(A, upper panel) Growth chart, (B, middle panel) timeline of medications and (C, lower panel) serial serum IGF1. (A) Growth chart shows height (cm) plotted from aged 5 to 18 years, horizontal arrow on right hand side of panel A indicates mid-parental height accompanied by vertical blue bar to indicate target centile range; vertical arrows indicate start date of each of the 4 medications (lanreotide [Somatuline], cabergoline, octreotide LAR, and pegvisomant), with horizontal label width visually indicating duration of each therapy. (B) Plots the 4 medications showing respective dose increases: lanreotide doses plotted against left hand y-axis (dose increments 30, 60, 90, and 120 mg/mo), whereas remaining 3 medication doses plotted against right hand y-axis: cabergoline dose increments 0.25 and 0.5 mg/wk (lower green line), octreotide (blue line) dose increments 20 mg then 30 mg/mo for 12 months. Pegvisomant (purple line) commenced at 10 mg/d, rapidly escalated to 20 mg then increased to 30 mg ongoing. (C) Serum IGF-1 plotted against y-axis (nmol/L, conversion factor to µg/L is 7.65) over 13 years (x-axis). Blue line indicates serial values of the patient and green shaded band encompasses normal age ranges. IGF-1 normal range differs according to age. In addition, serum IGF-1 was measured at 4 different laboratories over the 13 years, which accounts for the undue fluctuation in the green band of normal range. Panels B and C have same x-axis time scale to illustrate IGF-1 response to respective medications (ie, persistently elevated IGF-1 throughout somatostatin analogue and cabergoline treatments) and then prompt IGF-1 reduction on introduction of pegvisomant followed by brief escape during puberty, when dose increase to 30 mg pegvisomant per day rapidly regained control.