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KEY CONCEPTS
Pharmacologic therapy for acromegaly should be considered when surgery and irradiation are contraindicated, when there is a poor likelihood of surgical success, when rapid control of symptoms is needed, or when other treatments have failed to normalize growth hormone (GH) and insulin-like growth factor-1 (IGF-1) serum concentrations.
Pharmacotherapy for acromegaly using dopamine agonists has several advantages including oral administration and lower cost when compared to somatostatin analogs and pegvisomant. However, dopamine agonists effectively normalize IGF-1 serum concentrations in only 10% to 30% of patients. Therefore, somatostatin analogs remain the mainstay of therapy.
Blood glucose concentrations should be monitored frequently in the early stages of somatostatin analog therapy, especially pasireotide.
Pegvisomant appears to be the most effective agent for normalizing IGF-1 serum concentrations.
Recombinant growth hormone (GH) is currently considered the drug of choice for the treatment of children with growth hormone–deficient short stature. Prompt diagnosis of growth hormone deficiency (GHD) and initiation of replacement therapy with recombinant GH is crucial for optimizing final adult heights.
All GH products are equally effective. The recommended initial dose for treatment of GHD short stature in children is 0.16 to 0.24 mg/kg/wk.
Pharmacologic agents that antagonize dopamine or increase the release of prolactin can induce hyperprolactinemia. Discontinuation of the offending medication and initiation of an appropriate therapeutic alternative usually normalizes serum prolactin concentrations.
Cabergoline appears to be more effective than bromocriptine for the medical management of prolactinomas and offers the advantage of less-frequent dosing and fewer adverse effects.
Although preliminary data do not suggest that cabergoline has significant teratogenic potential, cabergoline is not recommended for use during pregnancy. Patients receiving cabergoline or bromocriptine who plan to become pregnant should discontinue the medication as soon as pregnancy is detected.
Pharmacologic treatment of panhypopituitarism includes the use of glucocorticoids, thyroid hormone, sex steroids, and recombinant GH, when appropriate, as lifelong replacement therapies.
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PITUITARY DISORDERS Patient Care Process for Hyperprolactinemia
Collect
Patient characteristics (eg, age, sex, pregnancy status)
Patient history (past medical, menstrual cycle, family medical history)
Social history (stress level, physical activity, dietary habits)
Current medications including prescription, non-prescription, and herbal products
Objective data
Labs (eg, prolactin, macroprolactin, serum β-HCG, FSH, TSH, free T4, AST, ALT, BUN, and SCr)
Assess
Presence of symptoms related to local effects of prolactinoma (see Table e94-5)
Presence of medications likely to impact prolactin levels (see Table e94-4)
Emotional status (ie, presence of stress)
Patient’s desire to become pregnant in the future
Plan*
If drug-induced, discontinuation of offending medication and initiation of therapeutic alternative
If not drug-induced, treat with a dopamine agonist, if appropriate
Consider sex hormone replacement therapy if clinically appropriate
Monitoring parameters including efficacy (eg, prolactin, gonadal function, tumor size, galactorrhea) and safety (bromocriptine: CNS and GI adverse effects, cabergoline: CNS and GI adverse effects, ...