Acromegaly: Management

Key points

• Trans-sphenoidal surgery is first-line for most patients with a GH-secreting pituitary adenoma.
• Somatostatin analogues (octreotide, lanreotide; pasireotide in resistant cases) directly inhibit GH release — first-line medical therapy when surgery is unsuitable or incomplete.
• Pegvisomant is a GH-receptor antagonist — used when GH/IGF-1 remains high despite somatostatin analogues (it normalises IGF-1 but does not shrink the tumour).
• Dopamine agonists (cabergoline; formerly bromocriptine) are effective in only a minority, mainly when there is co-secretion of prolactin.
• Radiotherapy (external beam or stereotactic) is reserved for residual/recurrent disease. Monitor response with IGF-1 and an oral glucose tolerance test (failure of GH to suppress).