Somatostatin analog withdrawal in patients with acromegaly: an elusive goal?
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EDITORIAL
Somatostatin analog withdrawal in patients with acromegaly: an elusive goal? Moise´s Mercado
Received: 6 March 2014 / Accepted: 29 March 2014 Ó Springer Science+Business Media New York 2014
The depot somatostatin analogs (SA) Octreotide LAR and Lanreotide autogel are currently the mainstay of the pharmacological therapy of acromegaly. These analogs are capable of achieving biochemical control (GH levels \2.5 ng/mL and IGF-1 normalization) in 30–60 % of the patients and importantly, most patients report a significant improvement in clinical symptoms of the disease [1–3]. Primary pharmacological therapy of acromegaly with these agents is increasingly being used in patients with inoperable tumors or with medical contraindications for surgery [1–3]. Furthermore, in some cases SA are used as primary treatment simply because of patient’s preference. Perhaps the major disadvantage of SA therapy in acromegaly is the need to continue it indefinitely. Although long-term therapy with SA is safe and well tolerated, it does represent a significant economic burden [4]. Well-controlled patients can have their dose down titrated by increasing the injection interval, a strategy that can reduce costs significantly, while increasing convenience [5–7]. Although increasing the injection interval to every 6, 8, or more weeks is offlabel in the US, it is a common practice in Europe and in Latin America [5–7]. In some patients increasing the injection interval is medically necessary in order to avoid GH deficiency. The possibility of stopping SA after several years of successful therapy is tempting for obvious reasons. In this issue of Endocrine Vilar and colleagues from four Brazilian centers report a study in which octreotide LAR was
M. Mercado (&) Experimental Endocrinology Unit, Hospital de Especialidades, Centro Me´dico Nacional, Siglo XXI, IMSS, Aristo´teles 68, Polanco, 11560 Mexico City, Mexico e-mail: [email protected]; [email protected]
withheld in 20 patients with acromegaly (four on primary treatment) who had been adequately controlled for at least 2 years [8]. They carefully followed these subjects with serial IGF-1 measurements and defined recurrence as the rise of IGF-1 to above 1.29 the upper limit of normal (ULN). Within 9 months of octreotide LAR discontinuation, 16 of the 20 patients recurred and were started back on the SA; the four remaining patients (one on primary treatment) continued to be on remission after 12–18 months follow up [8]. The only distinctive feature of the patients who remained on remission was having a lower IGF-1 at the moment of drug discontinuation [8]. Earlier attempts to discontinue SA therapy in patients with acromegaly have been made with rather disappointing results as over 80 % of the subjects relapse within a year of drug discontinuation [9–11]. The majority of these studies were not specifically designed to assess the feasibility of drug withdrawal, used varying definitions of biochemical recurrence and included patients receiving standard monthly doses
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