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Challenges in the management of resistant acromegaly: Experience of multi-modal therapy in Sri Lanka: A case report

Authors:

M. D. S. A. Dilrukshi ,

National Hospital of Sri Lanka, LK
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H. A. Dissanayake,

National Hospital of Sri Lanka, LK
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P. Dissanayake,

National Hospital of Sri Lanka, LK
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M. R. Sumanatilleke,

National Hospital of Sri Lanka, LK
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S. Pathmanathan,

National Hospital of Sri Lanka, LK
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N. P. Somasundaram

National Hospital of Sri Lanka, LK
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Abstract

Background: Acromegaly is a rare endocrine disorder that is associated with significant systemic morbidity and mortality. A substantial proportion of patients are unable to achieve long-term biochemical and/ or tumour control despite the standard treatment [surgery and 1st generation somatostatin analog (SSA)] and develop systemic complications that depend on the duration of exposure to excess growth hormone (GI-I). 'Early multi-modal therapy' and 'personalized treatment' are novel concepts in the management of acromegaly based on advancements in the knowledge regarding the condition.

 

Case description: A 37-year-old female was noted to have characteristic features of acromegaly when she presented with an acute febrile illness to a tertiary care centre in Sri Lanka. She had worsening headaches, increased sweating, generalized ill health along with a history of secondary amenorrhoea and galactorrhoea. Endocrine work up confirmed acromegaly with severe GI-I burden and prolactin co-secretion from a Knosp grade 4 pituitary-macroadenoma. The disease was complicated with poorly controlled diabetes, hypertension, and bilateral knee joint osteoarthritis. Trans-sphenoidal surgery (TSS) and subsequent cabergoline therapy failed to achieve significant biochemical and/ or tumour control. Repeat TSS was not planned as per patient preference and conventional external beam radiotherapy (EBRT) and subsequent octreotide (1st generation SSA) therapy was offered which were useful in achieving satisfactory control of the residual tumour burden but failed to achieve biochemical remission. Add-on therapy with pegvisomant (a Growth hormone-receptor antagonist) was arranged through Pfizer compassionate use programme that helped to achieve normal IGF-1 levels and subsequent satisfactory blood glucose and blood pressure control without any significant adverse effects.

 

Conclusions: This case highlights successful use of multi-modal therapy in managing resistant acromegaly in a resource-limited setting and the first experience of GHRA-Pegvisomant use in Sri Lanka.

How to Cite: Dilrukshi, M.D.S.A., Dissanayake, H.A., Dissanayake, P., Sumanatilleke, M.R., Pathmanathan, S. and Somasundaram, N.P., 2022. Challenges in the management of resistant acromegaly: Experience of multi-modal therapy in Sri Lanka: A case report. Sri Lanka Journal of Diabetes Endocrinology and Metabolism, 13(2), pp.69–75. DOI: http://doi.org/10.4038/sjdem.v13i2.7482
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Published on 08 Dec 2022.
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