Exploring potential influencing factors of inadherence to specialist aftercare and long-term medication in patients with acromegaly

PURPOSE

To improve the understanding of adherence as one major factor of disease control in acromegaly patients, we systematically assessed patients' motivations to adhere to advised follow-up schedules and recommended medication for acromegaly.

METHODS

Cross-sectional, postal questionnaire study on adult patients with acromegaly, operated upon a growth hormone producing pituitary adenoma more than 1 year ago in two tertiary treatment centers. We assessed demographic and clinical characteristics, disease status, adherence to acromegaly medication and/or aftercare, and the five dimensions defined by the World Health Organization influencing adherence. Wherever applicable, we included validated short scales. The answers of 63 patients (33 f, 30 m; mean age 56.1 y) were analyzed.

RESULTS

Patients with problems in adherence to aftercare had a significantly lower subjective symptomload than those adherent to aftercare (p = 0.026) and a lower perceived need for treatment (p = 0.045). Patients with adherence problems to medication had a higher subjective symptomload than those without (p = 0.056). They also tended to have shorter consultations, were significantly more often dissatisfied with the duration of their medical consultations (42% vs 4.8%, p = 0.019) and tended to find that their physician explained potential difficulties with adherence less well than patients without adherence problems (p = 0.089).

CONCLUSIONS

To our knowledge, this is the first study which explored adherence to medication and aftercare in patients with acromegaly, taking into account potential influencing factors from all areas defined by the WHO model of adherence. Of the modifiable factors of adherence, patient-doctor relationship seemed to play a crucial role and could be one leverage point to improve adherence.

Pituitary enlargement in patients with cerebrospinal fluid drainage due to ventricular shunt insertion: know the condition and do not mistake for adenoma

OBJECTIVE

Childhood hydrocephalus patients treated by ventriculo-peritoneal (v.-p.) shunting are sometimes referred years after this therapy for evaluation of suspicious pituitary enlargement. Since pituitary size has been shown to depend on cerebrospinal fluid (CSF) pressure, we assume this phenomenon to be caused by shunt overdrainage. Therefore, we studied pituitary size and morphology in shunted hydrocephalus patients with radiological signs of high CSF drainage.

PATIENTS AND METHODS

Retrospective study of pituitary size and morphology in 15 shunted patients with non-tumoral hydrocephalus and 7 shunted hydrocephalus patients due to childhood brain tumor compared to a population mean. In five brain tumor patients also pre- and postsurgical comparisons were performed.

RESULTS

Pituitary mid-sagittal size and pituitary volume were significantly higher in both hydrocephalus groups, compared to the population mean (midsagittal size t = 5.91; p < 0.001; pituitary volume, t = 3.03; p = 0.006). In patients available for pre- and postoperative comparison, there was also a significant increase in pituitary size and volume postoperatively (mean preoperative midsagittal height 2.54 ± 1.0 mm vs. 6.6 ± 0.7 mm post-surgery; mean pre-operative pituitary volume 120.5 ± 69.2 mm³ vs. 368.9 ± 57.9 mm³ post-surgery).

CONCLUSION

Our results confirmed a significant increase in pituitary size and volume, mimicking pituitary pathology, after v.-p. shunt insertion. This phenomenon can be explained by the Monro-Kellie doctrine, stating that intracranial depletion of CSF-as caused by v.p. shunting-leads to compensatory intracranial hyperemia, especially in the venous system, with the consequence of engorged venous sinuses, most likely responsible for enlargement of the pituitary gland.

Adults' Adherence to Growth Hormone Replacement in Relation to Medication-Related Beliefs, Coping and Quality of Life - An Exploratory Analysis

INTRODUCTION

Little is known about psychological reasons associated with adherence to growth hormone (GH) replacement therapy (GHRx) in adults. As in other chronic diseases, medication-related beliefs, coping strategies and disease impact on quality of life (QoL) might play an important role. We thus explored these psychological factors in relation to adherence in patients with GH deficiency (GHD) in order to find leverage points for the improvement of adherence.

PATIENTS AND METHODS

Cross-sectional analysis including 107 adult GHD patients on GHRx who completed self-assessment inventories on health-related QoL (Short-Form SF-36), coping style (Freiburg questionnaire on coping with illness, FKV-LIS) and medication beliefs (Beliefs about Medicine questionnaire, BMQ). Results were correlated to general and GH-specific adherence to medication.

RESULTS

In the BMQ, 92.5% of the patients (n=99) reported a strong belief in the need for their medication, which correlated significantly with general adherence (r_s = 0.325). Active coping was significantly related to general (r_s = 0.307) and GH-specific adherence (r_s = 0.226). Better mental QoL (r_s = 0.210) but worse physical QoL (r_s = -0.198; all p < 0.05) were related to higher GH-specific adherence. Older age was associated with a higher degree of active coping, a higher belief in the necessity of medication and worse physical QoL.

CONCLUSION

We provide preliminary data that most GHD patients on GHRx are strongly convinced of their need for medication and that adherence to GHRx is influenced by coping strategies and QoL. Patients with impaired psychological QoL are less able to translate their convictions into good adherence, a phenomenon to be addressed in future research.

Motivation for and adherence to growth hormone replacement therapy in adults with hypopituitarism: the patients' perspective

INTRODUCTION

While reasons for non-adherence in children requiring growth hormone (GH) replacement (GH-Rx) are well researched, few studies have investigated adherence in adult GH deficient patients. Against the background of the adverse medical sequelae of untreated severe GH deficiency (GHD) in adults, we explored adherence to GH-Rx and associated factors in this patient group.

METHOD

Cross-sectional analysis including 107 adult patients with severe GHD on GH-Rx, 15 untreated GDH patients and 19 who had discontinued therapy. Patients completed self-developed ad hoc surveys on adherence to medication and GH-Rx, specific beliefs about GH-Rx, side effects and burden of injection, reasons for never receiving or dropping out of therapy, respectively.

RESULTS

Adherence to GH-Rx was high (mean 15.8/18 points on the self-developed adherence score) and significantly correlated with general medication adherence. Higher age was significantly associated with better adherence to GH-Rx, while injection side effects, duration of treatment or device used were not. The most frequent reasons for not being on GH-Rx apart from medical reasons included fear of side effects, lack of belief in treatment effects and dislike of injections. In patients not on GH-Rx, the proportion of patients in employment was significantly smaller than in the treatment group, despite similar age and comorbidities.

CONCLUSIONS

Adherence to GH-Rx was high for those patients on therapy. Instead of focusing on improving adherence in those adults already on GH-Rx, efforts should be undertaken to ally fear of side effects and provide education on positive treatment effects for those eligible but not receiving therapy.

Neuropsychological Functioning in Patients with Cushing's Disease and Cushing's Syndrome

PURPOSE

To present a systematic review of the presence and severity of neuropsychological impairment in the six main neuropsychological domains (attention, executive function, language, visuospatial processing, intelligence, and memory) in patients with Cushing's disease (CD) and/or Cushing's Syndrome (CS) at various stages of the illness. The work aims to identify neuropsychological leverage points for focused diagnosis and rehabilitation in CS/CD patients.

METHODS

A pubmed literature search was performed and augmented by searching the reference lists of review articles identified by this search strategy. After excluding irrelevant hits, we systematically extracted data from 27 studies for each main neuropsychological domain, differentiating between active disease, short- and long-term remission.

RESULTS

The literature gives evidence for neuropsychological impairment in all domains in Cushing patients with active disease. The most consistent impairments concerned memory and visuo-spatial processing, whereas the data are discordant for all other domains. Significant improvement of neuropsychological function - although not returning to normal in all domains - is shown in short-term and long-term remission of the disease. However, the published literature is thin, suffering from repetitive subsample analyses publishing, methodological concerns as lack of control for confounders such as depression.

CONCLUSIONS

Memory is the most extensively investigated domain in CS/CD patients and impairment is most prominent in active disease. Patients should be counseled that neuropsychological function will improve with normalization of hypercortisolism and over time. More studies with more stringent methodological criteria, larger patient samples and controlling for confounders are required to enhance our understanding of neuropsychological function in patients with CS/CD.

SUN-272 Significant Response to Temozolomide in Two Aggressively Growing Pituitary Adenomas

Introduction: Aggressive atypical pituitary tumors are characterized by invasive growth, recurrence and resistance to standard therapies. We present two female patients with pituitary adenomas in whom multiple other therapies had failed, who presented with significant response to temozolomide. Case presentations: In patient #1 (w, 78y), the diagnosis of macroprolactinoma had been made in a community hospital and dopaminagonistic treatment with bromocriptin had been initiated. After failure to achieve significant tumor reduction under this treatment and persisting visual field disturbances, first transnasal-transphenoidal surgery (TSS) was performed in 07/2011, followed by cabergoline exposure in increasing dose due to failure to control prolactin levels. Repeat TSS and stereotactic radiosurgery were performed in both 2014 and 2018 because of invasive tumor growth and double vision. She was then put on temozolomide. Patient #2 (w, 58y) presented with apoplectic gonadotropinoma in 2013. She also underwent 3 courses of TSS as well as stereotactic radiosurgery because of repeated tumor growth leading to visual field disturbances and double vision. Despite these measures, the tumor could not be controlled and she, as well, was put on temozolomide in 2018. In both cases costs were reimbursed by the patient’s health care insurance and in both the first cycle was conducted with 150 mg/ body surface area (BSA) with escalation to 200 mg/BSA in the second. After only 2 cycles, double vision resolved in both patients and the tumor had shrunk by approximately 20% on MRI in patient #1 and even more in patient #2. In both patients, temozolomide dose was reduced again to 150 mg/BSA due to side effects. Nevertheless, in both patients tumor volume further continued to decrease under therapy. Conclusion: This promising clinical course after exposure to temozolomide with early, significant tumor shrinkage in two heavily pretreated patients with aggressive pituitary adenomas indicates that this therapy can be considered also in older patients and may yield astonishing results. Although temozolomide is increasingly becoming a therapeutic option for those patients whose pituitary tumors are refractory to standard therapies, further research and observance over time of temozolomide therapy in aggressive pituitary adenomas and carcinomas is indicated.

MON-452 Development of Concepts for Improved Patient Care: What Do Patients with Acromegaly Expect from Their Caregivers?

Introduction:Traditional patient-clinician relationships are paternalistic in the sense that the clinician makes the decision of what is best for the patient. However, modern medicine requires a paradigm shift away from this type of interaction and a drive towards more patient-centered care, implying that physicians must gain a broader knowledge about the patients’ view of their illness. This also hold true for neuroendocrine disorders such as acromegaly. Here, we present the results of a focus group with acromegaly patients on their perceptions and needs concerning their illness. Patients and method:As a pre-project for a larger questionnaire study, a focus group research was conducted. Six patients with acromegaly who could not be cured by neurosurgery but required further therapies such as medical treatment and/or radiotherapy took part in this group, which was moderated by an external medical communication company (SDMed. Cologne, Germany). The group discussion focused on topics such as impact of the illness on everyday life and support needs. Results: The patients reported that the diagnosis “acromegaly” was experienced as a nightmare but also a relief after a long medical odyssey. The management of numerous doctors’ visits, procuring and applying medication (“illness as a part-time job”), the irreversible bodily changes due to acromegaly (“buying shoes ruins my day”, “I cannot look at photographs of myself”, “buying work gloves is simply impossible”), treating physicians’ lack of knowledge about the disease, but also a lack of reliable information for patients and relatives, maintaining the cold chain for medication when travelling and fears of the results of medical investigations were named as chronic stressors of living with acromegaly. Patients’ coping strategies included family support, sport, activities to balance out work and everyday life, and humor. The participants wished for a more interdisciplinary treatment of their illness, medical rehabilitation services with special knowledge on acromegaly-related morbidity, a stable contact person in the medical process and reliable information material about their illness for themselves and their relatives. Conclusion: Next to traditional medical care, a successful management of acromegaly requires knowledge about the everyday illness-related stressors and patients’ desires for successful treatment. Placing the focus solely on normalization of IGF-I levels does not seem to be adequate. This study was sponsored under a grant from Ipsen. Ipsen had no input into the study design, analysis or interpretation of results.

Support Needs of Patients with Cushing's Disease and Cushing's Syndrome: Results of a Survey Conducted in Germany and the USA

BACKGROUND

Cushing's disease (CD) and Cushing's syndrome (CS) are chronic illnesses, characterized by symptoms of prolonged hypercortisolism, which often changes to hypocortisolism after successful treatment. In view of the high disease burden of CD/CS patients and long-term impaired quality of life, the present survey was conducted to gain information about subjective illness distress and patients' specific needs in terms of supportive measures beyond medical interventions.

PATIENTS AND METHODS

Cross-sectional questionnaire study including patients with CD treated in 2 German neurosurgical tertiary referral centers and CD/CS patient members of a US-based patient support group completed a survey inquiring about disease burden, coping strategies, and support needs. Additionally, the degree of interest in different offers, e.g., internet-based programs and seminars, was assessed.

RESULTS

84 US and 71 German patients answered the questionnaire. Patients in both countries indicated to suffer from Cushing-related symptoms, reduced performance, and psychological problems. 48.8% US patients and 44.4% German patients stated that good medical care and competent doctors helped them the most in coping with the illness. US patients were more interested in support groups (p = 0.035) and in courses on illness coping (p = 0.008) than the German patients, who stated to prefer brochures (p = 0.001). 89.3% of US patients would attend internet-based programs compared to 75.4% of German patients (p = 0.040). There were no differences between groups for the preferred duration of and the willingness to pay for such a program, but US patients would travel longer distances to attend a support meeting (p = 0.027).

CONCLUSION

Patients in both countries need skilled physicians and long-term medical care in dealing with the effects of CD/CS, whereas other support needs differ between patients of both countries. The latter implies that not only disease-specific but also culture-specific training programs would need to be considered to satisfy the needs of patients in different countries.

Presence of headache and headache types in patients with tumors of the sellar region-can surgery solve the problem? Results of a prospective single center study

PURPOSE

Headache is a common presenting feature of patients with pituitary adenomas and other tumors of the sellar region. However, at present, it still is unclear whether the headache is actually caused by the tumor. To explore whether there is a relation, we examined in detail the headache types, their relationship to the underlying pathology, and if the headache responded to neurosurgery in a prospective study design.

METHODS

One hundred twelve patients with tumors of the sellar region scheduled for neurosurgery in a single center were analyzed for presence and quality of headache before surgery and at least 3 months after surgery. Patients received headache and depression self-rating inventories, presented on a handheld computer (PainDetect^®). Clinical variables thought to impact on headache were analyzed in conjunction with the inventories.

RESULTS

Fifty-nine (53%) patients reported headache in the 3 months prior to neurosurgery, 49 (44%) had headache at the time of filling in the questionnaires. The four patients with pituitary apoplexy described thunderclap headache. In the other patients diverse headache types were encountered, most frequently migraine. Untreated gonadotroph deficiency was significantly associated with absence of headache, while none of the other clinical and morphological variables related to headache. Presence of headache and disability due to headache were not significantly reduced after surgery.

CONCLUSION

Apart from pituitary apoplexy we detected no specific headache type in our patient group and no significant improvement of headache after neurosurgery. Headache alone constitutes neither a valid diagnostic marker for the presence of tumors of the sellar region nor a sufficient indication for tumor removal.