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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1259-1260

Acromegaly and Diabetes - A Hand in Glove Combination


Department of Neurosurgery, Sherikashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Abrar A Wani
Department of Neurosurgery, Sherikashmir Institute of Medical Sciences, Sours, Srinagar - 190 014, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.299150

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How to cite this article:
Wani AA. Acromegaly and Diabetes - A Hand in Glove Combination. Neurol India 2020;68:1259-60

How to cite this URL:
Wani AA. Acromegaly and Diabetes - A Hand in Glove Combination. Neurol India [serial online] 2020 [cited 2020 Nov 26];68:1259-60. Available from: https://www.neurologyindia.com/text.asp?2020/68/5/1259/299150




Acromegaly has a multitude of systemic manifestations, and one of them having serious ramifications are diabetes. Although diabetes is a widely known complication of increased growth hormone (GH) levels, the mechanism of diabetes is complex and intriguing in these patients. Under physiologic conditions in a normal person, GH is important for the growth of lean body mass, adipose tissue, and glycogen reserves and these actions are due to the positive effect of GH on hybrid insulin/IGF-1 (Insulin-like growth factor) receptors in adipose tissue, muscles, and hepatocytes, which ensures its insulin-like action. Under stressful circumstances, GH leads to an increase in lipolysis and free fatty acid (FFA) levels and eventually leading to conserving glycogen stores.[1] In acromegaly, there is a phenomenon of “insulin resistance”, which leads to decreased uptake of glucose and glycolysis in adipose tissue and increased gluconeogenesis in hepatocytes with resultant hyperglycemia and diabetes.[1],[2] Most of the actions of GH are mediated via IGF -1, so it seems, quite rational to follow its levels to assess the degree of control of disease after the surgery and decide on the further strategy for the patient. The target of the treatment is to lower the serum insulin-like growth factor-1 (IGF-1) concentration to within the normal range for the patient's age and gender, reduce mass effects, improve symptoms, and reverse metabolic abnormalities such as diabetes mellitus.[3] The GH levels start normalizing just a few hours after surgery; however, IGF-1 levels and symptoms take days to months to improve depending upon the severity of the disease.[4]

The lowering of IGF- 1 correlates better with the control of disease and insulin resistance when compared to levels of GH alone in acromegaly. Many patients have active disease and still their GH can be suppressed to <1 mcg/L, and this was found in 50% of patients in one of the studies.[5]

The degree of extent of surgical resection is the strongest variable for the normalization of GH and IGF-1 level, which in turn predicts the control of diabetes in these patients. The authors have done an exhaustive study, and their results are important as they reflect the scenario for our country as their center is catering to the huge population of Northern India. They are reporting a cure rate of 60% in patients with microadenoma and only 28.7% in patients of macroadenoma, which is lesser than reported in many reviews.[6] This is possibly due to a common problem of the patients reporting late to a medical facility in this part of the world hence they have large tumor sizes. The second factor is the absence of dedicated teams for a particular disease. The operating team in this series is not a team of dedicated pituitary surgeons alone, but the team consists of general neurosurgeons with various degrees of experience. On comparing, the results retrieved from any study with existing ones in literature there arises a problem often overlooked. In developed countries, there are surgeons who perform a particular group of surgeries alone while this is not possible in this country; hence, the results ought to be different. Nevertheless, the experience of surgeon is a very strong factor in determining the outcome of the disease as well as preventing the complications of the procedure.[7]

A point not discussed by the authors is the role of reoperation and adjuvant therapy in achieving remission. This becomes important as persistent growth hormone excess may require reoperation, radiotherapy (in the form of gamma knife, or stereotactic radiosurgery), or medical treatment in nearly all the cases where one fails to achieve biochemical cure by surgery alone. With an interdisciplinary approach a team of neurosurgeons, endocrinologists, and radiotherapists, nearly all acromegaly patients can be managed with reasonable success.



 
  References Top

1.
Moller N, Jorgensen JO. Effects of growth hormone on glucose, lipid, and protein metabolism in human subjects. Endocrine Reviews 2009;30:152-77.  Back to cited text no. 1
    
2.
Pratipanawatr T, Pratipanawatr W, Rosen C, Berria R, Bajaj M, Cusi K, et al. Effect of IGF-I on FFA and glucose metabolism in control and type 2 diabetic subjects. Am J Physiol Endocrinol Metab 2002;282:E1360-8.  Back to cited text no. 2
    
3.
Melmed S. Acromegaly pathogenesis and treatment. J Clin Invest 2009;119:3189-202.  Back to cited text no. 3
    
4.
Feelders RA, Bidlingmaier M, Strasburger CJ, Janssen JA, Uitterlinden P, Hofland LJ, et al. Postoperative evaluation of patients with acromegaly: Clinical significance and timing of oral glucose tolerance testing and measurement of (free) insulin-like growth factor I, acid-labile subunit, and growth hormone-binding protein levels. J Clin Endocrinol Metab 2005;90:6480-9.  Back to cited text no. 4
    
5.
Freda PU, Post KD, Powell JS, Wardlaw SL. Evaluation of disease status with sensitive measures of growth hormone secretion in 60 postoperative patients with acromegaly. J Clin Endocrinol Metab 1998;83:3808.  Back to cited text no. 5
    
6.
Carmichael JD, Broder MS, Cherepanov D, Chang E, Mamelak A, Said Q, et al. Long-term treatment outcomes of acromegaly patients presenting biochemically-uncontrolled at a tertiary pituitary center. BMC Endocr Disord 2017;17:49.  Back to cited text no. 6
    
7.
Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: Results of a national survey, review of the literature, and personal experience. Neurosurgery 1997;40:225-36.  Back to cited text no. 7
    




 

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