Endocrine Abstracts

Objective: To find consensus on issues that may raise clinical doubts in the management of patients with acromegaly in Spain.

Methods: Nominal group and Delphi methodology was followed. Four experts on acromegaly were selected, who defined important clinical questions in the management of acromegaly. A set recommendations were proposed to solve these questions. Subsequently, a group of 30 additional endocrinologits from all over Spain was selected according to acromegaly expertise criteria. The level of agreement with the recommendations was tested through two Delphi rounds. A literature narrative review was performed in order to support the recommendations.

Results: The recommendations cover different aspects of clinical practice including: 1) Useful instruments for the individualization of treatment (predictive markers of treatment response, imaging techniques, etc.); 2) Specific clinical profiles of patients and relevant comorbidities for the individualization of the treatment; 3) Role of the patients in the treatment decision making; and 4) Access to treatments (accessibility and equity). In the first Delphi round, 35 recommendations were evaluated, reaching consensus in 6, 2 were eliminated and 2 reformulated. In the second Delphi round, 27 recommendations were included, reaching consensus in 24 (22 consensus in the agreement, 2 in the disagreement) and 3 were eliminated because they did not reach the level of agreement established. For example, consensus was reached to associate cabergoline in a partial response to 1st generation somatostatin analogs, before the use of other costly drugs. In the second line therapy, although the presence of a non-aggressive residual tumor mass following surgery does not contraindicate pegvisomant monotherapy, the experts consider that, if the residual tumor in close to the chiasm, pasireotide is the best choice. In addition, pasireotide may be indicated in case of partial tumor response with 1st generation somatostatin analogs. In diabetic patients with insufficient control, pegvisomant alone or associated with a 1st generation somatostatin analog is considered more adequate than pasireotide. However, diabetes is not considered a limiting factor for this treatment. On the other hand, the panel also consider that the acromegalic patients should be responsible for taking the treatment correctly, in order to obtain an adequate benefit. The same way, patients should have the possibility of a second opinion and to be treated in a reference center.

Conclusions: These recommendations aim to solve some common clinical questions and facilitate decision-making process in the management of patients with acromegaly in Spain.