What is the initial treatment for acromegaly?

Initial Treatment for Acromegaly

Transsphenoidal surgery performed by an experienced neurosurgeon is the first-line treatment for acromegaly, offering the prospect of complete remission and surgical success rates of approximately 50% in experienced centers. 1

Surgical Approach as Primary Treatment

• Surgery is the definitive initial treatment for most patients with acromegaly, particularly when complete tumor resection is achievable, as with microadenomas or when decompression of surrounding structures (optic chiasm, ophthalmic motor nerves) is required 2, 3

• The transsphenoidal approach is preferred and should be performed by an experienced neurosurgeon to maximize cure rates and minimize complications 1

• Surgical success depends heavily on tumor characteristics: smaller tumors without cavernous sinus invasion have the highest cure rates, while macroadenomas and invasive tumors have lower success rates 2, 3

When Medical Therapy Becomes First-Line Treatment

Primary medical therapy is increasingly appropriate when surgical cure probability is low based on tumor size, location, or patient factors 2, 3:

• Somatostatin receptor ligands (SRLs) such as octreotide LAR or lanreotide are the drugs of choice for primary medical therapy, achieving biochemical normalization in approximately 25% of unselected treatment-naive patients 4, 1

• Consider primary medical therapy in patients with:

  • Large macroadenomas with cavernous sinus invasion where complete resection is unlikely 2
  • Advanced age or serious comorbidities that increase surgical risk 2
  • Patient refusal of surgery 3

• Both octreotide LAR and lanreotide formulations have equivalent efficacy with no reported difference between long-acting preparations 4

Preoperative Medical Therapy Consideration

• Preoperative SRL treatment may facilitate tumor resection through tumor shrinkage (occurring in 30-50% of patients) and reduce perioperative complications from GH excess 2

• However, the impact of pre-surgical SRL treatment on subsequent post-surgical GH and IGF-I levels should be considered when interpreting postoperative biochemical results 4

Alternative Primary Medical Options

• Cabergoline can be considered for patients with mild disease (IGF-I <2 times upper limit of normal) as primary therapy, with a 3-6 month trial using dose escalation from 1.5 to 3.5 mg per week if tolerated 4

• Cabergoline shows best response in patients with mildly elevated GH levels and is particularly effective in tumors that cosecrete prolactin 4, 5

Treatment Goals

The primary objectives are to normalize GH and IGF-I levels, reduce tumor size, preserve vision, and ultimately decrease mortality rates to match the general population 1, 6