KP, a 32-year old female presents to an outpatient facility with complaints of joint pain and enlarged hands. KP has extensive headaches and also noticed more symptoms such as extensive sweating, a deeper voice, and an enlarged nose. KP’s laboratory findings and vitals are below:

Past medical history:

Opioid Use Disorder: Suboxone 8-2 mg: Place one tablet under the tongue once a day

Labs/Vitals:

Ht: 5’3 ft

Wt: 162 lbs

BP: 122/82 mmHg

HR: 76 BPM

Temp: 98.1 F

Fasted IGF-1 level: 275 ng/mL (88-246 ng/mL)

Growth hormone: 9 ng/mL (0.05-8 ng/mL)

Glucose: 81 mg/dL (70-130 mg/dL)

Scr: 1.2 mg/dL (0.5-1.2 mg/dL)

Na: 142 mEq/L (135-145 mEq/L)

Cl: 95 mEq/L (95-105 mEq/L)

K: 3.8 mEq/L (3.5-5 mEq/L)

Ca: 9 mg/dL (8.5-10.5 mg/dL)

Mg: 2 mg/dL (1.7-2.2 mg/dL)

What pharmacotherapy option would be most appropriate to treat acromegaly in KP?

A. Somatropin 0.4 mg once daily SubQ

B. Hydrocortisone 7.5 mg PO BID

C. Octreotide 50 mg SubQ TID

D. Mitotane 500 mg PO TID

Answer with rationale:

Adrenal and pituitary glands disorders are always tricky and often have difficult medications that go alongside it. Understanding negative and positive feedback loops can help keep these disorders straight. Age of diagnosis for acromegaly is around 40 years old. Acromegaly is caused by excessive growth hormone that is being produced by the anterior pituitary gland. Primary acromegaly is when the root cause is from excess growth hormone from the anterior pituitary gland typically from adenoma. Ectopic acromegaly is produced by other tumors like lymphoma. The third cause of acromegaly can be from excessive production of growth hormone releasing-hormone which is produced by the hypothalamus. Typical management would be an operation to remove the cancer. If surgery can not be done or a patient elects to not have surgery, medical management is then considered. 

Answer A is incorrect. Somatropin is used for growth hormone deficiency. The medical team should monitor IGF-1 levels and titrate appropriately.

Answer B is incorrect. Hydrocortisone can be used for many different things, but this dose is used to treat addison’s disease. Addison’s disease is where there is a low cortisol, aldosterone, and androgen level but an increased cortisol receptor hormone and ACTH.

Answer C is correct. Octreotide is a somatostatin analog which is used to treat acromegaly. Somatostatin analogs work by inhibiting growth hormone secretion. Clinicians should titrate octreotide based on GH and IGF-1 levels. You can also use GH receptor antagonists like pegvisomant or dopamine agonists such as bromocriptine. 

Answer D is incorrect. Mitotane is used to treat cushing’s syndrome. Cushing’s syndrome is an excess of cortisol, it can be from acth-dependent such a patient taking glucocorticoids or acth-independent from adrenal adenomas. 

Brand/generics Covered:

Suboxone (Buprenorphine/naloxone), Somatropin (Genotropin), Hydrocortisone (Cortef), Octreotide (Mycapssa), Mitotane (Lysodren)

Naplex Competencies Covered:

1.1 - Laboratory and diagnostic findings

1.5 - Signs or symptoms of medical conditions

2.1 - Pharmacology, mechanism of action, or therapeutic class