Î ES suggests monitoring liver function tests monthly for the first 6
months and then every 6 months in a patient receiving pegvisomant, with
consideration of discontinuation of pegvisomant if transaminases
are ≥3-fold elevated. (2|⊕⊕
)
Î ES suggests addition of pegvisomant or cabergoline in a patient with
inadequate response to a SRL. (2|⊕⊕
)
Î ES suggests use of a SRL as primary therapy in a patient who cannot be
cured by surgery, has extensive cavernous sinus invasion, does not have
chiasmal compression, or is a poor surgical candidate. (2|⊕⊕⊕
)
Radiotherapy/Radiosurgery
Î ES suggests use of radiation therapy (RT) in the setting of residual tumor
mass following surgery or if medical therapy is unavailable, unsuccessful,
or not tolerated. (2|⊕⊕
)
Î ES suggests use of stereotactic radiotherapy (SRT) over conventional RT
in patients with acromegaly, unless the technique is not available, there
is significant residual tumor burden, or the tumor is too close to the optic
chiasm, resulting in an exposure of more than 8 Gy. (2|⊕⊕
)
Î To monitor the efficacy of RT, ES recommends annual GH/IGF-1
reassessment following medication withdrawal. (1|⊕⊕⊕
)
Î Following RT, ES recommends annual hormonal testing of patients for
hypopituitarism and other delayed radiation effects. (1|⊕⊕⊕⊕)
Special Circumstances
Gigantism
Î In patients with the rare presentation of gigantism, ES recommends the
standard approaches to normalizing GH and IGF-1 hypersecretion as
described elsewhere in this guideline. (1|⊕⊕⊕
)
Pregnancy
Î ES suggests women discontinue long-acting SRL formulations and
pegvisomant approximately 2 months before attempting to conceive, with
use of short-acting octreotide as necessary until conception. (2|⊕⊕
)
Î During pregnancy, ES recommends that acromegaly medical therapy
be withheld and administered only for tumor and headache control.
(1|⊕⊕
)
Î During pregnancy, ES suggests serial visual field testing in patients with
macroadenomas. (2|⊕⊕⊕
)
Î ES suggests against monitoring GH and/or IGF-1 levels during pregnancy.
(2|⊕⊕⊕
)
