The place of pegvisomant in the acromegaly treatment algorithm.

The disfiguring disease acromegaly results from hypersecretion of growth hormone (GH). The main goals of treatment for acromegaly include normalisation of biochemical markers of disease activity to restore normal life expectancy, amelioration of signs and symptoms of the disease, removal of the pituitary tumour without damaging the optic chiasm and other peripituitary structures, and preservation of pituitary function. Conventional options for treatment of acromegaly include surgery, radiotherapy (RT), and medical therapy with either dopamine agonists or somatostatin (SMS) analogues. The advent of the genetically engineered growth hormone analogue pegvisomant is unlikely to alter significantly the place of surgery and RT in the treatment algorithm for acromegaly biochemical control as determined based on serum IGF-I concentrations is achievable with pegvisomant in virtually all patients, and it will clearly become the drug of choice in patients partially or completely unresponsive to SMS analogues. Preliminary studies suggest improved insulin sensitivity for a given IGF-I with pegvisomant compared with SMS analogues; if these results are confirmed by results of future studies, such a metabolic advantage may encourage the use of pegvisomant.