No abstract

A 22-year-old woman presented with worsening vision loss and headaches. A diagnosis of acromegaly was confirmed after detection of an invasive pituitary macroadenoma and biochemical testing. Despite two attempts of surgical debulking of the tumour and administration of long-acting octreotide and cabergoline, growth hormone (GH) and insulin-like growth factor 1 (IGF-1) levels were uncontrolled. The patient experienced persistent headaches despite surgery, gamma knife radiation and ventriculoperitoneal shunt placement; she was then enrolled in the ACCESS trial (ClinicalTrials.gov identifier, NCT01995734). Pasireotide (Signifor; Signifor LAR) was initiated, which led to reduced GH and IGF-1 levels and resolution of her intractable headaches. This highlights the use of monthly pasireotide in resolving headaches and improved biochemical control in a patient with acromegaly. We postulate that the headaches improved due to an analgesic and/or anti-inflammatory effect mediated by somatostatin receptors targeted by pasireotide. This may represent an additional benefit of pasireotide and requires further investigation.

Development of the newer, sensitive assay for thyrotropin (thyroid-stimulating hormone [TSH]) has simplified the diagnosis and management of hypothyroidism. Serum free thyroxine (T4) levels measured by analogue techniques or free T4 index may be used in conjunction with TSH test results to confirm the diagnosis. Treatment consists of daily doses of levothyroxine sodium (Levothroid, Levoxine, Synthroid), which are increased slowly to achieve an optimal dose. Close monitoring with TSH assay is important to ensure adequate treatment. In euthyroid sick syndrome, results of thyroid function tests are abnormal in patients with nonthyroidal illness; treatment is indicated if symptoms of hypothyroidism are present. Patients with subclinical hypothyroidism also may benefit from treatment.

Osteoporosis is a silent disease with decreased bone strength and increased risk of low-trauma fractures. These fractures lead to significant morbidity and mortality and are a major source of medical costs as well as indirect costs from reduced quality of life, disability and death. Calcium and vitamin D (vit D) are important interventions in preventing and treating osteoporosis along with anti-osteoporotic agents. Patients with diabetes mellitus (DM) are at an increased risk of fractures, particularly hip fractures (1). Additionally, bone healing after a fracture is compromised in patients with DM (2). Therefore, addressing bone health can have a significant impact on the well-being of a patient with DM. Optimal management of DM requires a multidisciplinary approach with care that is typically focused on glucose, lipid, and blood pressure management. We hypothesized that bone health may not be addressed consistently in patients with DM due to the need to address these other aspects of their care. We, therefore, conducted a retrospective chart review of patients with DM over the age of 50 with the aim to determine if bone health is being identified and if treatment is being initiated. A total of 100 patients (67 female, 33 male) were studied at the University of New Mexico Diabetes Comprehensive Care Center. Information regarding age, sex, DM type, vit D status and therapy, BMD, and FRAX score were collected. Vit D levels were checked in 68% female and 76% male patients. Mean vit D level was 31.8 ng/ml (reference range 30–100 ng/ml). Low vit D was identified in 33 patients of which only 18% were started on treatment. None of the 10 men identified received treatment for low vit D. BMD was obtained in only 21% of patients even though more than half met criteria for BMD screening based on age alone. Younger women (age < 65y) had more DXA scans performed than older women. Osteoporosis was diagnosed in one female and one male patient. Two female patients over age 65 met criteria for treatment based on FRAX. None of these 4 patients received osteoporosis therapy other than vit D replacement. In conclusion, vit D levels were checked in the majority of our patients indicating that bone health is being considered to some extent. However, low vit D levels were treated in only a minority of women, and in none of the men. Also, none of the patients who met criteria for osteoporosis treatment were started on therapy suggesting a lack of appropriate interventions. Using the results from this study, we plan to improve our clinical practice by incorporating bone health more into the care of our patients with DM, identify those at risk for osteoporosis-related fractures, and institute appropriate interventions. References: 1. Fan Y, Wei F, Lang Y, Liu Y. Osteoporosis Int 2016: 27: 219–228 2. Jiao H, Xiao E, Graves DT. Curr Osteoporosis Rep. 2015 Oct; 13(5): 327 – 335.

Acromegaly is most often caused by a somatotroph adenoma of the pituitary gland. Infrequently, these adenomas co-secrete other hormones. Transsphenoidal resection is the treatment of choice for these adenomas, especially when they cause visual impairment. The role of medical therapy has not been clearly established as primary treatment, but medical therapy is often used when surgery carries an unacceptable risk. Studies have shown that treatment with somatostatin analogues decreases IGF-1 levels and also decreases adenoma size. However, these studies have measured the outcomes at a minimum of 3 months. We report a unique case of acromegaly due to a somatotroph adenoma with a dramatic response to octreotide within 1 week. A 53-year-old woman with a history of multiple myeloma, colon cancer, and recent-onset diabetes mellitus was referred to our institution for headaches, blurry vision, left visual field cut, decreased hearing, and ataxia. MRI of the brain revealed a large, lobulated homogeneous enhancing mass extending superiorly and posteriorly from the clivus, causing compression of the optic chiasm as well as encasing bilateral carotid arteries. Biopsy of the mass revealed a pituitary adenoma with staining strongly positive for chromogranin and prolactin along with focal GH, LH, and FSH immunoreactivity. Serum laboratories included IGF-1 level 926 ng/mL, GH 2.17 ng/mL, prolactin 30.6 ng/mL, LH < 0.2 mIU/mL, FSH 1.2 mIU/mL, TSH 0.747 UIU/mL, free T4 0.7 ng/dL, and glucose 395 mg/dL. The patient was started on octreotide 100 μg subcutaneously every 8 hours. After 1 week of therapy, the patient had significantly improved visual acuity, improved visual fields, and decreased insulin requirement. Her IGF-1 level decreased by > 50% to 434 ng/mL. Repeat MRI revealed a decrease in size of the adenoma and no compression of the optic chiasm. This case illustrates an unusually rapid response of a somatotroph adenoma to octreotide. Thus, octreotide should be strongly considered in patients with an advanced tumor burden and in patients with compressive neurologic symptoms for whom urgent surgical intervention may be indicated. Response to the octreotide, as demonstrated by this case, may occur more quickly than previous studies have shown.