Assessment of sleep apnea syndrome in treated acromegalic patients and correlation of its severity with clinical and laboratory parameters

Prevalence of sleep apnea and lung function abnormalities in patients with acromegaly

Background:

Sleep apnea (SA) is highly prevalent in acromegaly. Ethnicity influences the prevalence of SA in the general population. We studied the prevalence of SA and other respiratory comorbidities in North Indian patients with active acromegaly.

Design:

Prospective, observational.

Materials and Methods:

Consecutive adult patients with active acromegaly (n = 35, age 39.7 ± 13.2 years) and hypersomatotropism (nonsuppression of serum growth hormone after oral glucose and elevated serum insulin-like growth factor-1 [IGF-1]) were evaluated for respiratory symptoms, scoring for SA (Epworth Sleepiness Score [ESS] and STOP-BANG), pulmonary function tests (PFT), high-resolution computerized tomography (HRCT) of the thorax, polysomnography (PSG), and transthoracic echocardiography. Age- and sex-matched healthy individuals (n = 34) served as controls.

Results:

Acromegaly subjects had dyspnea (34%), cough (37%), excessive daytime somnolence (43%), and fatigue (49%). Clinically significant ESS (>10) and STOP-BANG score (≥3) were present in 41% and 68.6% of subjects, respectively. PFT showed restrictive and obstructive patterns in 45.7% and 11.4% of acromegalics respectively; with higher total lung capacity (TLC), thoracic gas volume (TGV), and residual volume (RV). PSG revealed significantly higher SA events in acromegalics (central [acromegaly 24.63 ± 37.82 vs. control 3.21 ± 5.5], mixed [11 ± 19.46 vs. 3.50 ± 5.96], obstructive [34.86 ± 44.37 vs. 9.71 ± 10.48], and mean apnea-hypopnea index [AHI] [16.91 ± 18.0 vs. 7.86 ± 7.84]). Acromegalics had significantly higher prevalence of obstructive SA (71.4% [mild 31.4%, moderate 20%, severe 20%]) as compared to controls (38.2%). There was no correlation of AHI with serum IGF-1 and disease duration.

Conclusion:

Acromegaly subjects have a significantly higher prevalence of respiratory symptoms, SA, and abnormalities in PFT. Screening for respiratory comorbidities should be routinely recommended in all patients with acromegaly.

Densely granulated adenoma pattern is associated with an increased risk of obstructive sleep apnea in patients with acromegaly

OBJECTIVES

To explore the prevalence of obstructive sleep apnea (OSA) and the association between the adenoma granulation patterns and OSA in patients with acromegaly.

METHODS

An overnight polysomnography (PSG) assessment was carried out on participants with acromegaly. Results classified participants into a non-OSA group, mild to moderate OSA group, and severe OSA group. Morphological and biochemical analyses were performed. Demographic, clinical, biochemical, and polysomnographic data were compared among the three groups. Using logistic regression models, the risk of OSA in acromegalic subjects was estimated.

RESULTS

OSA was reported in 36 of 49 patients (74%) with acromegaly. Contrasted with the non-OSA group, OSA patients had a larger proportion of the densely granulated (DG) pattern. The OSA groups with DG acromegaly had a smaller maximum tumor diameter and Vol/2 than those with the sparsely granulated (SG) pattern. Furthermore, a higher growth hormone (GH) level (45.0 ± 36.9 vs 18.6 ± 15.8, P = 0.047) and GH index (28.4 ± 13.8 vs 6.6 ± 8.2, P = 0.003) were found in DG acromegaly patients with severe OSA. Additionally, there was a trend toward higher standardized insulin-like growth factor 1 (IGF-1) in patients with DG acromegaly than in those with SG acromegaly in the severe OSA group. After adjusting for potential confounding variables, the DG pattern was correlated with the risk of OSA (OR = 14.84, 95%CI 1.36-162.20, P = 0.027) in patients with acromegaly.

CONCLUSIONS

The findings indicate that a high prevalence of OSA exists in patients with acromegaly, and the DG pattern may be a risk factor for OSA in acromegaly.

Updates in rare and not-so-rare complications of acromegaly: focus on respiratory function and quality of life in acromegaly

Acromegaly is a complex disease with excessive growth hormone and insulin-like growth factor 1 (IGF-1) causing multisystem effects, particularly cardiovascular, respiratory, and metabolic. Psychological concerns and poor quality of life (QoL) are also major disease consequences. This review is intended for clinicians and focuses on the latest developments related to respiratory and QoL effects of long-term growth hormone excess. Along with biochemical disease control, patient treatment satisfaction and outcomes have become major treatment objectives; current knowledge and tools to evaluate and manage this aspect of the disease are described. Sleep apnea syndrome and other derangements of lung function and apparatus, from pathophysiology to treatment, and evaluation tools and determinants of QoL in patients with acromegaly are discussed.

Acromegaly in the elderly patients

BACKGROUND

Acromegaly is a rare disease characterized by a chronic exposition to growth hormone (GH) and insulin-like growth factor-1 (IGF-1), caused in most cases by a pituitary GH-secreting adenoma. Chronic GH excess induces systemic complications (metabolic, cardiovascular, respiratory, neoplastic, and musculoskeletal) and increased mortality if not appropriately treated. Recent epidemiological data report an improved life span of patients with acromegaly probably due to better acromegaly management; additionally, the number of pituitary incidentaloma in general population also increased over time due to more frequent imaging. Therefore, the number of elderly patients, newly diagnosed with acromegaly or in follow-up, is expected to grow in the coming years and clinicians will need to be aware of particularities in managing these patients.

PURPOSE

This review aims to explore different aspects of acromegaly of the elderly patients, focusing on epidemiology, diagnosis, clinical presentation, complications, and management options.

METHODS

Available literature has been assessed through PubMed (data until August 2019) by specific keywords.

CONCLUSIONS

Available data on acromegaly in the elderly patient are sparse, but point to important differences. Further studies are needed comparing elderly with younger patients with acromegaly to better define a tailored diagnostic and therapeutic management.

The Course of Obstructive Sleep Apnea Syndrome in Patients With Acromegaly During Treatment

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is common in active acromegaly and negatively influences quality of life, morbidity, and mortality. This prospective study with 3 predetermined timepoints and a standardized treatment protocol investigates changes in sleep parameters during the first 2.5 years of acromegaly treatment.

METHODS

Before initiation of acromegaly treatment (medical pretreatment followed by surgery), polysomnography (PSG) was performed in 27 consecutive patients with treatment-naive acromegaly. PSG was repeated after 1 year (N = 24) and 2.5 years (N = 23), and anthropometric and biochemical parameters were obtained.

RESULTS

At baseline, 74.1% of the patients was diagnosed with OSAS. The respiratory disturbance index (RDI; P = 0.001), oxygen desaturation index (ODI; P = 0.001), lowest oxygen saturation (LSaO2; P = 0.007) and the Epworth Sleepiness Scale (ESS; P < 0.001) improved significantly during treatment, with the greatest improvement in the first year. After 2.5 years of treatment, all patients had controlled acromegaly. Of the 16 patients with repeated PSG and OSAS at baseline, 11 (68.8%) were cured of OSAS. Changes in RDI, ODI, LSaO2, and ESS correlated with insulin-like growth factor 1 levels.

CONCLUSION

OSAS has a high prevalence in active acromegaly. There is a substantial decrease in prevalence and severity of OSAS following acromegaly treatment, with the largest improvement during the first year. Most patients recover from OSAS following surgical or biochemical control of the acromegaly. Therefore, a PSG is advised after diagnosis of acromegaly. When OSAS is present, it should be treated and PSG should be repeated during acromegaly treatment.

Temporal relationship of sleep apnea and acromegaly: a nationwide study

PURPOSE

Patients with acromegaly have an increased risk of sleep apnea, but reported prevalence rates vary largely. Here we aimed to evaluate the sleep apnea prevalence in a large national cohort of patients with acromegaly, to examine possible risk factors, and to assess the proportion of patients diagnosed with sleep apnea prior to acromegaly diagnosis.

METHODS

Cross-sectional multicenter study of 259 Swedish patients with acromegaly. At patients' follow-up visits at the endocrine outpatient clinics of all seven university hospitals in Sweden, questionnaires were completed to assess previous sleep apnea diagnosis and treatment, cardiovascular diseases, smoking habits, anthropometric data, and S-IGF-1 levels. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale. Patients suspected to have undiagnosed sleep apnea were referred for sleep apnea investigations.

RESULTS

Of the 259 participants, 75 (29%) were diagnosed with sleep apnea before the study start. In 43 (57%) of these patients, sleep apnea had been diagnosed before the diagnosis of acromegaly. After clinical assessment and sleep studies, sleep apnea was diagnosed in an additional 20 patients, yielding a total sleep apnea prevalence of 37%. Higher sleep apnea risk was associated with higher BMI, waist circumference, and index finger circumference. Sleep apnea was more frequent among patients with S-IGF-1 levels in the highest quartile.

CONCLUSION

Sleep apnea is common among patients with acromegaly, and is often diagnosed prior to their acromegaly diagnosis. These results support early screening for sleep apnea in patients with acromegaly and awareness for acromegaly in patients with sleep apnea.

Association of Acromegaly and Central Sleep Apnea Syndrome

Acromegaly is usually characterized by the excessive secretion of growth hormone (GH) after the closure of epiphyseal plaques, resulting from functional pituitary adenomas. The most common manifestations of acromegaly are acral and soft tissue overgrowth, diabetes mellitus, hypertension, and heart and respiratory failure. In patients, obstruction of the upper airway may develop due to enlargement of the tongue and thickening of the tissues of the larynx; consequently, obstructive sleep apnea syndrome (OSAS) occurs commonly in acromegaly. Previous studies have shown an association between acromegaly and central sleep apnea syndrome (CSAS). Some of these described patients described showed that an elevation in the GH level may cause a defect in the respiratory drive. Most systemic diseases seen in acromegaly require effective treatment. We believe that it is necessary to perform effective treatments by examining respiratory disorders in sleep.

Increased Risk of Persistent Glucose Disorders After Control of Acromegaly

Purpose:

Combining surgery and medical treatments allows the control of growth hormone hypersecretion in 80% of cases. Our objective was to determine the rate of acromegaly comorbidities once hypersecretion of growth hormone is controlled.

Methods:

Our retrospective monocentric study was based on 130 patients followed on a regular basis, with acromegaly controlled by medical treatments or cured by surgery or radiation technique. Our main outcome measures were the prevalence of major metabolic complications of acromegaly (diabetes, hypertension, low-density lipoprotein cholesterol, triglycerides) at diagnosis and last follow-up in comparison with French epidemiological data.

Results:

As expected, controlling hypersecretion significantly improved the metabolic complications of acromegaly. However, the proportion of patients having at least one metabolic complication of acromegaly at last follow-up (mean, 72 months after remission) was 27% for altered glucose tolerance or diabetes, 39% for hypertension, 34.3% for hypercholesterolemia, and 13.3% for hypertriglyceridemia. Interestingly, our data showed that diabetes was the only comorbidity different with a higher prevalence in patients in remission versus a general population of a similar median age (21.6% vs 6.9%, respectively).

Conclusions:

The follow-up of glucose disorders needs to be maintained on a long-term basis in patients controlled for acromegaly.

Quality of life in female patients with acromegaly

AIM

The aim of the study was to assess the quality of life and depression status in female patients with acromegaly.

PATIENTS AND METHODS

Fifty-seven female patients with acromegaly (21 inactive, 36 active) who were being followed-up at the Cerrahpasa Medical School, Endocrinology and Metabolism out-patient clinic, were included in the study. Depression status and quality of life of the patients were evaluated according to disease activity using the Beck Depression Inventory (BDI) and the Acromegaly Quality of Life (AcroQoL) Questionnaire. Prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-SO4), 17α-hydroxyprogesterone, androstenedione, free thyroxin (FT4), thyrotropin (TSH), cortisol, GH and IGF-I were studied in the groups.

RESULTS

The AcroQoL total score in female patients with controlled acromegaly and uncontrolled acromegaly were 45.5 [Interquartile range (IQR)= 32.9-57.4], 47.7 [(IQR)= 38.6-63.3], respectively (p=0.53). There was no difference in BDI scores in acromegalic patients according to disease activity (p=0.41). In the correlation analysis, a strong negative correlation was found between AcroQoL total score and BDI score (r=-0.72, p<0.0001), OSAS (r=-0.32, p=0.01).

CONCLUSION

This study showed that QoL was impaired in female patients with acromegaly even if they were in remission. Depressive mood and obstructive sleep apnea syndrome (OSAS) could affect QoL in female patients with acromegaly.

Improving Quality of Life in Patients with Pituitary Tumours

Evaluation of health-related quality of life (QoL) in people with pituitary tumours has received much attention over the last 10-15 years. Most of them show impaired QoL, but little is known about how to prevent impairment or how to improve QoL. Our aim is to review what is known about QoL in pituitary tumours patients and to highlight the areas worth improving, for the patient's well being. The article has four sections: acromegaly, Cushing's syndrome, prolactinomas and non-functioning adenomas. Control of comorbidities is usually an important factor to prevent QoL impairment; however, each disease has specific characteristics that should be properly addressed in order to obtain full patient recovery after successful therapy.