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. 2022 Sep 3;14(9):e28722. doi: 10.7759/cureus.28722

Table 3. Comparison of ES, AACE, PS, and ACG guidelines for medical management.

ES: Endocrine Society; AACE: American Association of Clinical Endocrinologists; PS: Pituitary Society; ACG: Acromegaly Consensus Group; SRL: somatostatin receptor ligands; SSA: somatostatin analogs; GH: growth hormone; IGF-1: insulin-like growth factor 1; HQ: high-quality evidence; MQ: medium-quality evidence; SR: systematic review; LAR: long-acting release

Treatment ES AACE PS ACG
SRL/SSA Recommended as first line. SRL is used 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 Recommended as first line. SSAs are effective in normalizing IGF-1 and GH levels in approximately 55% of patients. SSAs reduce pituitary tumor size modestly in about 25% to 70% of patients, depending on whether they are used as adjuvant or de novo therapy, respectively. The short-acting subcutaneously administered SSA octreotide is effective, especially when low cost and rapid onset of action is the goal Recommended as first line. Extended-dosing intervals (>4 weeks) for 120 mg lanreotide may be effective among selected patients previously controlled with long-acting SRLs. Older age, female sex, lower IGF-1 levels, and tumor T2 MRI hypointensity at baseline predict more favorable long-term biochemical responses to primary lanreotide 120 mg therapy every 4 weeks (MQ, SR). They recommend that pasireotide LAR is an effective alternative for patients who did not receive much benefit from lanreotide or octreotide LAR. For patients who have shown complete or partial biochemical response on injectable octreotide or lanreotide, oral octreotides are suitable (HQ, SR) Recommended as first line. For patients who are on SRL therapy, tumor shrinkage was observed in up to 80% of subjects. Tumor shrinkage did not show any link to biochemical remission (MQ). Response to SRL therapy was more pronounced after surgical debulking (MQ)
Pegvisomant It is also recommended as first line It is recommended as second line. Pegvisomant is often used in patients who respond poorly or are unable to tolerate SSAs. It is extremely effective in normalizing IGF-1 values (>90%). This includes patients who are partially or entirely resistant to other therapies It is recommended as second line. Studies have shown a 73% biochemical control rate. For patients who are diabetic, it improves glucose metabolism independent of IGF-1 control but does not have the same effects in patients without diabetes (MQ) It is recommended as second line in patients with persistently elevated IGF-1 levels after high doses of SRLs
Dopamine agonists Cabergoline is first line in patients with only modest elevations of serum IGF-1 and mild signs and symptoms of GH excess. In such cases, ES suggests a trial of a dopamine agonist, usually cabergoline, as the initial adjuvant medical therapy Recommended as first line. Cabergoline has been shown to yield better clinical results than bromocriptine. Dopamine agonists are recommended as first line. because of their oral availability and cheaper price. They recommend using dopamine agonists in patients with modestly elevated serum IGF-1 levels Not specified They recommend using dopamine agonists as first line occasionally in patients who prefer oral formulations, have markedly elevated prolactin, or those with modestly raised GH or IGF-1 levels
Combination therapy They recommend the addition of pegvisomant or cabergoline in a patient with inadequate response to SRLs. Combining medical therapies may improve efficacy, reduce side effects associated with an individual medication, decrease the frequency of injections and total drug dose, and potentially offer a cost benefit and improved compliance during long-term treatment In patients with a partial response to SSA therapy, the addition of cabergoline may be useful. In patients with a partial response to SSA therapy, pegvisomant can also be considered as daily or weekly doses Combination therapy of SRL and pegvisomant is already being used and has shown impressive results with up to 96% biochemical control rate achieved They recommend SRL and pegvisomant combination therapy in patients with poor response to first and second-line management modalities, improve cost-effectiveness in patients who require high-dose pegvisomant monotherapy or patients with an inability to achieve biochemical control after surgery
Radiotherapy The third line of treatment. It is recommended in the setting of a residual tumor mass following surgery and if medical treatment is unavailable, unsuccessful, or not tolerated The third line of treatment. It is recommended as an adjunctive treatment in patients not fully responding to medical or surgical treatments The third line of treatment. It can be used after a response to prior surgery or medical treatments The third line of treatment; however, is occasionally used as second line. It is indicated in patients with poor tumor growth control or failure of normalization of hormone levels with surgical or medical therapy