Acromegaly: Current Challenges and Future Directions in Latin America
Received Date: Jan 25, 2018 / Accepted Date: Feb 07, 2018 / Published Date: Feb 12, 2018
Acromegaly is a rare disease, associated with significant morbidity and high mortality. The international literature provides different figures on the epidemiology of acromegaly in different populations, mainly in Europe and US. However, there are few studies that address its epidemiology in Latin America. The creation, starting in the 1990s, of national acromegaly registries in developed countries has stimulated the need to create them in our region, being Mexico the only country that has developed a national Registry. The clinical and biochemical characterization of patients with acromegaly in our region does not seem to be different from that described in the international literature; however, population studies are necessary to establish the epidemiological trends in Latin America.
Keywords: Acromegaly; Epidemiology; Incidence; Prevalence; Latin America; Ecuador
Acromegaly is an infrequent disease, is associated with high morbidity, and has a mortality rate 2 to 3 times higher than expected [1-3]. The epidemiology of the disease has changed in recent decades, due to advances in diagnostic techniques and recent treatments. In 2010, recommendations on the management of acromegaly specifically for Latin America were published . In Mexico and Brazil [5,6], guides have also been developed at the national level. In the present mini-review, we address the particularities of the epidemiology of acromegaly in Latin America, as well as trends in clinical presentation, diagnosis and treatment modalities. Finally, we analyze the present and future challenges that arise in the region for the early detection and optimization of the treatment of acromegaly.
Epidemiology of Acromegaly in the World
Information on the epidemiology of acromegaly has been obtained from the national registries that were created in Europe from the 90s and from the data obtained in a limited number of cases attended in highly specialized centers. This information is the best reflection of the specific trends in each country of the epidemiology, diagnosis and treatment of the disease [7-10].
Although the prevalence figures tend to differ depending on the region and/or country examined, these range between 40 and 95 cases per million inhabitants , with an estimated average of approximately 69 cases per million inhabitants [12,13] .
The estimated incidence in Europe averages approximately 3-4 cases per million inhabitants [13,16]. While, in the Latin American countries, incidence figures are not reported; only in Ecuador has an incidence of 1.3 cases per million persons/year been described .
National Registries of Acromegaly
In Europe, at the end of the 1990s, national acromegaly registries were started to establish the epidemiological characteristics and design adequate diagnosis and treatment strategies. The best organized records are those of Spain, Belgium and Germany [7,8,16,17].
The Spanish  and Belgian  databases register subjects diagnosed before 1980 and report considerably higher prevalences of 38 and 35 cases per million, respectively. In contrast, the German  and Italian  registries included patients diagnosed after 1990 and have lower prevalences of 19 and 25 cases per million, respectively.
In Latin America, until now the only national registry of acromegaly cases is the National Epidemiological Program of Acromegaly of Mexico, Epiacro, which issued its first report in 2010 , and the Mexican registry of Acromegalia (MAR) recently released .
Epidemiology of Acromegaly in Latin America
The Mexican registry of acromegaly "EpiAcro" gives an estimated general prevalence of 13 cases per million, which is lower than in other parts of the world and suggests an important sub-diagnosis . More recently in the MAR registry, the first and largest non-European record of the disease, a prevalence of 18 cases per million inhabitants is reported .
In Buenos Aires, Argentina, a cohort of pituitary tumors reports a prevalence of 14.07 cases per 100,000 people and a standardized incidence rate of 0.92 cases per 100,000 persons/year . In Brazil, in a screening study, the prevalence reported in 2011 was 294 cases per 1'000.00 inhabitants, and in 2012, 480 cases per 1'000,000 inhabitants [19,20,22].
Recently in Ecuador the epidemiology of acromegaly was described in Guayaquil, the most populated city of Ecuador , reporting a prevalence of 18.7 cases/million inhabitants and the incidence of 1.3 cases/million persons/years .
Clinical and Biochemical Characterization
The diagnosis of acromegaly is based mainly on clinical manifestations and is generally confirmed by measuring the serum levels of GH and IGF-1 . The clinical manifestations depend on the levels of GH (and IGF-1), age, size of the tumor mass, and the time of delay in diagnosis. Since the clinical effects of excess GH occur insidiously over time, many of the symptoms of acromegaly are nonspecific and similar to other more common diseases, so the diagnosis is often omitted or delayed by 5 to 10 years. Starting from the onset of symptoms [15,18,24].
The first clinical manifestations and reasons for medical consultation in most cases, are alterations of the physiognomy and growth of the acral parts [1,7,12]. These manifestations have not changed in the last 2 decades, and show that acromegaly is still underdiagnosed and remains under-recognized .
In all the series a greater incidence of the disease in women is demonstrated . In the Epiacro registry of Mexico, the proportion of women was 60% . In Ecuador, the predominance of females is confirmed (64.5%), with a female-male ratio of 1.8: 1.
In European series, patients are usually diagnosed between the fourth and sixth decades of life, and the estimated time of delay from the onset of symptoms to clinical or biochemical diagnosis varies from 9 to 35 years [11,13].
In Mexico, the main clinical characteristic of the patients was acral enlargement of the hands and feet, headache and fatigue. The prevalence of comorbidities was similar to that described in European registries. [3,7-9,14,17,26], and it is emphasized that diabetes and high blood pressure were more common in women than in men [14,27]. The time between onset of clinical manifestations and diagnosis varied from 5 to 17 years, and approximately one third of patients had an invasive tumor at the time of diagnosis .
In Ecuador, the clinical and biochemical characterization in the cases described in the city of Guayaquil was not different from that described in the international literature. There is a predominance of the disease in women; it is diagnosed in the fourth decade with a delay in the diagnosis of about 8 years, which is usually even greater in men .
Comorbidities and Mortality in Acromegaly
Active or untreated disease is associated with significant morbidity and mortality, mainly due to cardiovascular and neoplastic causes [28-30]. In studies published before 1995, acromegaly was associated with a two to three fold increase in mortality rates compared to the general population . More recently, due mainly to the availability of modern treatments, an improvement in survival and the standardized mortality rate have been described . The most common causes of death have been cardiovascular diseases and, in some studies, dysfunction of the respiratory system [3,28]. More recently, the cause of death changes from predominantly cardiovascular to deaths predominantly related to cancer .
Trends in the Treatment of Acromegaly in Latin America
The objectives of treatment are to eliminate morbidity and recover life expectancy. The treatment must control the growth of the tumor mass and restore the normal secretion of GH. The biochemical control criteria are to reduce the plasma IGF-1 values to the normal ones according to age and sex and to achieve suppress the serum levels of GH to less than 1 ng/ml during the TTGO [4,14,31]. In guidelines and consensus statements specific to Latin America, it is generally recommended as primary therapy in acromegaly, surgery or, if there is a low probability of surgical cure somatostatin analogues (SSAs) .
The percentage of surgical cure described in the literature varies from 80% to 100% for microadenomas and 50 to 65% for macroadenomas, depending on the chosen cure criteria . In the MAR registry, in 500 patients almost 40% were considered as cured. The surgical cure rate was higher in microadenomas than in macroadenomas. These figures are similar to the cure rates reported by the different European registers .
In Chile, a study in 53 surgically treated patients reported disease control in 66.7% of the microadenomas and 21.4% of the macroadenomas .
In Ecuador, the main treatment is transsphenoidal surgery (in 81% of patients), followed (and sometimes proceeded) by somatostatin analogues (sustained-release octreotide). In general, the surgical cure rate was much lower (3%) than that of the surgical series reported by other reference hospitals, ranging between 21% and 95% [11,15,16,25,26].
Despite recent advances in the treatment of acromegaly with surgery, drugs and radiation therapy, some patients do not achieve hormonal control.
The evidence to support the use of SSAs as primary pharmacological treatment is now extensive and includes several studies in Latin American populations [34-38]. Specific guidelines for Latin America  generally recommend therapy with SSAs as the next line of treatment in patients with insufficient control of GH secretion after surgery [39,40].
In most Latin American countries the cost of pharmacological treatment, particularly, SSAs are absorbed by the state. The formulations of octreotide and lanreotide Depot are actively marketed and are prescribed in Argentina, Brazil, Chile, Colombia, Mexico, Peru, Ecuador (only octreotide)  and Venezuela .
Treatment with SSAs may improve surgical outcomes , similarly surgical reduction of the tumor mass may improve the outcome of SSAs treatment in patients resistant to primary therapy with SSAs [40,42]. In Mexico, 187 patients who were treated mainly or in addition with SSAs were analyzed  and the results in relation to primary therapy with SSAs were similar to those reported by European registries [8,13,16].
Cabergoline is usually reserved for patients with relatively low concentrations of GH and IGF-1, or those in whom an oral drug is preferred over injectable therapy . It is widely available in Latin America, it is less expensive and can improve the response in patients not controlled only with SSAs [6,39,43,44]. It is considered as an alternative treatment (although less effective) in situations in which SSAs are not available .
GH receptor antagonist
Pegvisomant is usually reserved for third line therapy , is used less frequently due to its higher cost , requires daily injections and is not available throughout Latin America. It may be effective as an additional therapy in cases with partial response to SSAs [40,46,47].
Other Pharmacological Therapeutic Options used in Latin America
Some therapeutic options less explored in the international literature have been used in Latin America. Although they may be less effective and discontinued in some countries, in selected cases, these drugs alone or in combination may be useful, less expensive and are available in some countries of Latin America.
Estrogens were used in the past to treat acromegaly, achieving almost a 50% decrease in IGF-1 values, but these drugs were discontinued due to the side effects caused by the high doses administered and the undesirable effects [48-50]. In women of reproductive age, without contraindications, oral contraceptives would be an option. In postmenopausal women, oral estrogens, tamoxifen and raloxifene may be useful .
In men, due to obvious side effects, estrogen would not be an option. For them and for postmenopausal women who are not candidates for estrogen therapy, selective estrogen receptor modulators (SERMs) may be an option . There are studies in men and women with clomiphene , tamoxifen  and raloxifene [54,55]. In men, especially in hypogonadics, clomiphene could achieve good results [51,52].
Rosiglitazone, a selective agonist of PPAR gamma receptors, has been used in patients with acromegaly with different results [56-58]. In some selected patients, rosiglitazone can decrease the levels of GH and IGF-1 [56,58]. Additional research with rosiglitazone, alone or in combination with other treatment modalities, is required to define its usefulness in the long-term treatment of acromegaly.
Radiation therapy in most of its modalities is used more frequently in the region, due to its relatively low cost and proven efficacy .Radiosurgery is considered an option in selected cases when no control of the disease is achieved with surgery and drug therapy, especially if the pegvisomant is not available.  Radiosurgery and modern external-beam radiation therapy can be an effective, low-cost, and reasonably safe means of controlling the activity of acromegaly, although it has a long latency period for its efficacy [59,60]. The results of transsphenoidal surgery, radiotherapy and treatment with somatostatin analogues described in publications in Latin America, are comparable to those achieved in Europe and the United States [35,60-65].
Challenges and Future Directions in the Management of Acromegaly in Latin America
The main challenges that Latin American countries face are the early and efficient detection of cases and the registration of cases in national and/or regional databases, for which we must carry out screening programs and implement national acromegaly registries. Other challenges involve achieving better access to modern diagnostic tools (biochemical, genetic, radiological), pharmacological resources (current) and multidisciplinary teams of experts.
Screening of Acromegalia
Since acromegaly is rare disease, it can be difficult to establish strategies that help in diagnosis and detection in an effective and costeffective manner . Early recognition of typical clinical manifestations of the disease can help to identify patients at risk, instead of focusing on comorbidities, which generally appear at later stages and are not always present in all cases. The implementation of screening programs for these at-risk patients could anticipate diagnosis in decades. For a screening program for a rare disease (such as acromegaly) to be viable and effective, the total cost/benefit ratio of the search for a case must be in balance with the medical expense as a whole . The treatment of comorbidities associated with delayed diagnosis increases the overall costs of care. Therefore, the type of screening of choice should be directed to the population at risk .
Implementation of National Acromegaly Registries
The importance of registering patients with acromegaly through computerized databases is to obtain data on clinical characteristics, prevalence, morbidity and mortality, and response to treatments. This information represents a useful tool for designing local or regional health strategies in the medium and long term. Scientific societies in coordination with public health institutions in each country play a fundamental role in the creation of these national registries. In our Central and South America region, the Latin American Society of Neuroendocrinology (SLANE) groups a large number of specialists dedicated to the study and dissemination of programs related to acromegaly. Its main guidelines are to encourage the formation of national groups that implement the creation of the registry of cases of the disease. In Ecuador, since 2000, the Association of Clinical Endocrinologists of Ecuador (AECE) has carried out the systematic search of cases in the main hospitals of the public health network in the city of Guayaquil and is committed to developing an online registry of cases at the national level. We hope that these efforts bear fruit in the short term.
In summary, in Latin American countries specialists in pituitary surgery are not always available or centralize their professional practice in the 2 or 3 main cities of the country; the economic and material resources, especially the last generation drugs, are scarce or difficult to access for the majority of the population. This determines that doctors use treatments that are not indicated in international guidelines but are more accessible in our countries. The education of general practitioners and the performance of simple screening studies based on phenotypic characteristics can be a cost-effective method for the early identification of acromegaly. Finally, we believe that a national registry system for patients diagnosed with acromegaly should be implemented in all the countries of our region, with the objective of coordinating the design of adequate health care strategies in the region.
- Melmed S (2006) Acromegaly. N Engl J Med 355: 2558-2573.
- Ritvonen E, Löyttyniemi E, Jaatinen P, Ebeling T, Moilanen L, et al. (2016) Mortality in acromegaly: a 20-year follow-up study. Endocrine-Related Cancer 23: 469-480.
- Arosio M, Reimondo G, Malchiodi E, Berchialla P, Borraccino A, et al. (2012) Predictors of morbidity and mortality in acromegaly: An Italian survey. Eur J Endocrinol 167: 189-198.
- Barkan A, Bronstein MD, Bruno OD, Cob A, Espinosa-de-los-Monteros AL, et al. (2010) Management of acromegaly in Latin America: expert panel recommendations. Pituitary 13: 168-175.
- Arellano S, Aguilar P, Domınguez B, Espinoza de Los Monteros AL, Gonzalez Virla B, et al. (2007) Segundo Consenso Nacional de Acromegalia: recomendaciones para su diagnostico, tratamiento y seguimiento. Revista de Endocrinologıa y Nutricion 15: S7-S16.
- Vilar L, Azevedo MF, Naves LA, Casulari LA, Albuquerque JL, et al. (2011) Role of the addition of cabergoline to the management of acromegalic patients resistant to long-term treatment with octreotide LAR. Pituitary 14: 148-156.
- Mestron A, Webb SM, Astorga R, Benito P, Catala M, et al. (2004) Epidemiology, clinical characteristics, outcome,morbidity and mortality in acromegaly based on the SpanishAcromegaly Registry (Registro Espanol de Acromegalia, REA).Eur J Endocrinol 151: 439-446.
- Bex M, Abs R, T Sjoen G, Mockel J, Velkeniers B, et al. (2007) AcroBel - the Belgian registry on acromegaly: a surveyof the «real-life» outcome in 418 acromegalic subjects. Eur JEndocrinol 157: 399-409.
- ReinckeM, Petersenn S, Buchfelder M, Gerbert B, Skrobek-Engel G, et al. (2006) The German acromegaly registry: description of the database and initial results. Exp Clin Endocrinol Diabetes 114: 498-505.
- Dal J, Skou N, Nielsen EH, Jorgensen JO, Pedersen L (2014) Acromegaly according to the Danish Registry of Patients: How valid are ICD diagnoses and how do patterns of registration affect the accuracy of registry data. Clin Epidemiol 6: 295-299.
- Melmed S (2009) Acromegaly pathogenesis and treatment. J ClinInvest 119: 3189-3202.
- Reddy R, Hope S, Wass J (2010) Acromegaly. BMJ 16: c4189.
- Sesmilo G (2013) Epidemiology of acromegaly in Spain. Endocrinol Nutr 60: 470-474.
- Portocarrero Ortiz L, Vergara-Lopez A, Vidrio-Velazquez M, Uribe-Diaz AM, García-Dominguez A, et al. (2016) The Mexican Acromegaly Registry: Clinical and biochemical characteristics at diagnosis and therapeutic outcomes. J Clin Endocrinol Metab 101: 3997-4004.
- Lopez Gavilanez E, Guerrero Franco K, Solórzano Zambrano N, Navarro Chávez M, López Estrella C, et al. (2016) Epidemiology of acromegaly in Ecuador. Endocrinol Nutr 63: 333-338.
- Petersenn S, Buchfelder M, Reincke M, Strasburger CM, FranzH, et al. (2008) Participants of the German AcromegalyRegister. Results of surgical and somatostatin analog therapiesand their combination in acromegaly: a retrospective anal-ysis of the German Acromegaly Register. Eur J Endocrinol 159: 525-532.
- Schofl C, Franz H, Grussendorf M, Honegger J, Jaursch-Hancke C, et al. (2013) Long-term outcome in patients with acromegaly: analysis of 1344 patients from the German Acromegaly Register. Eur J Endocrinol 168: 39-47.
- Acevedo K, Aguilar-Pacheco PE, Arellano Montano S, Bastidas-Adrián MY, Domínguez B, et al. (2010) Primer reporte del registro nacional de acromegalia: programa. Endocrinol Nutr 18: 176-180.
- Rosario PW (2011) Frequency of acromegaly in adults with diabetes or glucose intolerance and estimated prevalence in the general population. Pituitary 14: 217-221.
- Rosario PW, Calsolari MR (2012) Screening for acromegaly by application of a simple questionnaire evaluating the enlargement of extremities in adult patients seen at primary health care units. Pituitary 15: 179-183.
- Day PF, Loto MG, Glerean M, Picasso MF, Lovazzano S, et al. (2016) Incidence and prevalence of clinically relevant pituitary adenomas: retrospective cohort study in a Health Management Organization in Buenos Aires, Argentina. Arch Endocrinol Metab 60: 554-561.
- Ribeiro-Oliveira A Jr, Barkan A (2012) The changing face of acromegaly-advances in diagnosis and treatment. Nat Rev Endocrinol 8: 605-611.
- Available at: http://www.ecuadorencifras.gob.ec/censo-de-poblacion-y-vivienda/accesado 21 dic/2017.
- Reid TJ, Post KD, Bruce JN, Nabi Kanibir M, Reyes-Vidal CM, et al. (2010) Features at diagnosis of 324 patients with acromegaly did not change from 1981 to 2006: acromegaly remains under-recognized and under-diagnosed. Clin Endocrinol 72: 203-208.
- Luque-Ramírez M, Carreno A, Álvarez Escolá C, del Pozo Picó C, Varela da Costa C, et al. (2011) The OASISstudy: Therapeutic management of acromegaly in standard clin-ical practice. Assessment of the efficacy of various treatmentstrategies. Endocrinol Nutr 58: 478-486.
- Sesmilo G, Gaztambide S, Venegas E, Picó A, del Pozo C, et al. (2013) Changes in acromegaly treatment over 4 decades inSpain: analysis of the Spanish Acromegaly Registry (REA). Pituitary 16: 115-121.
- Espinosa-de-los-Monteros AL, Gonzalez B, Vargas G, Sosa E, Mercado M (2011) Clinical and biochemical characteristics of acromegalic patients with different abnormalities in glucose metabolism. Pituitary 14: 231-235.
- Mercado M, Gonzalez B, Vargas G, Ramirez C, Espinosa-de-los-Monteros AL, et al. (2014) Successful mortality reduction and control of comorbidities in patients with acromegaly followed at a highly specialized multidisciplinary clinic. J Clin Endocrinol 99: 4438-4446.
- Holdaway IM, Rajasoorya RC, Gamble GD (2004) Factors influencing mortality in acromegaly. J Clin Endocrinol Metab 89: 667-674.
- Dekkers OM, Biermasz NR, Pereira AM, Romijn JA, Vandenbroucke JP (2008) Mortality in acromegaly: a meta-analysis. J Clin Endocrinol Metab 93, 61-67.
- Melmed A. S, Colao A, Barkan M, Molitch AB, Grossman D, et al. (2009) Guidelines for acromegaly management: an update. J Clin Endocrinol Metab 94:1509-1517.
- Laws ER, Vance Ml, Tapar K (2000) Pituitary surgery for the management of acromegaly. Horm Res 53: 71-75.
- Carrasco M C, Jesús Véliz L, David Rojas Z, Nelson Wohllk G (2006) Results of surgical treatment for acromegaly in 53 patients. Rev Méd Chile 134: 989-996.
- Mangupli R, Lisette A, Ivett C, Paul C, de los Rıos Victoria C, et al. (2003) Improvement of acromegaly after octreotide LAR treatment. Pituitary 6: 29-34.
- Jallad RS, Musolino NR, Salgado LR, Bronstein MD (2005) Treatment of acromegaly with octreotide LAR: extensive experience in a Brazilian institution. Clin Endocrinol (Oxf) 63: 168-175.
- Mercado M, Borges F, Bouterfa H, Chang TC, Chervin A, et al. (2007) A prospective, multicentre study to investigate the efficacy, safety and tolerability of octreotide LAR (long-acting repeatable octreotide) in the primary therapy of patients with acromegaly. Clin Endocrinol 66: 859-868.
- Murray RD, Melmed S (2008) A critical analysis of clinically available somatostatin analog formulations for therapy of acromegaly. J Clin Endocrinol Metab 93: 2957-2968.
- Sosa E, Espinosa-de-los-Monteros AL, Gonzalez B, Vargas G, Mier F, et al. (2008) Treatment of acromegaly with octreotide LAR. Rev Med Inst Mex Seguro Soc 46: 651-658.
- Bronstein MD (2010) Optimizing acromegaly treatment. Front Horm Res 38: 174-183.
- Bronstein MD, Bruno OD, Abreu A, Mangupli R, Mercado M (2014) A practical approach to acromegaly management in Latin America. Pituitary 17: S30-S35.
- Mao ZG, Zhu YH, Tang HL, Wang DY, Zhou J, et al. (2010) Preoperative lanreotide treatment in acromegalic patients with macroadenomas increases short-term postoperative cure rates: a prospective, randomised trial. Eur J Endocrinol 162: 661-666.
- Jallad RS, Musolino NR, Kodaira S, Cescato VA, Bronstein MD (2007) Does partial surgical tumour removal influence the response to octreotide-LAR in acromegalic patients previously resistant to the somatostatin analogue? Clin Endocrinol 67: 310-315.
- Jallad RS, Bronstein MD (2009) Optimizing medical therapy of acromegaly: beneficial effects of cabergoline in patients uncontrolled with long-acting release octreotide. Neuroendocrinology 90: 82-92.
- Mattar P, Alves Martins MR, Abucham J (2010) Short- and longterm efficacy of combined cabergoline and octreotide treatment in controlling IGF-I levels in acromegaly. Neuroendocrinology 92: 120-127.
- Mercado M (2014) Acromegaly: a Latin American perspective. Pituitary 17: S1-S3.
- Neggers SJ, de Herder WW, Janssen JA, Feelders RA, van der Lely AJ (2009) Combined treatment for acromegaly with longacting somatostatin analogs and pegvisomant: long-term safety for up to 4.5 years (median 2.2 years) of follow-up in 86 patients. Eur J Endocrinol 160: 529-533.
- van der Lely AJ, Bernabeu I, Cap J, Caron P, Colao A, et al. (2011) Coadministration of lanreotide Autogel and pegvisomant normalizes IGF1 levels and is well tolerated in patients with acromegaly partially controlled by somatostatin analogs alone. Eur J Endocrinol 164: 325-333.
- Duarte FH, Jallad RS, Bronstein MD (2016) Estrogens and selective estrogen receptor modulators in acromegaly. Endocrine 54: 306-314.
- Vallette S, Serri O (2010) Oral estroprogestin: an alternative low cost therapy for women with postoperative persistent acromegaly? Pituitary 13: 311-314.
- Shimon I, Barkan A (2012) Estrogen treatment for acromegaly. Pituitary 15: 601-607.
- Stone JC, Clark J, Cuneo R, Russell AW, Doi SA (2014) Estrogen and selective estrogen receptor modulators (SERMs) for thetreatment of acromegaly: a meta-analysis of published observational studies. Pituitary 17: 284-295.
- Duarte FH, Jallad RS, Bronstein MD (2015) Clomiphene citrate for treatment of acromegaly not controlled by conventional therapies. J Clin Endocrinol Metab 100: 1863-1869.
- Balil Ii, Barkan A (2014) Tamoxifen as a therapeutic agent in acromegaly. Pituitary 17: 500-504.
- Attanasio R, Barausse M, Cozzi R (2003) Raloxifene lowers IGF-I levels in acromegalic women. Eur J Endocrinol 148: 443-448.
- Dimaraki EV, Symons KV, Barkan AL (2004) Raloxifene decreases serum IGF-I in male patients with active acromegaly. Eur J Endocrinol 150: 481-487.
- Tamez-Pérez HE, Bahena-García A, Gómez de Ossio MD, Gutiérrez-Hermosillo H, Tamez-Peña AL (2011) Rosiglitazone as an option for patients with acromegaly: a case series. J Med Case Rep 21: 200.
- Grardišer M, Matovinović M, Vrkljan M (2007) Decrease in growth hormone and insulin-like growth factor (IGF)-1 release and amelioration of acromegaly features alter rosiglitazone treatment of type 2 diabetes mellitus in a patient with acromegaly. Croat Med J 48: 87-91.
- Bastemir M, Akin F, Yaylali GF (2007) The PPAR-γ activator rosiglitazone fails to lower plasma growth hormone and insulin-like growth factor-1 levels in patients with acromegaly. Neuroendocrinology 86:119-123.
- Jallad RS, Musolino NR, Salgado LR, Bronstein MD (2007) Treatment of acromegaly: is there still a place for radiotherapy? Pituitary 10: 53-59.
- Gonzalez B, Vargas G, Espinosa-de-los-Monteros AL, Sosa E, Mercado M (2011) Efficacy and safety of radiotherapy in acromegaly. Arch Med Res 42: 48-52.
- Espinosa de los Monteros AL, Sosa E, Cheng S, Ochoa R, Sandoval C, et al. (2006) Biochemical evaluation of disease activity after pituitary surgery in acromegaly: a critical analysis of patients who spontaneously change disease status. Clin Endocrinol (Oxf) 64: 245-249.
- Manavela MP, Juri A, Danilowicz K, Bruno OD (2010) Therapeutic management in 154 acromegalic patients. Medicina (B Aires) 70: 328-32.
- Neto LV, Machado Ede O, Luque RM, Taboada GF, Marcondes JB, et al. (2009) Expression analysis of dopamine receptor subtypes in normal human pituitaries, nonfunctioning pituitary adenomas and somatotropinomas, and the association between somatostatin receptors with clinical response to octreotide-LAR in acromegaly. J Clin Endocrinol Metab 94: 1931-1937.
- Garcıa Basavilbaso N, Guitelman M, Nagelberg A, Stalldecker G, Carabelli A, et al. (2010) Experience from the argentine pegvisomant observational study: preliminary data. Front Horm Res 38: 42-49.
- Ramırez C, Vargas G, Gonzalez B, Grossman A, Rabago J, et al. (2012) Discontinuation of octreotide LAR after long-term successful treatment of patients with acromegaly. Is it worth trying? Eur J Endocrinol 166: 21-26.
- Danilowicz K, Fainstein Day P, Manavela MP, Herrera CJ, Deheza ML, et al. (2016) Implementing a screening program for acromegaly in Latin America: necessity versus feasibility. Pituitary 19: 370-374.
Citation: Gavilanez EL, Litardo NB, Bonilla MH, Chavez MN, Gualpa HA, et al. (2018) Acromegaly: Current Challenges and Future Directions in Latin America. J Clin Exp Pathol 8: 337. DOI: 10.4172/2161-0681.1000337
Copyright: ©2018 Gavilanez EL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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