Acromegaly may take years to diagnose, Tissue over growth may not be the Primary presentation-Dr. Ali Imran


 Endocrinology conference proceedings-III

Acromegaly may take years to diagnose, 
Tissue over growth may not be the 
Primary presentation - Dr. Ali Imran

Growth Hormone dosing should be
individualized therapy - Njamul Islam

Monitoring of patients is important once
Growth Hormone therapy is started

LAHORE: The Plenary Session on Day-II during the SAFES-PES conference held here from November 23-25, 2017 was chaired by Prof. Abdul Basit along with Prof. Noel Somasundaram from Sir Lanka and Prof. Khurshid A. Khan. Dr. Ali Imran from Canada was the first speaker who spoke on “Devil in the master gland: Update on Acromegaly”. He discussed in detail the current management options of acromegaly and limitations. He pointed out that at times it takes many years to diagnose acromegaly. He also discussed its pathophysiology, the diagnostic test for acromegaly and said that IGF-1 elevated serum levels are suggestive of acromegaly. One should know the growth hormone cut of level to diagnose it. It is the second most common functioning pituitary tumours. He then talked about the management of over six hundred patients in Canada which they had managed. From 1980-1994 the mean age at diagnosis was 41.03 years while from 1995-2010 the mean age at diagnosis was 46.1 years.

Continuing Dr. Ali Imran said that tissue over growth may not be the primary presentation in these patients. Many patients also have psychiatric problems like depression, anxiety. In some cases depression as a co-morbidity was revealing. Women are more likely to have identity problems, they suffer from low quality of life, and they are more dis-satisfied with their appearance. Treatment options include surgery if there is no response with medications. Cost of treatment of acromegaly is very high and majority of the patients cannot afford it. It is useful to use personalized medicine, treat right patient with right drug. Our objective is to achieve normal growth hormones. He also discussed the assessment and management of co-morbid conditions. Response to cabrergoline is seen in 34% of patients and GH<2.5 is achieved. He also highlighted the efficacy of Lanreotide in acromegaly besides monotherapy with SSA. Some newer drugs, he pointed out, are more effective which can be used. He then also shared the suggested approach in treatment of acromegaly by his group besides talking in detail about its medical and surgical treatment. Prof. Najmul Islam remarked that acromegaly treatment is very costly hence it is advisable to shrunk the tumour and then remove it surgically.

Prof. Najmul Islam from Aga Khan University was the next speaker whose presentation was on use of Growth Hormones in Adults. He discussed in detail when to use them and how much. It was a historical review. We, Prof. Najmul Islam stated, do not have much experience with growth hormones. The first results treating children with growth hormones were published in 1932. In 1985 some companies started producing it. He also briefly referred to physiology of growth hormones. After traumatic brain injury, GH deficiency of 12% is noted. We use it in adults because of cardiac abnormalities, neuro psychiatric abnormalities. Use of growth hormones in adults improve their quality of life. Lot of questions are asked from the patients before they are offered treatment with growth hormones. He also talked about cardiovascular morbidity and mortality and pointed out that Growth Hormones improve endothelial function. These patients have muscular abnormalities. AGHD cause bone abnormalities. There are some side effects and false positive results of test during diagnosis. In 2008 the manufacture of GHRH was discontinued in United States, he added.

Continuing Prof. Najmul Islam said that with the use of Growth Hormone, about 20% of patients suffer from side effects which can be reduced by lowering the dose. Others tolerated this with good clinical response. Growth Hormones, he further stated are not recommended for enhancement of athletic performance. Monitoring of patients is important once Growth Hormone therapy is started. He concluded his presentation by stating that Growth Hormone dosing should be individualized therapy. Risk of treatment is low. AGHD can persist from childhood. Participating in the discussion Dr. Naeem ul Haque remarked that he had treated just one patient in forty years since the cost of treatment is very high. We should not test patient if they cannot afford treatment.

Dr. Manilka Sumanatilleka from Sri Lanka spoke about Resistant Prolactinomas: How to manage it? Differential diagnosis, various drugs and treatment of hypothyroidism, pituitary tumours were all discussed in detail. Pituitary tumours account for 15% of all intra cranial tumours. This presentation was based on some case studies. Some of the patients had severe headache, vomiting, eye sight problems, Giant prolactinomas. With the use of Cabrergoline tumour shrinks. Majority of these lesions are micro adenomas and occasionally they are aggressive. Some patients do develop resistance to this drug after one or two years use. Resistance to dopamine agonists was also discussed. Giant Prolactinomas account for 1-4% when the tumour size is 4cm or more. Pituitary carcinoma is very rare about 0.4%. About 40% malignant prolactinomas present as atypical adenomas and they have high risk of resistance and malignancy. The prevalence of these tumours is almost the same in male and female patients after the age of fifty years. Its peak incidence is seen in child bearing age. Treatment options include surgery, radiotherapy and chemotherapy. Surgery is effective in 75% of patients in prolactinomas but radiotherapy has poor response. Gama Knife facilities if available is a good tool for treatment Temozolamide, it was stated, is the drug of choice. It can be used for five to six cycles. It has good response but recurrence is seen in some patients after four to five years of use. Multimodal treatment is recommended. If one drug is resistant, one can use other medications like Bromocriptine etc. Chairperson in his concluding remarks said that many patients do not get better with the use of Growth Hormones. There is most often modest improvement in BMD.

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