Current controversies in acromegaly care

Persistent disease after surgery for acromegaly is common. Expanding medical management options improves long-term biochemical and clinical outcomes, but controversies in acromegaly care remain. We review literature and provide recommendations regarding accelerating diagnosis, biochemical monitoring, symptom variability, preconception/pregnancy management, predictors of treatment response, and alternative dosing regimens. Delayed diagnosis of acromegaly persists, associated with increased morbidity. Advances in artificial intelligence may reduce diagnostic delay; but ethics, privacy issues, and application in diverse populations present challenges. Symptom variability is observed in patients receiving long-acting somatostatin receptor ligands (SRLs) and with other regimens, even when biochemical control is achieved. Dose titration intervals vary across therapies; discordance between biochemical and clinical response requires consideration of signs and symptoms in addition to insulin-like growth factor 1 levels. Premenopausal women with uncontrolled acromegaly are at risk of increased complications during pregnancy. Data on fertility, pregnancy, and fetal effects of acromegaly drugs are limited to case reports and series. Pregnancies and spontaneous conceptions occur in patients with acromegaly, typically with good maternal and fetal outcomes. Predictive algorithms identifying for whom first-line SRLs will be effective have been validated in investigational contexts, but implementation strategy, accuracy, and standardization in clinic practice are yet undetermined. Finally, alternative dosing regimens show promise for decreasing medication burden, cost, and/or improving control. We conclude that while there has been progress in emerging medical treatment options, controversies in acromegaly care persist, particularly with regard to patient-centered outcomes and utility of personalized approaches in real-life, large-scale clinical practice.