Perspectives on Combination Medical Therapy in the Treatment of Acromegaly

Dawn Shao Ting Lim, Maria Fleseriu

Research output: Chapter in Book/Report/Conference proceedingChapter


The management of patients with acromegaly, who are inadequately controlled after surgery and medical therapy with first-generation somatostatin receptor ligands (SRLs), is challenging. Treatment with a second-generation SRL, pasireotide long-acting release (LAR), or treatment with the growth hormone antagonist, pegvisomant (PEG), as a monotherapy may be considered. However, combined medical therapy remains an important option. With the development of oral octreotide capsule (OOC) and a reduced burden on patients (no injections), additional combination therapies may be also possible. This chapter focuses on the efficacy and safety of first-generation SRL-PEG combination therapy. Also highlighted are pasireotide LAR-PEG studies and SRL-cabergoline and cabergoline-PEG combination medical treatments. Somatostatin receptor ligand-PEG combination treatment normalizes insulin-like growth factor-1 (IGF-1) in approximately two thirds of patients. Treatment efficacy continues despite individual drug dosing or frequency reduction in those patients who are responsive. Pegvisomant may also negate the adverse effects of first-generation SRLs on glycemic control. Somatostatin receptor ligand- PEG combination treatment may also be considered in those patients who benefit from symptom relief with SRLs despite inadequate IGF-1 reduction during SRL monotherapy and those patients with large remnant tumor volumes. Pasireotide LAR-PEG has been shown to be effective in patients with uncontrolled acromegaly, tumor growth, or persistent symptoms despite high doses of first-generation SRLs-PEG. It has been shown that PEG has a sparing effect of pasireotide LAR. The risk of hyperglycemia is, however, significantly higher than with first-generation SRLs. As such a pasireotide LAR-PEG combination option may not be suitable for patients with poorly controlled diabetes mellitus (DM). A combination of SRLs-cabergoline is generally well-tolerated and may be most effective in patients with mildly elevated IGF-1. Data on PEG-cabergoline combination treatments are limited. However, PEG-cabergoline may be an option in cases of SRL intolerance or in cases of poorly controlled DM. Individualization of patient medical therapy (mono or combination) remains key.

Original languageEnglish (US)
Title of host publicationContemporary Endocrinology
PublisherHumana Press Inc.
Number of pages20
StatePublished - 2022

Publication series

NameContemporary Endocrinology
ISSN (Print)2523-3785
ISSN (Electronic)2523-3793


  • Acromegaly
  • Combination medical therapy
  • Dopamine agonist
  • Growth hormone receptor antagonist
  • Pasireotide LAR
  • Pegvisomant
  • Somatostatin receptor ligand

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Endocrinology


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