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Effect of Different Dopaminergic Agents in the Treatment of Acromegaly

Department of Molecular and Clinical Endocrinology and Oncology (A.C., D.F., P.M., A.D.S., G.C., F.S., B.M., G.L.) and Department of Radiology (S.C.), University Federico II, Naples, Italy

Address all correspondence and requests for reprints to: Annamaria Colao, M.D., Ph.D., Department of Molecular and Clinical Endocrinology and Oncology, Federico II, via S. Pansini 5, 80131 Naples, Italy.

	Abstract

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Medical treatment of acromegaly with dopamine agonists possesses 2 main advantages: the oral administration and the low costs. In this study, we reported on the results of chronic treatments with quinagolide (CV 205–502), cabergoline (CAB) and long-acting depot preparation of bromocriptine (BRC-LAR) in 34 acromegalics. Patients were divided into three groups on the basis of different treatment: CV 205–502 given to 16 patients at the dose of 0.3–0.6 mg/day for 6 months; CAB given to 11 patients at the dose of 1.0–2.0 mg weekly for 6 months; and BRC-LAR injected into 7 patients at the dose of 100 mg/month for 6–12 months. Basal and oral glucose tolerance test-stimulated serum GH levels, basal and TRH-stimulated PRL levels, plasma insulin-like growth factor I (IGF-I) levels, computed tomography scan, and/or magnetic resonance imaging were assessed before and quarterly during treatments. The chronic administration of CV 205–502, CAB, and BRC-LAR caused a significant decrease of circulating GH, IGF-I, and PRL levels (P < 0.005). Normalization of circulating GH and IGF-I levels was obtained in 7 of 16 (43.8%) patients treated with CV 205–502. Serum GH response to oral glucose tolerance test (oGTT) significantly improved (P < 0.005), and PRL levels were significantly suppressed during treatments. No correlation was found between basal and TRH-stimulated PRL levels and GH suppression during different therapies. Immunohistochemical staining revealed 19 GH-positive and 10 GH+PRL-positive adenomas. A significant association was found between GH/PRL staining and responsiveness to chronic treatments (² = 7.985, P < 0.005). Three patients had significant adenoma shrinkage. Slight nausea and hypotension, which spontaneously disappeared within therapy progression, were referred by 5/16 patients during CV 205–502 and 2/7 during BRC-LAR.

The results of this study indicate that CAB and BRC-LAR cannot be considered as useful medical approaches for acromegalics, whereas CV 205–502 normalized circulating GH and IGF-I levels in 47.8% of patients.

	Introduction

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THE EFFECTIVENESS of medical treatment in acromegaly is based on the suppression of circulating GH and insulin-like growth factor I (IGF-I) concentrations, remission of clinical signs and symptoms of the disease, and tumor shrinkage. Dopamine agonist drugs, in particular bromocriptine (BRC), have been used for over 20 yr in the medical therapy of acromegaly (1, 2, 3). Results often are disappointing because normalization of serum GH levels is reported only in 20% of patients, although clinical improvement occurs in approximately 50% of cases (4). Moreover, the effects of dopaminergic drugs in responsive patients are usually short-lasting (5). Since long-acting somatostatin analogs have became available, pharmacotherapy of acromegaly has significantly improved, and normalization of hormone levels has been reached in up to 50% of acromegalics (6). The appearance of side effects, the need of thrice-daily administrations, and the high cost of the treatment are current limitations.

It has been reported recently that quinagolide (CV 205–502) causes a suppression of GH levels more prolonged than BRC (7) and that it is effective either alone or combined with octreotide in a few acromegalics (8). In contrast, little experience has been accumulated so far with cabergoline (CAB) and long-acting depot preparation of BRC (BRC-LAR) in acromegaly (9, 10, 11, 12).

In this study, we report on the chronic treatment with CV 205–502, CAB, and BRC-LAR in acromegaly. Because silent GH, PRL-mixed adenomas might affect the results of chronic administration of dopaminergic agents, GH suppression during therapy was correlated to serum PRL inhibition, assessed both in baseline conditions and after TRH stimulation. In addition, the results of immunohistochemical staining carried out a posteriori were correlated with the response to chronic treatments.

	Subjects and Methods

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Patients

Thirty-four patients with active acromegaly (12 males and 22 females, aged 25–64 yr) entered this study after their written consent had been obtained. Twenty-five were untreated and 9, previously subjected to unsuccessful surgery, had a detectable residual mass and/or high circulating GH and IGF-I levels. Sixteen patients had been treated previously with oral BRC at the daily dose of 7.5–20 mg before starting CV 205–502, CAB, or BRC-LAR without normalizing GH/IGF-I levels. Moreover, 9 of 16 were given octreotide (300–450 µg/day, sc) but withdrew the treatment because of the appearance of side effects. Active acromegaly was diagnosed in accordance with high serum GH levels being not suppressible below 2 µg/L after glucose administration (oGTT) and high plasma IGF-I levels. Computed tomography (CT) and/or magnetic resonance imaging (MRI) showed macroadenoma in 20 patients, microadenoma in 4, remnant tumor in 9, and empty sella in 1. Four patients showed temporal quadranopia. The 34 patients were divided into three groups in line with treatment schedule.

Group 1

Sixteen patients were treated with CV 205–502 at the dose of 0.3–0.6 mg/day for 6 months. The drug was given once daily at 1900 h (after dinner) (0.3 mg) or twice daily at 1300 h and 1900 h. (after lunch and dinner) (0.6 mg). Baseline serum GH levels were 30.1 ± 6.1 µg/L (mean ± SEM); plasma IGF-I levels were 315.6 ± 20 µg/L.

Group 2

Eleven patients were treated with CAB at the dose of 1.0–2.0 mg weekly for 6 months. The starting dose was 0.5 mg twice/week, increased to 1.0 mg twice/week after the first month of treatment. Baseline serum GH levels were 20.4 ± 3.1 µg/L; plasma IGF-I levels were 336.4 ± 13.9 µg/L.

Group 3

Seven patients were treated with BRC-LAR at the dose of 100 mg/month for 6–12 months. The drug was administered during hospitalization at 0800 h, after breakfast. Baseline serum GH levels were 72.7 ± 11 µg/L; plasma IGF-I levels were 460 ± 50.4 µg/L.

Screening and follow-up

Routine clinical and endocrinological evaluations did not show any evidence of thyroid or adrenal abnormalities. Five males referred decrease of libido and/or potency, whereas 10 females had oligoamenorrhea. Serum GH and PRL levels in multiple samplings at hourly intervals during 6 h (0800–1400 h) and plasma IGF-I levels were assessed in baseline and at 0800 h after 15 days, and 1, 2, 3, 6 and 12 months of treatment. Serum GH levels during oGTT and GH and PRL levels during TRH test were assayed before and after 3, 6, and 12 months of treatment. A general clinical examination was performed every month. The study protocol of BRC-LAR therapy already has been reported in detail (13).

Radiological imaging

A CT scan was carried out with a CGR 10,000 apparatus (General Electric, Milwaukee, WI) in axial and coronal projections with injection of contrast medium. MRI was carried out using a super conductive magnetic resonance (0.5–1.0 Tesla, Siemen, Germany) and superficial coil in axial, coronal and sagittal sections. The acquisitions were spin echo with 1000-ms repetition time and 40–120-ms echo time 21 ms. CT or MRI was performed before and after 3, 6, and 12 months of drug administration. A reduction more than 30% of tumor volume was considered significant shrinkage.

Visual field

Visual field examination was performed with the Goldmann-Friedmann perimetry (Maag-Streit, Bern, Switzerland), and it was carried out in all the patients in baseline, then quarterly during the follow-up in patients with visual field defects.

Assay

Serum GH and PRL levels were assessed by RIA using commercial kits. The normal ranges were below 5 µg/L and 5–20 µg/L, respectively. Plasma IGF-I levels were assessed by immunoradiometric assay using commercial kits. The normal range was 90–210 µg/L.

Statistical analysis

Data are expressed as mean ± SEM. The statistical analysis was performed using ANOVA followed by the Neumann and Keuls test, when appropriate. Serum PRL response to TRH was evaluated as area under the curve calculated by the trapezoid integration method. Serum GH levels during oGTT was evaluated as nadir value. Linear correlation analysis was used to correlate the suppression of GH values to both PRL suppression and PRL response to TRH. The ² test was used to calculate the association between GH and PRL staining and serum GH normalization.

	Results

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Effects on clinical signs and hormonal values

The chronic administration of CV 205–502, CAB, and BRC-LAR caused a significant decrease of circulating GH, IGF-I, and PRL levels (P < 0.005; Tables 1, 2, and 3 and Figs. 1, 2, and 3). After 3 months of CV 205–502 therapy, GH and IGF-I levels normalized in 7 (43.8%) patients, but (31.3%) they remained normalized after 6 months of therapy only in 5. Conversely, no patient normalized GH and IGF-I levels during CAB and BRC-LAR therapy. The percent GH suppression during chronic CV 205–502 and BRC-LAR therapy was significantly greater than that obtained during chronic CAB treatment (71.4 ± 5.3% and 72.4 ± 3.3% vs. 48.5 ± 4.0%; P < 0.05).

View larger version (15K): [in this window] [in a new window]   Figure 1. Serum GH response to oGTT (glucose 75 mg): •, baseline; , 3 months; , 6 months. Also, percent GH and IGF-I suppression (top right) during CV 205–502 treatment: , GH; , IGF-I.

View larger version (14K): [in this window] [in a new window]   Figure 2. Serum GH response to oGTT (glucose 75 mg): •, baseline; , 3 months; , 6 months. Also, percent GH and IGF-I suppression (top right) during CAB treatment: , GH; , IGF-I.

View larger version (18K): [in this window] [in a new window]   Figure 3. Serum GH response to oGTT (glucose 75 mg): •, baseline; , 3 months; , 6 months; , 12 months. Also, percent GH and IGF-I suppression (top right) during long-acting injectable BRC treatment: , GH; ; IGF-I.

Serum PRL levels and PRL and GH response to TRH test

Basal serum PRL levels were in the normal range in all the patients except in 7 with mild hyperprolactinemia (21.5–31 µg/L). TRH administration caused a significant increase of serum PRL (from 60 to 250% of baseline) in all 34 patients and a paradoxical GH increase in 15 of them. During treatments, serum PRL levels were suppressed in all the patients, whereas the paradoxical GH response disappeared in 5 patients responsive to CV 205–502 (nos. 2, 3, 4, 11, and 14; Table 1). No difference in pretreatment PRL levels was found between patients with and without GH/IGF-I normalization during different treatments (14.9 ± 1.5 vs. 17.1 ± 1.1 µg/L). Moreover, no correlation was found either between the percent of PRL suppression or PRL area under the curve after TRH and the GH suppression during treatments (Table 4).

Effects on tumor mass and visual perimetry

Two patients treated with CV 205–502 (nos. 9, 12; Table 1) and 1 with BRC-LAR (no. 5; Table 3) had a significant adenoma shrinkage. Visual field and acuity improved in all the four patients suffering visual abnormalities.

Tolerability

Four of the 16 patients had nausea and 1 had postural hypotension during chronic CV 205–502 treatment. No patient had notable side effects during CAB therapy, whereas 2 patients treated with BRC-LAR experienced nausea, postural hypotension, and headache after the first injection. Side effects spontaneously disappeared without any specific cure.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Current methods for treating acromegaly include several options. Pharmacotherapy with SRIH analogs, in particular octreotide, was shown to possess the same efficacy of surgery and radiotherapy. The complications associated with octreotide therapy are moderate compared with the benefits, but the inconvenience of thrice-daily sc injections, the incidence of gallstone formation, and the high cost are current disadvantages. Conversely, dopamine-agonist therapy offers two main advantages: the oral administration that improves patients’ compliance; and a lower cost compared with octreotide (14). It has been widely shown that dopamine agonists suppress GH and IGF-I secretion in a minority of acromegalics with significant improvement of symptoms and signs in half of them. In recent years, new dopaminergic agents and long-acting formulations of BRC, such as CV 205–502, CAB, and BRC-LAR have been shown to possess a greater efficacy than standard BRC in hyperprolactinemia. In a previous study, CV 205–502, alone or in combination with octreotide, was shown to normalize GH and IGF-I levels in 5 acromegalics resistant to other treatments (8). The results of the present study confirm the efficacy of CV 205–502 in 7 of 16 acromegalics who normalized GH and IGF-I levels and improved the GH response to oGTT, with patients’ good compliance as well. In addition, the paradoxical GH response to TRH disappeared in 5 patients during CV 205–502 therapy. By contrast, chronic therapy with CAB and BRC-LAR, despite the noteworthy PRL lowering activity, modified basal GH and IGF-I levels poorly, although it improved GH response to oGTT. In recent years, a few data on the usefulness of these two dopaminergic agents have been reported in acromegaly. Acute and long-term CAB administration were shown to cause the normalization of circulating GH and IGF-I levels in 3 of 8 (37.5%) patients shown to be responsive to BRC therapy (9). BRC-LAR has been used in 13 acromegalics so far, and, circulating GH/IGF-I levels were not normalized in any case , although a significant reduction (>50%) of GH levels was observed in 5 patients (11, 12). On the other hand, it should be considered that the studies on the effect of medical therapy in acromegaly have demonstrated that greater benefit is obtained when the pretreatment GH level is as low as possible. Because several patients enrolled in this study were not previously subjected to surgery, the poor effect of dopamine agonist treatment can be partially caused by very high pretreatment GH levels. As suggested by other reports (15, 16), a significant association between positive GH and PRL immunostaining and a favorable response to dopaminergic agents was found in the present study, whereas no correlation between serum PRL (evaluated as percent suppression or response to TRH) and GH levels (as percent suppression) was found during different treatments.

In conclusion, CAB and BRC-LAR do not seem to play a main role in the pharmacotherapy of acromegalics, whereas CV 205–502 stably normalized GH and IGF-I levels in 37.5% of our patients, and it caused a significant adenoma shrinkage in 2 of 11 patients not previously treated by surgery. However, taking into account that a combined treatment with dopaminergic agents and octreotide has been reported to be useful in selected acromegalic patients (8, 17, 18), this therapeutic strategy using CV 205–502, CAB, and BRC-LAR combined with octreotide could be advisable.

	Acknowledgments

 
We are indebted to Dr. I. Lancranjan (Sandoz, Ltd. Basle) for kindly providing Parlodel LAR, to Dr. G. Gamboni (Sandoz, Ltd. Milan) for kindly providing CV 205–502, and to Dr. K. Annoni (Pharmacia-Upjohn, Milan) for kindly providing CAB.

Received April 5, 1996.

Revised July 17, 1996.

Accepted August 21, 1996.

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This Article Abstract Full Text (PDF) Submit a related Letter to the Editor Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Copyright Permission Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Colao, A. Articles by Lombardi, G. Search for Related Content PubMed PubMed Citation Articles by Colao, A. Articles by Lombardi, G.