今日の臨床サポート

先端巨大症

著者: 高橋 裕 神戸大学医学部附属病院糖尿病・内分泌内科

監修: 平田結喜緒 公益財団法人 兵庫県予防医学協会 健康ライフプラザ

著者校正/監修レビュー済:2021/12/01
患者向け説明資料

概要・推奨   

  1. 先端巨大症においては、死亡率を正常化するために、治療によってランダムGH<1.0ng/ml、年齢・性別をマッチさせたIGF-1の正常化を目指すべきである(推奨度1)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
高橋 裕 : 講演料(ノボノルディスク),研究費・助成金など(帝人ファーマ),奨学(奨励)寄付など(ノボノルディスク)[2021年]
監修:平田結喜緒 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(大きな改訂はない)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 先端巨大症の診断は、成長ホルモン(GH)およびインスリン様成長因子(IGF-I)の分泌過剰と、それによる症状に基づいて行う。
  1. GH分泌の自律性は、75g経口ブドウ糖負荷試験によって血中GH値が正常域(0.4ng/ml未満)に抑制されないことで示される。
  1. GH分泌の過剰は、年齢・性別ごとの正常値と比較した血中IGF-I値(SDスコア(SDS))の上昇によって判断する。
  1. GH分泌過剰の症状については、特異的な所見である手足の容積の増大、先端巨大症様顔貌(眉弓部の膨隆、鼻・口唇の肥大、下顎の突出など)、巨大舌と発汗過多、頭痛、視力、視野障害(視野異常)、女性における月経異常(続発性無月経)、睡眠時無呼吸症候群、耐糖能異常、高血圧、不正咬合、変形性関節症、手根管症候群、頭蓋骨および手足の単純X線の異常などの副所見あるいは参考所見を合わせて診断する。
  1. MRIまたはCTで下垂体腺腫の所見を認める。
  1. 先端巨大症のほとんどを占める下垂体性成長ホルモン分泌亢進症は指定難病であり、申請し認定されると保険料の自己負担分の一部が公費負担として助成される。(平成27年1月施行
  1. 難病法に基づく医療費助成制度
病歴・診察のポイント  
  1. 先端巨大症様顔貌の特徴的な所見(眉弓部の膨隆、鼻・口唇の肥大、下顎の突出)は非常に重要な所見であるが、本人は自覚していないことが多い。

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文献 

著者: Laurence Katznelson, Edward R Laws, Shlomo Melmed, Mark E Molitch, Mohammad Hassan Murad, Andrea Utz, John A H Wass, Endocrine Society
雑誌名: J Clin Endocrinol Metab. 2014 Nov;99(11):3933-51. doi: 10.1210/jc.2014-2700. Epub 2014 Oct 30.
Abstract/Text OBJECTIVE: The aim was to formulate clinical practice guidelines for acromegaly.
PARTICIPANTS: The Task Force included a chair selected by the Endocrine Society Clinical Guidelines Subcommittee (CGS), five experts in the field, and a methodologist. The authors received no corporate funding or remuneration. This guideline is cosponsored by the European Society of Endocrinology.
EVIDENCE: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. The Task Force reviewed primary evidence and commissioned two additional systematic reviews.
CONSENSUS PROCESS: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society and the European Society of Endocrinology reviewed drafts of the guidelines.
CONCLUSIONS: Using an evidence-based approach, this acromegaly guideline addresses important clinical issues regarding the evaluation and management of acromegaly, including the appropriate biochemical assessment, a therapeutic algorithm, including use of medical monotherapy or combination therapy, and management during pregnancy.

PMID 25356808  J Clin Endocrinol Metab. 2014 Nov;99(11):3933-51. doi: ・・・
著者: I M Holdaway, M J Bolland, G D Gamble
雑誌名: Eur J Endocrinol. 2008 Aug;159(2):89-95. doi: 10.1530/EJE-08-0267. Epub 2008 Jun 4.
Abstract/Text OBJECTIVE: Formal studies of acromegaly have found increased mortality associated with the disorder, although reduction of serum levels of GH and IGF-I by treatment appears to improve survival. A meta-analysis of mortality studies in acromegaly has thus been performed to assess the effect of lowering serum GH and IGF-I on survival.
DESIGN AND METHODS: Medline was searched for studies under 'acromegaly', 'mortality' and 'cause of death' (1965-2008), and abstracts of recent meetings of the US Endocrine Society were hand searched. Studies were restricted to those presenting mortality data according to serum GH and IGF-I at last follow-up, and with mortality expressed as a standardized mortality ratio (SMR).
RESULTS: Patients with random serum GH <2.5 microg/l following treatment, mostly measured by standard RIA, had mortality close to expected levels (SMR 1.1, 95% confidence interval (CI) 0.9-1.4) compared with an SMR of 1.9 (95% CI 1.5-2.4) for those with final GH >2.5 microg/l. Similarly, a normal serum IGF-I for age and sex at last follow-up after treatment was associated with an SMR of 1.1 (95% CI 0.9-1.4) compared with an SMR of 2.5 (95% CI 1.6-4.0) for those with continued IGF-I elevation. There was a significant trend for reduced mortality in series reporting frequent use of somatostatin analogues and in studies reporting high (>70%) rates of biochemical remission after treatment.
CONCLUSIONS: Clinicians treating acromegalic patients should aim for random serum GH <2.5 microg/l measured by RIA (probably <1 microg/l measured by modern sensitive immunoassay) and normal serum IGF-I values, to restore the elevated mortality of the condition to normal levels.

PMID 18524797  Eur J Endocrinol. 2008 Aug;159(2):89-95. doi: 10.1530/E・・・
著者: S Melmed, A Colao, A Barkan, M Molitch, A B Grossman, D Kleinberg, D Clemmons, P Chanson, E Laws, J Schlechte, M L Vance, K Ho, A Giustina, Acromegaly Consensus Group
雑誌名: J Clin Endocrinol Metab. 2009 May;94(5):1509-17. doi: 10.1210/jc.2008-2421. Epub 2009 Feb 10.
Abstract/Text OBJECTIVE: The Acromegaly Consensus Group reconvened in November 2007 to update guidelines for acromegaly management.
PARTICIPANTS: The meeting participants comprised 68 pituitary specialists, including neurosurgeons and endocrinologists with extensive experience treating patients with acromegaly. EVIDENCE/CONSENSUS PROCESS: Goals of treatment and the appropriate imaging and biochemical and clinical monitoring of patients with acromegaly were enunciated, based on the available published evidence.
CONCLUSIONS: The group developed a consensus on the approach to managing acromegaly including appropriate roles for neurosurgery, medical therapy, and radiation therapy in the management of these patients.

PMID 19208732  J Clin Endocrinol Metab. 2009 May;94(5):1509-17. doi: 1・・・
著者: Mark Sherlock, Conor Woods, Michael C Sheppard
雑誌名: Nat Rev Endocrinol. 2011 May;7(5):291-300. doi: 10.1038/nrendo.2011.42. Epub 2011 Mar 29.
Abstract/Text Acromegaly is a rare disease characterized by excess secretion of growth hormone (GH) and increased circulating insulin-like growth factor 1 (IGF-1) concentrations. The disease is associated with increased morbidity and premature mortality, but these effects can be reduced if GH levels are decreased to <2.5 μg/l and IGF-1 levels are normalized. Therapy for acromegaly is targeted at decreasing GH and IGF-1 levels, ameliorating patients' symptoms and decreasing any local compressive effects of the pituitary adenoma. The therapeutic options for acromegaly include surgery, radiotherapy and medical therapies, such as dopamine agonists, somatostatin receptor ligands and the GH receptor antagonist pegvisomant. Medical therapy is currently most widely used as secondary treatment for persistent or recurrent acromegaly following noncurative surgery, although it is increasingly used as primary therapy. This Review provides an overview of current and future pharmacological therapies for patients with acromegaly.

PMID 21448141  Nat Rev Endocrinol. 2011 May;7(5):291-300. doi: 10.1038・・・
著者: Sonia Cheng, Ludovica Grasso, Jose A Martinez-Orozco, Rany Al-Agha, Rosario Pivonello, Annamaria Colao, Shereen Ezzat
雑誌名: Clin Endocrinol (Oxf). 2012 Feb;76(2):264-71. doi: 10.1111/j.1365-2265.2011.04180.x.
Abstract/Text BACKGROUND: Acromegaly results from increased growth hormone and its target insulin-like growth factor-1, most commonly due to a pituitary tumour. As it is frequently accompanied by infertility, little is known about the course of this disease in pregnancy.
OBJECTIVE: We describe 13 new pregnancies in acromegalic women and compare their outcomes in a systematic review of the literature.
METHODS: We collected clinical, biochemical, imaging, and outcomes data during and following pregnancy and performed a systematic review for a total of 47 pregnancies. An extended analysis of 106 pregnancies was also performed.
RESULTS: In 13 newly described cases, pregnancy was un-complicated without need for additional surgical intervention. In these pregnancies, adjunctive medical therapy was required in three patients. This was in the form of somatostatin analogs (SA) (3/13) as well as pegvisomant in 1/13 to control symptomatic and biochemical progression. One 37-year-old female succeeded in having two separate pregnancies 2 years apart both without need for any form of medical therapy. Review of an additional 34 published reports allowed for an analysis of outcomes in 47 pregnancies. Adjunctive medical therapy during pregnancy was required in 15 of these cases where 12 received SA and an additional three received dopamine agonists. None of these patients developed endocrine or neurologic complications during pregnancy. In an extended analysis of 106 pregnancies, treatment during pregnancy appears to be associated with good disease control but increased risk of microsomic or macrosomic newborns depending on the medical agent used.
CONCLUSIONS: In 13 newly described pregnancies along with systematic review of an additional 34 cases indicate that pregnancy in treated acromegalic women can proceed without significant complications or teratogenicity. Medical treatment during pregnancy with DA or SA appears to be associated with altered neonatal weight. Nevertheless, gestation may have a beneficial impact on acromegaly control both during and following pregnancy.

© 2011 Blackwell Publishing Ltd.
PMID 21777265  Clin Endocrinol (Oxf). 2012 Feb;76(2):264-71. doi: 10.1・・・
著者: Annamaria Colao, Renata S Auriemma, Gaetano Lombardi, Rosario Pivonello
雑誌名: Endocr Rev. 2011 Apr;32(2):247-71. doi: 10.1210/er.2010-0002. Epub 2010 Dec 1.
Abstract/Text Somatostatin analogs (SA) are widely used in acromegaly, either as first-line or adjuvant treatment after surgery. First-line treatment with these drugs is generally used in the patients with macroadenomas or in those with clinical conditions so severe as to prevent unsafe reactions during anesthesia. Generally, the response to SA takes into account both control of GH and IGF-I excess, with consequent improvement of clinical symptoms directly related to GH and IGF-I excess, and tumor shrinkage. This latter effect is more prominent in the patients treated first-line and bearing large macroadenomas, but it is also observed in patients with microadenomas, even with little clinical implication. Predictors of response are patients' gender, age, initial GH and IGF-I levels, and tumor mass, as well as adequate expression of somatostatin receptor types 2 and 5, those with the highest affinity for octreotide and lanreotide. Only sporadic cases of somatostatin receptor gene mutation or impaired signaling pathways have been described in GH-secreting tumors so far. The response to SA also depends on treatment duration and dosage of the drug used, so that a definition of resistance based on short-term treatments using low doses of long-acting SA is limited. Current data suggest that response to these drugs is better analyzed taking together biochemical and tumoral effects because only the absence of both responses might be considered as a poor response or resistance. This latter evidence seems to occur in 25% of treated patients after 12 months of currently available long-acting SA.

PMID 21123741  Endocr Rev. 2011 Apr;32(2):247-71. doi: 10.1210/er.2010・・・
著者: Manel Puig-Domingo, Eugenia Resmini, Beatriz Gomez-Anson, Joana Nicolau, Mireia Mora, Elisabet Palomera, Camelia Martí, Irene Halperin, Susan M Webb
雑誌名: J Clin Endocrinol Metab. 2010 Nov;95(11):4973-8. doi: 10.1210/jc.2010-0573. Epub 2010 Aug 25.
Abstract/Text CONTEXT: Transsphenoidal surgery is considered first-line therapy for acromegaly; however, there is often a need for adjunctive therapy. Somatostatin analogs (SSA) have greatly improved the effectiveness of medical treatment, but one third of patients are resistant.
OBJECTIVE: The aim was to evaluate whether magnetic resonance imaging (MRI) signal could predict long-term response to SSA in patients with active acromegaly after neurosurgery.
PATIENTS AND METHODS: Sixty-two patients who were active acromegalic after surgery were included in this retrospective study. Remaining pituitary tumor was classified as hyper-, iso-, or hypointense by evaluating T2-weighted MRI signal. Treatment with SSA at maximal effective doses was prescribed and evaluated at 6 and 12 months by monitoring IGF-I, GH, and T2 MRI.
RESULTS: Complete response to SSA treatment (defined as normal IGF-I) at 6 months was observed in 30%, partial response (defined as IGF-I between 2 and 3 sd score) in 15%, and no response in 55% of patients. At 12 months, 28, 20, and 52% were observed, respectively. MRI signal was hypointense in 40%, hyperintense in 48%, and isointense in 12%. At 6 months, complete response to SSA was observed in 71% of cases having hypointense MRI signal and in 20% of hyperintense (P = 0.04). At 12 months, 62% of hypointense remained well controlled, whereas in the hyperintense group, good, partial, or no response results did not change from that observed at 6 months (P = 0.04).
CONCLUSION: In active acromegalic patients after surgery, a hypointense T2-weighted MRI signal is associated with a better response to SSA treatment at 6 and 12 months.

PMID 20739382  J Clin Endocrinol Metab. 2010 Nov;95(11):4973-8. doi: 1・・・
著者: Mônica R Gadelha, Marcello D Bronstein, Thierry Brue, Mihail Coculescu, Maria Fleseriu, Mirtha Guitelman, Vyacheslav Pronin, Gérald Raverot, Ilan Shimon, Kayo Kodama Lievre, Juergen Fleck, Mounir Aout, Alberto M Pedroncelli, Annamaria Colao, Pasireotide C2402 Study Group
雑誌名: Lancet Diabetes Endocrinol. 2014 Nov;2(11):875-84. doi: 10.1016/S2213-8587(14)70169-X. Epub 2014 Sep 24.
Abstract/Text BACKGROUND: Many patients with acromegaly do not achieve biochemical control despite receiving high doses of the first-generation somatostatin analogues octreotide or lanreotide. In the PAOLA trial, we aimed to assess the efficacy and safety of two different doses of the somatostatin analogue pasireotide long-acting release compared with active control (octreotide or lanreotide) in patients with inadequately controlled acromegaly.
METHODS: In a multicentre, randomised, phase 3 trial, we enrolled eligible patients aged 18 years or older with acromegaly who were inadequately controlled (5-point, 2 h mean growth hormone concentration >2·5 μg/L and insulin-like growth factor 1 [IGF-1] concentration >1·3 times the upper normal limit) and had received 30 mg octreotide long-acting repeatable or 120 mg lanreotide (Somatuline Autogel; Ipsen, UK) as monotherapy for 6 months or longer. We randomly assigned patients in a 1:1:1 ratio with an interactive voice-web response system to receive 40 mg pasireotide long-acting release once every 28 days for 24 weeks, 60 mg pasireotide long-acting release once every 28 days for 24 weeks, or continued treatment with octreotide or lanreotide (active control). Patients were stratified according to previous treatment (octreotide or lanreotide) and growth hormone concentrations at screening (2·5-10 μg/L and >10 μg/L). Patients and study investigators were not masked to study drug assignment but were masked to pasireotide dose allocation. The primary endpoint was number of patients achieving biochemical control, defined as mean growth hormone concentration less than 2·5 μg/L and normalised IGF-1 concentration. Efficacy analyses were based on intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01137682.
FINDINGS: Between Dec 17, 2010, and Aug 6, 2012, 198 patients were enrolled and randomly assigned to pasireotide 40 mg (n=65), pasireotide 60 mg (n=65), or active control (n=68) groups. At 24 weeks, ten (15%) patients in the pasireotide 40 mg group and 13 (20%) patients in the pasireotide 60 mg group achieved biochemical control, compared with no patients in the active control group (absolute difference from control group 15·4%, 95% CI 7·6-26·5, p=0·0006 for pasireotide 40 mg group, 20·0%, 11·1-31·8, p<0·0001 for pasireotide 60 mg group). The most common adverse events were hyperglycaemia (21 [33%] for treatment with 40 mg pasireotide, 19 [31%] with 60 mg pasireotide, and nine [14%] with active control), diabetes (13 [21%], 16 [26%], and five [8%]), and diarrhoea (ten [16%], 12 [19%], and three [5%]); most were grade 1 or 2 in severity. Serious adverse events were reported in six (10%) patients in the pasireotide 40 mg group, two (3%) in the pasireotide 60 mg group, and three (5%) in the active control group.
INTERPRETATION: Pasireotide provides superior efficacy compared with continued treatment with octreotide or lanreotide, and could become the new standard pituitary-directed treatment in patients with acromegaly who are inadequately controlled using first-generation somatostatin analogues.
FUNDING: Novartis Pharma AG. Financial support for medical editorial assistance was provided by Novartis Pharmaceuticals Corporation.

Copyright © 2014 Elsevier Ltd. All rights reserved.
PMID 25260838  Lancet Diabetes Endocrinol. 2014 Nov;2(11):875-84. doi:・・・
著者: Laure Sandret, Patrick Maison, Philippe Chanson
雑誌名: J Clin Endocrinol Metab. 2011 May;96(5):1327-35. doi: 10.1210/jc.2010-2443. Epub 2011 Feb 16.
Abstract/Text CONTEXT: Cabergoline is widely considered to be poorly effective in acromegaly.
OBJECTIVE: The aim of this study was to obtain a more accurate picture of the efficacy of cabergoline in acromegaly, both alone and in combination with somatostatin analogs.
DESIGN: We systematically reviewed all trials of cabergoline therapy for acromegaly published up to 2009 in four databases (PubMed, Pascal, Embase, and Google Scholar). We identified 15 studies (11 prospective) with a total of 237 patients; none were randomized or placebo-controlled. A meta-analysis was conducted on individual data (n = 227).
RESULTS: Cabergoline was used alone in nine studies. Fifty-one (34%) of the 149 patients achieved normal IGF-I levels. In multivariate analysis, the decline in IGF-I was related to the baseline IGF-I concentration (β = 1.16; P <0.001), treatment duration (β = 0.28; P < 0.001), and baseline prolactin concentration (β = -0.18; P = 0.01), and with a trend toward a relation with the cabergoline dose (β = 0.38; P =0.07). In five studies, cabergoline was added to ongoing somatostatin analog treatment that had failed to normalize IGF-I. Forty patients (52%) achieved normal IGF-I levels. The change in IGF-I was significantly related to the baseline IGF-I level (β = 0.74; P < 0.001) but not to the dose of cabergoline, the duration of treatment, or the baseline prolactin concentration.
CONCLUSION: This meta-analysis suggests that cabergoline single-agent therapy normalizes IGF-I levels in one third of patients with acromegaly. When a somatostatin analog fails to control acromegaly, cabergoline adjunction normalizes IGF-I in about 50% of cases. This effect may occur even in patients with normoprolactinemia.

PMID 21325455  J Clin Endocrinol Metab. 2011 May;96(5):1327-35. doi: 1・・・
著者: Adrian F Daly, Maria A Tichomirowa, Patrick Petrossians, Elina Heliövaara, Marie-Lise Jaffrain-Rea, Anne Barlier, Luciana A Naves, Tapani Ebeling, Auli Karhu, Antti Raappana, Laure Cazabat, Ernesto De Menis, Carmen Fajardo Montañana, Gerald Raverot, Robert J Weil, Timo Sane, Dominique Maiter, Sebastian Neggers, Maria Yaneva, Antoine Tabarin, Elisa Verrua, Eija Eloranta, Arnaud Murat, Outi Vierimaa, Pasi I Salmela, Philippe Emy, Rodrigo A Toledo, Maria Isabel Sabaté, Chiara Villa, Marc Popelier, Roberto Salvatori, Juliet Jennings, Angel Ferrandez Longás, José Ignacio Labarta Aizpún, Marianthi Georgitsi, Ralf Paschke, Cristina Ronchi, Matti Valimaki, Carola Saloranta, Wouter De Herder, Renato Cozzi, Mirtha Guitelman, Flavia Magri, Maria Stefania Lagonigro, Georges Halaby, Vinciane Corman, Marie-Thérèse Hagelstein, Jean-François Vanbellinghen, Gustavo Barcelos Barra, Anne-Paule Gimenez-Roqueplo, Fergus J Cameron, Françoise Borson-Chazot, Ian Holdaway, Sergio P A Toledo, Günter K Stalla, Anna Spada, Sabina Zacharieva, Jerome Bertherat, Thierry Brue, Vincent Bours, Philippe Chanson, Lauri A Aaltonen, Albert Beckers
雑誌名: J Clin Endocrinol Metab. 2010 Nov;95(11):E373-83. doi: 10.1210/jc.2009-2556. Epub 2010 Aug 4.
Abstract/Text CONTEXT: AIP mutations (AIPmut) give rise to a pituitary adenoma predisposition that occurs in familial isolated pituitary adenomas and less often in sporadic cases. The clinical and therapeutic features of AIPmut-associated pituitary adenomas have not been studied comprehensively.
OBJECTIVE: The objective of the study was to assess clinical/therapeutic characteristics of AIPmut pituitary adenomas.
DESIGN: This study was an international, multicenter, retrospective case collection/database analysis.
SETTING: The study was conducted at 36 tertiary referral endocrine and clinical genetics departments.
PATIENTS: Patients included 96 patients with germline AIPmut and pituitary adenomas and 232 matched AIPmut-negative acromegaly controls.
RESULTS: The AIPmut population was predominantly young and male (63.5%); first symptoms occurred as children/adolescents in 50%. At diagnosis, most tumors were macroadenomas (93.3%); extension and invasion was common. Somatotropinomas comprised 78.1% of the cohort; there were also prolactinomas (n = 13), nonsecreting adenomas (n = 7), and a TSH-secreting adenoma. AIPmut somatotropinomas were larger (P = 0.00026), with higher GH levels (P = 0.00068), more frequent extension (P = 0.018) and prolactin cosecretion (P = 0.00023), and occurred 2 decades before controls (P < 0.000001). Gigantism was more common in the AIPmut group (P < 0.000001). AIPmut somatotropinoma patients underwent more surgical interventions (P = 0.00069) and had lower decreases in GH (P = 0.00037) and IGF-I (P = 0.028) and less tumor shrinkage with somatostatin analogs (P < 0.00001) vs. controls. AIPmut prolactinomas occurred generally in young males and frequently required surgery or radiotherapy.
CONCLUSIONS: AIPmut pituitary adenomas have clinical features that may negatively impact treatment efficacy. Predisposition for aggressive disease in young patients, often in a familial setting, suggests that earlier diagnosis of AIPmut pituitary adenomas may have clinical utility.

PMID 20685857  J Clin Endocrinol Metab. 2010 Nov;95(11):E373-83. doi: ・・・
著者: A Giustina, P Chanson, M D Bronstein, A Klibanski, S Lamberts, F F Casanueva, P Trainer, E Ghigo, K Ho, S Melmed, Acromegaly Consensus Group
雑誌名: J Clin Endocrinol Metab. 2010 Jul;95(7):3141-8. doi: 10.1210/jc.2009-2670. Epub 2010 Apr 21.
Abstract/Text OBJECTIVE: The Acromegaly Consensus Group met in April 2009 to revisit the guidelines on criteria for cure as defined in 2000.
PARTICIPANTS: Participants included 74 neurosurgeons and endocrinologists with extensive experience of treating acromegaly. EVIDENCE/CONSENSUS PROCESS: Relevant assays, biochemical measures, clinical outcomes, and definition of disease control were discussed, based on the available published evidence, and the strength of consensus statements was rated.
CONCLUSIONS: Criteria to define active acromegaly and disease control were agreed, and several significant changes were made to the 2000 guidelines. Appropriate methods of measuring and achieving disease control were summarized.

PMID 20410227  J Clin Endocrinol Metab. 2010 Jul;95(7):3141-8. doi: 10・・・

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