[Difficulties of treating acromegaly in the light of 12 years of experience]

Acromegalic patients’ expected survival rate and quality of life are worse than those of the healthy population. This is due to delayed diagnosis and often persistent post-surgical residual hormonal activity of the disease. Therefore, early, effective and individualized endocrine treatment and care are especially important. Our female patient was born in 1965, and has required therapy for tension-type headaches since 2008. In 2012, sella MR examination confirmed a pituitary macroadenoma of 13 mm, which was completely removed by transsphenoidal neurosurgery. Histological examination verified a somatotroph adenoma. Based on the results of post-operative oral glucose load, biochemically active acromegaly was detected, along with a negative sella MR image, thus dopamine agonist treatment was started. Later, due to rising insulin-like growth factor 1 levels and increasing headaches, she was switched to first-generation somatostatin receptor ligand (SRL) therapy. Her developing diabetes mellitus required first biguanide, then later on insulin therapy. Due to progressive complaints, growth hormone-receptor antagonist treatment was started, which resulted in partial disease control. The persistent, severe headaches significantly worsened her quality of life. Therefore, after a decade of different therapeutic approaches, despite the existing diabetes mellitus, second-generation SRL treatment was advised. On pasireotide therapy, her headache stopped immediately, and complete disease control was achieved. The retrospective somatostatin receptor (SSTR) subtype evaluation of the adenoma confirmed dominant SSTR5 expression. Pasireotide could be an optimal choice of first-line therapy in cases of acromegaly complicated by diabetes mellitus, if the adenoma has dominant SSTR5 expression. Orv Hetil. 2024; 165(40): 1587–1593.