Preoperative Medical Therapy
Î ES suggests against routinely using preoperative medical therapy to
improve biochemical control after surgery. (2|⊕⊕
)
Î For patients with severe pharyngeal thickness and sleep apnea, or high
output heart failure, ES suggests medical therapy with somatostatin
receptor ligands (SRLs) preoperatively to reduce surgical risk from severe
comorbidities. (2|⊕
)
Surgical Debulking
Î In a patient with parasellar disease making total surgical resection
unlikely, ES suggests surgical debulking to improve subsequent response
to medical therapy. (2|⊕⊕
)
Postoperative Testing
Î Following surgery, ES suggests measuring an IGF-1 level and a random GH
at 12 weeks or later. (2|⊕⊕⊕
) ES also suggests measuring a nadir GH
level after a glucose load in a patient with a GH >1 mcg/L. (2|⊕⊕⊕
)
Î ES recommends performing an imaging study ≥12 weeks following surgery
to visualize residual tumor and adjacent structures. (1|⊕⊕⊕
)
Î ES suggests MRI as the imaging modality of choice followed by CT scan
when MRI is contraindicated or unavailable. (2|⊕⊕
)
Therapeutic Options: Medical Therapy
Î ES recommends medical therapy in a patient with persistent disease
following surgery. (1|⊕⊕⊕⊕)
Î In a patient with significant disease (ie, with moderate-to-severe signs
and symptoms of GH excess and without local mass effects), ES suggests
use of either a SRL or pegvisomant as the initial adjuvant medical therapy.
(2|⊕⊕
)
Î In a patient with only modest elevations of serum IGF-1 and mild signs and
symptoms of GH excess, ES suggests a trial of a dopamine agonist (DA),
usually cabergoline, as the initial adjuvant medical therapy. (2|⊕⊕
)
Î ES suggests against routine abdominal ultrasound to monitor for gallstone
disease in a patient receiving a SRL. (2|⊕⊕
) Ultrasound should be
performed if the patient has signs and symptoms of gallstone disease.
(2|⊕⊕
)
Î ES suggests serial imaging with MRI scan to evaluate tumor size in a
patient receiving pegvisomant. (2|⊕⊕
)
Treatment
