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Anat Ben-Shlomo, Shlomo Melmed, The Role of Pharmacotherapy in Perioperative Management of Patients with Acromegaly, The Journal of Clinical Endocrinology & Metabolism, Volume 88, Issue 3, 1 March 2003, Pages 963–968, https://doi.org/10.1210/jc.2002-020072
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The major complications of acromegaly, including cardio- and cerebrovascular disease and respiratory and metabolic dysfunction, are associated with a significant increase in morbidity and mortality (1–3). These complications are well known to be major risk factors in perioperative patients, especially the elderly (4–8). Therefore, controlling cardio- and cerebrovascular disease, pulmonary dysfunction, and hyperglycemia is important in patients undergoing anesthesia and surgery. This review evaluates the rationale for administering somatostatin analog treatment before either transsphenoidal resection of a GH-secreting pituitary adenoma or any other surgical procedure requiring general anesthesia in the patient with uncontrolled acromegaly.
Preoperative pharmacotherapy and remission rates
Does treatment with somatostatin analogs before surgery improve surgical outcome?
In the hands of an experienced surgeon and if rigorous criteria are used to interpret surgical results [GH ≤ 1 ng/ml after oral glucose tolerance test (OGTT) and normalized IGF-I levels], approximately 90% of patients with microadenomas and 50% of those with macroadenomas are controlled by surgery in the most experienced centers (9). In a recent study, 70% of 57 surgically treated patients (67% of whom harbored macroadenomas) exhibited normalized IGF-I, and 61% exhibited nadir GH less than 1 μg/liter 12 months after surgery (10). Summarizing 14 studies (Table 1), 55–89% of patients harboring mostly macroadenomas experience disease control if short-term treatment with somatostatin analogs is administered before surgery, and 23–100% exhibit more than 20% tumor shrinkage. If tight control is achieved with sc octreotide (GH ≤ 1 ng/ml after OGTT and normal IGF-I levels; Ref.1), 55–75% of patients have controlled hormone levels, and 36–50% exhibit tumor shrinkage. Insufficient studies have been conducted using octreotide LAR (long-acting release) or lanreotide SR (slow release), but remission rates may well be higher because patient compliance is improved and control of serum hormone levels by slow-release drugs is readily attainable. The statistical estimation of disease control rose from 68% success rate for patients with macroadenomas treated with primary pharmacotherapy to 81% (and even 87% for noninvasive macroadenomas) for patients undergoing surgery followed by postoperative somatostatin analogs (11). The question of whether shrinkage of tumors before surgery may facilitate their complete resection has not been examined in a controlled, randomized, blinded manner and therefore cannot be rigorously answered.
