• Pregnant women with acromegaly would benefit from endocrinology and MFM referrals. • Test visual fields at end of the 1st trimester and then every 6 weeks. • Consider MRI without contrast if new symptoms develop or visual field testing suggests chiasmal lesion. • If planned pregnancy, consider discontinuing long-acting somatostatin. ADDITIONAL THERAPIES Radiotherapy • Used if acromegaly is uncontrolled by surgery or medical therapy • Conventional, proton beam, and stereotactic radiotherapy have been used. • Complication: hypopituitarism (50%) SURGERY/OTHER PROCEDURES • Transsphenoidal surgical resection by an experienced neurosurgeon is the treatment of choice for patients with pituitary tumors that are resectable. 4
• If serum IGF-1 is normalized after surgery (within 7 to 10 days after resection), no further therapy is recommended. Ongoing Care FOLLOW-UP RECOMMENDATIONS Patient Monitoring Monitoring for medical and surgical treatment: • At baseline - Echocardiogram - Colonoscopy • Every 3 to 4 months - Cardiovascular exam and BP measurement - Measurement of serum IGF-1 • Annually - MRI of pituitary sella • Patients with complications (cardiomyopathy, sleep apnea, colon polyps) should be followed appropriately according to guidelines for these conditions. • Specifically, after surgical resection: random IGF-1, GH level, and pituitary MRI performed 12 weeks PROGNOSIS • Patients with GH levels <2.5 after treatment have a mortality similar to the general population. • Death is primarily caused by cancer (15%), respiratory diseases (25%), and cardiovascular diseases (60%). • If untreated, there is an associated 30% decrease in lifespan related to the above complications. Clinical Pearls • The onset of acromegaly is insidious and may be initially subtle. • The serum IGF-1 level is the preferred screening test and is elevated in acromegaly. • An elevated IGF-1 should prompt an MRI of the pituitary. • First-line treatment of acromegaly is generally transsphenoidal surgery for resectable tumors, followed by long-acting somatostatin analogues, GH-receptor antagonists, and/or radiotherapy if surgery alone is not effective at reducing IGF-1 levels to normal. 5
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- Spring '16