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Samson SL. Is diabetes with acromegaly for life? Pituitary 2024:10.1007/s11102-024-01438-4. [PMID: 39088139 DOI: 10.1007/s11102-024-01438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Susan L Samson
- Departments of Medicine and Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Guarnotta V, Emanuele F, Salzillo R, Bonsangue M, Amato C, Mineo MI, Giordano C. Practical therapeutic approach in the management of diabetes mellitus secondary to Cushing's syndrome, acromegaly and neuroendocrine tumours. Front Endocrinol (Lausanne) 2023; 14:1248985. [PMID: 37842314 PMCID: PMC10569460 DOI: 10.3389/fendo.2023.1248985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Cushing's syndrome, acromegaly and neuroendocrine disorders are characterized by an excess of counterregulatory hormones, able to induce insulin resistance and glucose metabolism disorders at variable degrees and requiring immediate treatment, until patients are ready to undergo surgery. This review focuses on the management of diabetes mellitus in endocrine disorders related to an excess of counterregulatory hormones. Currently, the landscape of approved agents for treatment of diabetes is dynamic and is mainly patient-centred and not glycaemia-centred. In addition, personalized medicine is more and more required to provide a precise approach to the patient's disease. For this reason, we aimed to define a practical therapeutic algorithm for management of diabetes mellitus in patients with glucagonoma, pheochromocytoma, Cushing's syndrome and acromegaly, based on our practical experience and on the physiopathology of the specific endocrine disease taken into account. This document is addressed to all specialists who approach patients with diabetes mellitus secondary to endocrine disorders characterized by an excess of counterregulatory hormones, in order to take better care of these patients. Care and control of diabetes mellitus should be one of the primary goals in patients with an excess of counterregulatory hormones requiring immediate and aggressive treatment.
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Affiliation(s)
| | | | | | | | | | | | - Carla Giordano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Endocrinology, University of Palermo, Piazza delle Cliniche 2, Palermo, Italy
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Moustaki M, Paschou SA, Xekouki P, Kotsa K, Peppa M, Psaltopoulou T, Kalantaridou S, Vryonidou A. Secondary diabetes mellitus in acromegaly. Endocrine 2023; 81:1-15. [PMID: 36882643 PMCID: PMC10239382 DOI: 10.1007/s12020-023-03339-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Secondary diabetes mellitus (DM) is a common complication of acromegaly, encountered in up to 55% of cases. Vice versa, the prevalence of acromegaly is markedly higher in cohorts of patients with type 2 DM (T2DM). The presence of secondary DM depends primarily on acromegaly status and is associated with increased cardiovascular morbidity, malignancy rate and overall mortality. The principal pathophysiologic mechanism is increased insulin resistance due to excessive lipolysis and altered fat distribution, reflected at the presence of intermuscular fat and attenuated, dysfunctional adipose tissue. Insulin resistance is ascribed to the direct, diabetogenic effects of growth hormone (GH), which prevail over the insulin-sensitizing effects of insulin-like growth factor 1 (IGF-1), probably due to higher glucometabolic potency of GH, IGF-1 resistance, or both. Inversely, GH and IGF-1 act synergistically in increasing insulin secretion. Hyperinsulinemia in portal vein leads to enhanced responsiveness of liver GH receptors and IGF-1 production, pointing towards a mutually amplifying loop between GH-IGF-1 axis and insulin. Secondary DM occurs upon beta cell exhaustion, principally due to gluco-lipo-toxicity. Somatostatin analogues inhibit insulin secretion; especially pasireotide (PASI) impairs glycaemic profile in up to 75% of cases, establishing a separate pathophysiologic entity, PASI-induced DM. In contrast, pegvisomant and dopamine agonizts improve insulin sensitivity. In turn, metformin, pioglitazone and sodium-glucose transporters 2 inhibitors might be disease-modifying by counteracting hyperinsulinemia or acting pleiotropically. Large, prospective cohort studies are needed to validate the above notions and define optimal DM management in acromegaly.
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Affiliation(s)
- Melpomeni Moustaki
- Department of Endocrinology and Diabetes Center, Hellenic Red Cross Hospital, Athens, Greece
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Paraskevi Xekouki
- Department of Endocrinology and Diabetes, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece
| | - Kalliopi Kotsa
- Endocrine Unit and Diabetes Center, First Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Melpomeni Peppa
- Endocrine Unit and Diabetes Center, Second Department of Internal Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Kalantaridou
- 3rd Department of Obstetrics and Gynecology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes Center, Hellenic Red Cross Hospital, Athens, Greece
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Iwasaki K, Lalani B, Kahng J, Carapeto P, Sanjines S, Hela F, Abarca C, Tsuji T, Darcy J, Bartke A, Tseng YH, Kulkarni RN, Aguayo-Mazzucato C. Decreased IGF1R attenuates senescence and improves function in pancreatic β-cells. Front Endocrinol (Lausanne) 2023; 14:1203534. [PMID: 37441495 PMCID: PMC10335398 DOI: 10.3389/fendo.2023.1203534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/02/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction The enhanced β-cell senescence that accompanies insulin resistance and aging contributes to cellular dysfunction and loss of transcriptional identity leading to type 2 diabetes (T2D). While senescence is among the 12 recognized hallmarks of aging, its relation to other hallmarks including altered nutrient sensing (insulin/IGF1 pathway) in β-cells is not fully understood. We previously reported that an increased expression of IGF1R in mouse and human β-cells is a marker of older β-cells; however, its contribution to age-related dysfunction and cellular senescence remains to be determined. Methods In this study, we explored the direct role of IGF1R in β-cell function and senescence using two independent mouse models with decreased IGF1/IGF1R signaling: a) Ames Dwarf mice (Dwarf +/+), which lack growth hormone and therefore have reduced circulating levels of IGF1, and b) inducible β-cell-specific IGF1R knockdown (βIgf1rKD) mice. Results Compared to Dwarf+/- mice, Dwarf+/+ mice had lower body and pancreas weight, lower circulating IGF1 and insulin levels, and lower IGF1R and p21Cip1 protein expression in β-cells, suggesting the suppression of senescence. Adult βIgf1rKD mice showed improved glucose clearance and glucose-induced insulin secretion, accompanied by decreased p21Cip1 protein expression in β-cells. RNA-Seq of islets isolated from these βIgf1rKD mice revealed the restoration of three signaling pathways known to be downregulated by aging: sulfide oxidation, autophagy, and mTOR signaling. Additionally, deletion of IGF1R in mouse β-cells increased transcription of genes important for maintaining β-cell identity and function, such as Mafa, Nkx6.1, and Kcnj11, while decreasing senescence-related genes, such as Cdkn2a, Il1b, and Serpine 1. Decreased senescence and improved insulin-secretory function of β-cells were also evident when the βIgf1rKD mice were fed a high-fat diet (HFD; 60% kcal from fat, for 5 weeks). Discussion These results suggest that IGF1R signaling plays a causal role in aging-induced β-cell dysfunction. Our data also demonstrate a relationship between decreased IGF1R signaling and suppressed cellular senescence in pancreatic β-cells. Future studies can further our understanding of the interaction between senescence and aging, developing interventions that restore β-cell function and identity, therefore preventing the progression to T2D.
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Affiliation(s)
- Kanako Iwasaki
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
- Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Benjamin Lalani
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Jiho Kahng
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Priscila Carapeto
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Stephanie Sanjines
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Francesko Hela
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Cristian Abarca
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Tadataka Tsuji
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Justin Darcy
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Andrzej Bartke
- Department of Internal Medicine, Division of Geriatrics Research, Department of Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Yu-Hua Tseng
- Section on Integrative Physiology and Metabolism, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Rohit N. Kulkarni
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - Cristina Aguayo-Mazzucato
- Section on Islet Cell Biology and Regenerative Medicine, Joslin Diabetes Center and Harvard Medical School, Boston, MA, United States
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Pan J, Yang X, Zhu W. Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report. BMC Endocr Disord 2021; 21:109. [PMID: 34039339 PMCID: PMC8157700 DOI: 10.1186/s12902-021-00768-9] [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: 02/10/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis. CASE PRESENTATION A 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient's postoperative recovery was remarkable. CONCLUSIONS Long-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.
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Affiliation(s)
- JinYu Pan
- Graduate Department, BengBu Medical College, 233030, Bengbu, Anhui, China
| | - XiangHong Yang
- Department of Intensive Care Uint, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 310014, Hangzhou, Zhejiang, China
| | - Wei Zhu
- Department of Emergency Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 158 Shangtang Road, 310014, Hangzhou, Zhejiang, People's Republic of China.
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Biagetti B, Aulinas A, Casteras A, Pérez-Hoyos S, Simó R. HOMA-IR in acromegaly: a systematic review and meta-analysis. Pituitary 2021; 24:146-158. [PMID: 33085039 DOI: 10.1007/s11102-020-01092-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This review is aimed at examining whether the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) is higher in Caucasian, adult, treatment-naïve patients with acromegaly (ACRO) than in the reference population independently of diabetes presence and to evaluate the impact of treatment [surgery and somatostatin analogues (SSAs)] on its assessment. METHODS We systematically reviewed in PubMed and Web of Science from July 1985 to December 2019, registered with the code number CRD42020148737. The inclusion criteria comprised studies conducted in Caucasian adult treatment-naïve patients with active ACRO in whom HOMA-IR or basal insulin and glucose were reported. Three reviewers screened eligible publications, extracted the outcomes, and assessed the risk of biases. RESULTS Of 118 originally selected studies, 15 met the inclusion criteria. HOMA-IR was higher in ACRO than the reference population, with mean difference and (95% confidence intervals) of 2.04 (0.65-3.44), even in ACRO patients without diabetes, 1.89 (1.06-2.73). HOMA-IR significantly decreased after treatment with either surgery or SSAs - 2.53 (- 3.24- - 1.81) and - 2.30 (- 3.05- - 1.56); respectively. However, the reduction of HOMA-IR due to SSAs did not improve basal glucose. CONCLUSION HOMA-IR in treatment-naïve ACRO patients is higher than in the reference population, even in patients without diabetes. This finding, confirms that insulin resistance is an early event in ACRO. Our results also suggest that HOMA-IR is not an adequate tool for assessing insulin resistance in those patients treated with SSAs.
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Affiliation(s)
- Betina Biagetti
- Diabetes and Metabolism Research Unit, Vall D'Hebron Research Institute and CIBERDEM (ISCIII), Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Anna Aulinas
- Department of Endocrinology and Nutrition, Hospital de La Santa Creu I Sant Pau and Sant Pau-Biomedical Research Institute (IIB-Sant Pau), Barcelona, Spain
- Research Center for Pituitary Diseases, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERERUnidad 747), ISCIII, Barcelona, Spain
- Faculty of Medicine, University of Vic Central University of Catalonia (UVic/UCC), Vic, Spain
| | - Anna Casteras
- Diabetes and Metabolism Research Unit, Vall D'Hebron Research Institute and CIBERDEM (ISCIII), Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Santiago Pérez-Hoyos
- Genetics Microbiology and Statistics Department, Statistics and Bioinformatics Unit, Vall D'Hebron Research Institute, Universitat de Barcelona, Barcelona, Spain
| | - Rafael Simó
- Diabetes and Metabolism Research Unit, Vall D'Hebron Research Institute and CIBERDEM (ISCIII), Universidad Autónoma de Barcelona, Barcelona, Spain.
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He W, Yan L, Wang M, Li Q, He M, Ma Z, Ye Z, Zhang Q, Zhang Y, Qiao N, Lu Y, Ye H, Lu B, Shou X, Zhao Y, Li Y, Li S, Zhang Z, Shen M, Wang Y. Surgical outcomes and predictors of glucose metabolism alterations for growth hormone-secreting pituitary adenomas: a hospital-based study of 151 cases. Endocrine 2019; 63:27-35. [PMID: 30238327 DOI: 10.1007/s12020-018-1745-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE The surgical outcome on glucose metabolism in acromegaly patients is not fully understood. We aimed to investigate the impact of surgery on glucose metabolism and identify key factors that influence alterations of glucose metabolic status in acromegaly patients. METHODS Oral glucose tolerance test was performed in 151 newly diagnosed acromegaly patients before and 3-12 months after surgery. Insulin resistance and insulin secretion was assessed. Patients were grouped as cured, discordant, and having active disease according to postoperative growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels. Receiver-operating characteristic curves were generated to determine the optimal cut-off points to predict the impact of surgery on glucose metabolism. RESULTS At baseline, 32.5%, 41.7%, and 25.8% patients were categorized as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and diabetes mellitus (DM), respectively. After surgery, improved glucose tolerance was observed in 87.3% patients with IGT and 66.7% patients with DM. Deterioration was observed in 14.3% patients with NGT. Glucose tolerance improved in patients with lower preoperative FBG, 2 h-BG, and HbA1c and higher HOMA-β and IGI/IR. The proportion of NGT was significantly increased in surgically cured patients (28.3% vs. 79.2%, P < 0.001) and those with normal GH but elevated IGF-1 levels (25.6% vs. 79.5%, P < 0.001), but not in patients with active disease (42.9% vs. 57.1%, P = 0.131). Baseline FBG < 6.35 mmol/l predicted improved glucose metabolism after surgery. CONCLUSIONS Glucose metabolic status improved in patients with preserved β-cell function. Preoperative FBG was an independent predictor for improved glucose tolerance status after surgery.
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Affiliation(s)
- Wenqiang He
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Linling Yan
- Department of Endocrinology, the First People's Hospital of Taicang, Jiangsu, 215400, China
| | - Meng Wang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Qin Li
- Department of Endocrinology and Metabolism, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, 200011, China
| | - Min He
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yun Lu
- Department of Nuclear Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Hongying Ye
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Bin Lu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yiming Li
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Shiqi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Zhaoyun Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
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Yonenaga M, Fujio S, Habu M, Arimura H, Hiwatari T, Tanaka S, Kinoshita Y, Hosoyama H, Hirano H, Arita K. Postoperative Changes in Metabolic Parameters of Patients with Surgically Controlled Acromegaly: Assessment of New Stringent Cure Criteria. Neurol Med Chir (Tokyo) 2018; 58:147-155. [PMID: 29479042 PMCID: PMC5929912 DOI: 10.2176/nmc.oa.2017-0215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The criteria for surgical cure of acromegaly have become more stringent during the past decades and a change from Cortina to new consensus criteria has recently been proposed. However, the superiority of the new consensus over Cortina criteria with respect to postoperative metabolic parameters remains to be ascertained. We retrospectively assessed metabolic parameters, the body habitus, and other health-related parameters of 48 patients with surgically controlled acromegaly who met the Cortina criteria [normalized insulin-like growth factor-1 (IGF-1) level and nadir growth hormone (GH) level <1.0 ng/ml during postoperative oral glucose tolerance test]. The 48 patients were divided into two groups. Group A (n = 33) met the new consensus criteria (normalized IGF-1 and nadir GH level <0.4 ng/ml). Group B (n = 15) met Cortina criteria, but their nadir GH ranged from 0.4 to 1.0 ng/ml. In both groups, the level of triglyceride and homeostasis model assessment-insulin resistance (HOMA-IR) was significantly decreased 1 year after the operation (P < 0.05). High-density lipoprotein cholesterol showed a significant increase only in group B (P = 0.02). However, the two groups did not differ with respect to the postoperative improvement rate of these parameters and the other health-related parameters including body mass index, blood pressure, anterior pituitary function, and self-estimated quality of life scale. In conclusion, our findings show that with respect to changes in metabolic parameters and the body habitus assessed 1 year after surgery, the stricter consensus criteria seemed not to be superior to Cortina criteria.
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Affiliation(s)
- Masanori Yonenaga
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Shingo Fujio
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mika Habu
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Hiroshi Arimura
- Department of Diabetes and Endocrine Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Takaaki Hiwatari
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Shunichi Tanaka
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Yasuyuki Kinoshita
- Department of Neurosurgery, Graduate School of Biomedical Science, Hiroshima University
| | - Hiroshi Hosoyama
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Hirofumi Hirano
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University
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