Diagnosis, treatment and follow-up of patients with acromegaly in a clinical practice setting in Spain: the ACROPRAXIS program Delphi survey

Abstract

Aim The ACROPRAXIS program aims to describe the management of acromegaly in Spain and provide guidance. Methods Ninety-three endocrinologists were organized into 13 panels to discuss the practical issues in managing acromegaly. Based on the key learnings, an online Delphi survey with 62 statements was performed, so those statements achieving consensus could be used as guidance. Statements were rated on a 9-point scale (9, full agreement; consensus > 66.6% of response in the same tertile). Results Ninety-two endocrinologists (98.8%) answered two rounds of the survey (mean age 47.6 years; 59.8% women; median 18.5 years of experience). Consensus was achieved for 49 (79%) statements. Diagnosis: The levels of insulin-like growth factor I (IGFI) is the preferred screening test. If IGFI levels 1–1.3 ULN, the test is repeated and growth hormone (GH) after oral glucose tolerance test (OGTT) is assessed. A pituitary magnetic resonance is performed after biochemical diagnosis. Treatment: Surgery is the first treatment choice for patients with microadenoma or macroadenoma with/without optical pathway compression. Pre-surgical somatostatin analogues (SSA) are indicated when surgery is delayed and/or to reduce anaesthesia-associated risks. After unsuccessful surgery, reintervention is performed if the residual tumor is resectable, while if non-resectable, SSA are administered. Follow-up First biochemical and clinical controls are performed 1–3 months after surgery. Disease remission is considered if random GH levels are < 1 µg/L or OGTT is < 1 or ≤ 0.4 µg/L, depending on the assay’s sensitivity. Conclusion Current clinical management for acromegaly is homogeneous across Spain and generally follows clinical guidelines.

The Biochemical Diagnosis of Acromegaly

“…However, transdermal estrogens have no impact on IGF-I levels [22]. Renal failure can be associated with higher GH levels but IGF-1 values may remain unchanged or even decrease [23] (Table 1). Age is an important physiologic factor that may alter IGF-1 levels, as values rise from birth until puberty, followed by a decline with advancing age [19].…”

“…However, transdermal estrogens have no impact on IGF-I levels [ 22 ]. Renal failure can be associated with higher GH levels but IGF-1 values may remain unchanged or even decrease [ 23 ] ( Table 1 ).…”

“…Additional studies are required to determine the role of nadir GH following glucose load in patients with poorly controlled diabetes, and there is no consensus on the role of nadir GH after OGTT for diagnosis of acromegaly in these patients. At this point, experts agree to repeat measurement after improvement of glycemic control [ 23 ].…”

“… Low IGF-1 in the presence of clinical acromegaly could represent a later stage of a disease process that was initially associated with elevated IGF-1, resulting in burnt-out acromegaly, which may be associated with other features of hypopiuitarism [ 14 ]. Uncontrolled diabetes may be associated with low IGF-1 levels and hamper the diagnosis of acromegaly, but a rise in IGF-1 levels following glycemic control may support the diagnosis [ 23 ]. …”

“…IGFBP-3 levels may assist in the diagnosis and monitoring of acromegaly as there is a direct correlation between IGFBP-3 levels with IGF-1 [41]. • GHRH-measurement of GHRH will be reserved for patients with suspected ectopic GHRH secretion causing acromegaly, for instance, in patients with no evidence of a pituitary adenoma on imaging [8,23].…”