79%) statements reached a consensus. IGF-1 levels resulted central for evaluating resistance to fgSRLs, that should be defined considering also symptomatic clinical response, degree of tumor shrinkage and complications, using clinician- and patient-reported outcome tools available. Factors to be evaluated for the choice of second-line medical therapy are hyperglycemia-that should be managed as in non-acromegalic patients-tumor remnant, resistant headache and compliance. Costs do not represent a main determinant in the choice of second-line medical treatment. CONCLUSION The experts agreed on a holistic management approach to acromegaly. It is therefore necessary to choose currently available highly effective second-line medical treatment (pegvisomant and pasireotide) based on the characteristics of the patients.
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Affiliation(s)
- S Grottoli
- Department of Medical Science, Division of Endocrinology, Diabetes and Metabolism, University of Turin, Turin, Italy.
| | - P Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | | | - S Granato
- Medical Department, Pfizer Italia, Rome, Italy
| | - L Benedan
- Università Milano-Bicocca, Milan, Italy
| | - P Mariani
- Università Milano-Bicocca, Milan, Italy
| | - A Giustina
- Institute of Endocrine and Metabolic Sciences, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Milan, Italy
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Giustina A, Biermasz N, Casanueva FF, Fleseriu M, Mortini P, Strasburger C, van der Lely AJ, Wass J, Melmed S. Consensus on criteria for acromegaly diagnosis and remission. Pituitary 2024; 27:7-22. [PMID: 37923946 PMCID: PMC10837217 DOI: 10.1007/s11102-023-01360-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE The 14th Acromegaly Consensus Conference was convened to consider biochemical criteria for acromegaly diagnosis and evaluation of therapeutic efficacy. METHODS Fifty-six acromegaly experts from 16 countries reviewed and discussed current evidence focused on biochemical assays; criteria for diagnosis and the role of imaging, pathology, and clinical assessments; consequences of diagnostic delay; criteria for remission and recommendations for follow up; and the value of assessment and monitoring in defining disease progression, selecting appropriate treatments, and maximizing patient outcomes. RESULTS In a patient with typical acromegaly features, insulin-like growth factor (IGF)-I > 1.3 times the upper limit of normal for age confirms the diagnosis. Random growth hormone (GH) measured after overnight fasting may be useful for informing prognosis, but is not required for diagnosis. For patients with equivocal results, IGF-I measurements using the same validated assay can be repeated, and oral glucose tolerance testing might also be useful. Although biochemical remission is the primary assessment of treatment outcome, biochemical findings should be interpreted within the clinical context of acromegaly. Follow up assessments should consider biochemical evaluation of treatment effectiveness, imaging studies evaluating residual/recurrent adenoma mass, and clinical signs and symptoms of acromegaly, its complications, and comorbidities. Referral to a multidisciplinary pituitary center should be considered for patients with equivocal biochemical, pathology, or imaging findings at diagnosis, and for patients insufficiently responsive to standard treatment approaches. CONCLUSION Consensus recommendations highlight new understandings of disordered GH and IGF-I in patients with acromegaly and the importance of expert management for this rare disease.
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Affiliation(s)
- Andrea Giustina
- San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | | | | | | | - Pietro Mortini
- San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | | | | | | | - Shlomo Melmed
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, NT 2015, Los Angeles, CA, 90048, USA.
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Giustina A, di Filippo L, Uygur MM, Frara S. Modern approach to resistant acromegaly. Endocrine 2023; 80:303-307. [PMID: 36790521 DOI: 10.1007/s12020-023-03317-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Targets of acromegaly treatment are normalization of biochemical values, removal/reduction/stabilization of the pituitary mass, control of clinical activity and mortality with a multimodal/multidisciplinary approach. Despite significant technological and pharmacological progress, still several patients with acromegaly bear a resistant somatotroph adenoma and active disease may persist for many years with resultant poor clinical outcomes. AIM To review briefly definition and pathophysiology of resistance to acromegaly treatment and the options of medical treatment in this context, exploring the role of novel clinical and molecular biomarkers in the personalization of therapy and proposing updates to the currently available guidelines for the treatment of resistant GH-secreting adenomas. CONCLUSIONS In the last few years, in parallel with the increased number of medical options available for the therapy of acromegaly, relevant advances occurred in the understanding of the role of novel molecular and clinical biomarkers in predicting the responsiveness to second-line medical treatments, such as Pegvisomant and Pasireotide LAR, and helping clinicians in the personalization of the follow-up and treatment of resistant somatotroph adenomas. The integration of these findings into the existing guidelines may represent a possibly important step forward in the management of "difficult" acromegaly patients.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Melin M Uygur
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Frara
- Institute of Endocrine and Metabolic Sciences (IEMS), Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
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Samson SL, Nachtigall LB, Fleseriu M, Jensterle M, Manning PJ, Elenkova A, Molitch ME, Ludlam WH, Patou G, Haviv A, Biermasz NR, Giustina A, Strasburger CJ, Kennedy L, Melmed S. Durable biochemical response and safety with oral octreotide capsules in acromegaly. Eur J Endocrinol 2022; 187:733-741. [PMID: 36173649 PMCID: PMC9641789 DOI: 10.1530/eje-22-0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 09/29/2022] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Susan L Samson
- Department of Medicine and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
- Correspondence should be addressed to S L Samson;
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Fleseriu
- Pituitary Center, Oregon Health & Sciences University, Portland, Oregon, USA
| | | | | | - Atanaska Elenkova
- Department of Endocrinology, Medical University Sofia, USHATE ‘Acad. Ivan Penchev’, Sofia, Bulgaria
| | - Mark E Molitch
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Asi Haviv
- Amryt Pharmaceuticals, Dublin, Ireland
| | | | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, Milan, Italy
| | | | | | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Camerini S, Wennberg A, Adriani M, Martin B, Vettor R, Maffei P, Dassie F. Questionnaire and tools: clinical powerful instrument in acromegaly diagnosis and management. J Endocrinol Invest 2022; 45:1823-1834. [PMID: 35322391 PMCID: PMC9463243 DOI: 10.1007/s40618-022-01782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/07/2022] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- S Camerini
- DIMED, University of Padua, Padua, Italy
| | - A Wennberg
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Adriani
- DIMED, University of Padua, Padua, Italy
| | - B Martin
- DIMED, University of Padua, Padua, Italy
| | - R Vettor
- DIMED, University of Padua, Padua, Italy
| | - P Maffei
- DIMED, University of Padua, Padua, Italy
| | - F Dassie
- DIMED, University of Padua, Padua, Italy.
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