Acromegaly Diagnosis and Treatment

Diagnostic Evaluation

The American College of Endocrinology recommends measuring serum IGF-I levels as the initial screening test for suspected acromegaly, followed by an oral glucose tolerance test (OGTT) with GH measurement as the gold standard diagnostic test, with failure to suppress GH to <1 μg/L confirming acromegaly 1
The Endocrine Society suggests that using modern sensitive assays, normal individuals should suppress GH to <1 μg/L during OGTT 1

The American Heart Association recommends evaluating for cardiovascular complications, including left ventricular hypertrophy and heart failure, as these are the most common causes of death in untreated acromegaly 2, 3
The European Society of Endocrinology suggests screening for metabolic complications, including diabetes mellitus 4
The American Academy of Sleep Medicine recommends assessing for sleep apnea, which is common in acromegaly 5
The European Society of Endocrinology suggests evaluating for musculoskeletal complications, particularly arthropathy 5
The American College of Gastroenterology recommends colonoscopic screening starting at age 40 due to increased risk of colorectal neoplasia 6, 3

The Endocrine Society recommends transsphenoidal surgery as the first-line treatment when an experienced surgeon is available and the tumor is resectable, especially for small well-circumscribed adenomas 5
The American College of Endocrinology suggests that medical therapy is indicated for patients with persistent disease after surgery or as primary therapy when surgery is not appropriate 5
The European Society of Endocrinology recommends somatostatin receptor ligands (SRLs) as the primary medical treatment option if surgery is not appropriate 5
SRLs normalize IGF-I levels in approximately 25% of treatment-naive patients, with long-term results on efficacy and safety being reassuring 7

The American College of Endocrinology recommends that the primary goal is to reduce GH and IGF-I levels to normal, which reduces mortality to rates similar to the general population 4, 1
The Endocrine Society suggests aiming for GH <1 μg/L and age/sex-normalized IGF-I levels 4
The European Society of Endocrinology recommends monitoring GH and IGF-I levels regularly to assess treatment efficacy 4
The American Academy of Clinical Endocrinologists suggests evaluating improvement in clinical symptoms and comorbidities 5
The European Society of Endocrinology recommends monitoring for potential side effects of SRLs, including glucose metabolism alterations 5

Los valores de IGF-I deben interpretarse utilizando rangos de referencia específicos para edad, sexo y estadio de Tanner (en adolescentes) 8, 9
Con ensayos ultrasensibles, el punto de corte para la supresión de GH durante la PTOG puede ser tan bajo como 0.4 μg/L 9
En adultos sanos, la GH debe suprimirse a <1 μg/L durante la PTOG usando ensayos sensibles modernos 10

Los niveles de IGF-I pueden ser falsamente normales o bajos en presencia de hipotiroidismo severo 8
Los niveles de IGF-I pueden ser falsamente normales o bajos en presencia de desnutrición o infección severa 9
Los niveles de IGF-I pueden ser falsamente elevados en presencia de insuficiencia hepática y/o renal 9

Tanto GH como IGF-I deben monitorearse en el momento basal y durante el seguimiento 8, 9
Los niveles de IGF-I se correlacionan linealmente con GH solo hasta 4 μg/L y se estabilizan alrededor de 10 μg/L 8, 9

Los resultados de supresión de GH durante PTOG NO son útiles en el seguimiento de pacientes tratados médicamente debido a resultados inconsistentes 10, 11, 12
Los niveles elevados de GH e IGF-I son predictores de mortalidad en pacientes con acromegalia 10, 11, 13
Normalizar GH e IGF-I resulta en tasas de mortalidad similares a la población general 10, 11, 13