长效生长抑素类似物治疗肢端肥大症视野缺失可短期恢复

Sandostatin(SMS 201—995)为一长效生长抑素(SS)类似物,它抑制生长激素(GH)分泌,经常可改善肢端肥大症(脑下垂体瘤所致产生过剩GH引起的临床及生化表现)。但它对肿瘤大小及由于肿瘤向蝶鞍外扩散引起的神经科症状的疗效则不明显。曾有报告在治疗中肿瘤大小不变或稍有缩小。 作者近期治疗了61例由于脑下垂体腺瘤鞍上扩展引起的肢端肥大症有视力症状的病人。因以前曾用SS类似物治过6例肢端肥大症患者,肿瘤体积缩小10～33%,故设想单独使用此种药物以减低视     

长期应用octreotide对胆结石的形成和胆囊功能的影响

胆结石似乎是肢端肥大症患者应用长效生长抑素类似物 octreotide(OT)长期治疗的一种并发症。为了对胆石症的危险作进一步了解,作者在肢端肥大症患者和对照病人进行了 OT 治疗性试验,也对饥饿时胆囊体积和停用 OT 后胆结石的潜在可逆性进行了评估。     

肢端肥大症中Octreotide停用后致糖尿病酮症酸中毒死亡

生长抑素类似物Octreotide可使86％肢端肥大症患者循环生长激素(GH)浓度降低一半以上。36％患者生长介素C浓度恢复正常。作者报道1例肢端巨大症和胰岛素抵抗性糖尿病患者用Octreotide治疗。 一名30岁男性,1987年4月因大量GH分泌性垂体肿瘤向蝶鞍上和蝶鞍旁扩展,引起左眼视觉缺失和右颞侧视野缺损(术前GH浓度超过100ng/ml),     

肢端肥大症患者治疗前后心脏结构和功能的变化

目的:观察肢端肥大症患者手术和(或)伽马刀、长效奥曲肽治疗前后心脏结构及功能变化。方法:回顾性分析2016年1月至2019年10月在北京天坛医院诊断和治疗的62例肢端肥大症患者的一般临床资料和超声心动图检查结果,根据生长激素(GH)和胰岛素样生长因子-1(IGF-1)控制水平将治疗后患者分为病情控制组和未控制组,评估治...     

肢端肥大症的内科治疗新进展

1 简介 肢端肥大症（以下简称“肢大”）是由于过度的生长激素（GH）分泌导致的一组疾病，其病因绝大多数是由于垂体GH分泌型肿瘤导致。传统的治疗方法通常是以手术作为首选治疗，对于残留肿瘤给予放射治疗。近年来，随着神经内分泌学和垂体细胞生物学的发展，使得该领域的药物发展突飞猛进，生长抑素类似物的应用对手术作为首选治疗方法的传统治疗模式形成了巨大的挑战，它使得几乎所有肢大患者术前的临床症状和生化指标得到了明显快速的改善。肢大患者生化缓解的重要意义是生化达标可以明显降低患者的病死率。目前，临床上肢端肥大症的治疗模式正在发生着变化，对于肢大这种临床治疗上较为棘手的疾病，药物的应用有可能明显改善患者的预后。     

生长激素释放因子增加正常人和垂体腺瘤病人血清催乳素

本文旨在研究肢端肥大症患者和正常人的生长激素(GH)和催乳素(PRL)对生长激素释放因子(GRF)生长抑素类似物(SMS201—995)和促甲状腺素释放激素(TRH)的反应,并首次报告 GRF 对催乳素瘤患者GH 和 PRL 的影响。     

连续输注Octreotide治疗肢端肥大症

治疗肢端肥大症可选择切除腺瘤,但要做到完全切除常不易达到,往往需要附加放射治疗。本文作者报告应用生长抑素(SS)类似物—Octreo-tide治疗15例活动性肢端肥大症。患者在接受此药治疗前,10例曾施行一次或多次垂体手术不成功;7例次接受过未见功效的放射治疗;6例次既做过手术又做过放疗,但24小时平均GH值达5mU/l或更高,可判断其仍处于活动期;另外,在75g口服     

肢端肥大症的死亡风险及影响因素

肢端肥大症(acromegaly)是一种起病隐匿的慢性进展性内分泌代谢性疾病, 可引起多系统并发症。肢端肥大症患者的死亡风险较一般人群增加2～3倍, 既往传统的手术治疗并不能使死亡风险回归正常, 术后仍有40%～50%的患者血清生长激素水平未缓解, 这和患者死亡率增加密切相关。随着治疗药物的增多, 已证明长效生长抑素受体配体(somatostatin receptor ligands, SRLs)、生长激素受体拮抗剂(GH receptor antagonist, GHRA)等药物可有效控制患者生长激素水平, 进一步降低患者的死亡风险。本文对肢端肥大症患者的死亡风险及不同治疗方式对死亡风险的影响进行综述。     

肢端肥大症的现代治疗

肢端肥大症是一种由垂体腺瘤分泌的生长激素(GH)过多所引起的疾病。治疗的目的在于抑制GH的分泌及肿瘤对正常垂体及周围组织的压迫。近年来,随着病理、药理及显微外科技术等方面的发展,肢端肥大症的治疗取得了突破性进展。本文旨在对肢端肥大症的治疗近况作一介绍。 一、手术疗法 (一)冷冻及显微手术治疗肢端肥大症:手术治疗是肢端肥大症的主要治疗方法。治疗效果无可争议。当前手术治疗包括经鼻窦冷冻摘除术及经蝶窦显微手术两类。     

肢端肥大症性心肌病二例的临床诊治和文献回顾

目的 通过总结临床经验和分析文献资料,提高对肢端肥大症性心肌病的诊治水平.方法 在总结我院诊治2例肢端肥大症性心肌病临床经验的基础上,复习文献收集29个相同病例的完整临床资料,根据治疗后的生长激素水平将所有病例分为控制组(随机测定生长激素＜5μg/L)和未控制组,观察生长激素水平控制与肢端肥大症性心肌病治疗效果之间的关系.结果 通过治疗垂体原发疾病,降低生长激素水平,有助于改善肢端肥大症性心肌病患者的症状并使其心脏病变逆转.将生长激素水平控制于＜5μg/L以下与肢端肥大症性心肌病患者心功能的好转呈高度相关性(r=0.935,P＜0.01),控制组的好转率94.7%(18/19)明显高于未控制组(0/12,P＜0.01,χ~2=27.1);而年龄、性别、治疗方式、基础生长激素水平与好转率无显著相关性.结论 将生长激素水平控制在理想范围(＜5μg/L)是肢端肥大症性心肌病获得满意治疗效果的关键.     

Visceral adiposity index is associated with insulin sensitivity and adipocytokine levels in newly diagnosed acromegalic patients

Context: The visceral adiposity index (VAI) has proved to be a marker of visceral adipose dysfunction, strongly associated with insulin sensitivity in both the general and specific populations of patients at metabolic risk. Objective: The objective of the study was to test VAI as a useful tool to assess early metabolic risk in acromegaly. Patients: Twenty-four newly diagnosed acromegalic patients (11 women and 13 men, aged 54.9 ± 13.6 yr) were grouped into those with normal (group A, n = 13, 54.2%) and those with high VAI (group B, n = 11, 45.8%). Outcome Measures: Glucose, hemoglobin A1c, nadir and area under the curve (AUC) of GH (AUC(GH)) during the oral glucose tolerance test, AUC(Cpeptide) during a mixed-meal tolerance test, M value during euglycemic-hyperinsulinemic clamp, oral dispositional index (DIo), each component of the metabolic syndrome, leptin, adiponectin, TNF-α, and IL-6. Results: The VAI value was positively correlated with the age of patients (ρ = 0.408; P = 0.048), tumor volume (ρ = 0.638; P = 0.001), basal GH (ρ = 0.622; P = 0.001), nadir GH (ρ = 0.534; P = 0.007), AUC(GH) (ρ = 0.603; P = 0.002), IGF-I (ρ = 0.618; P = 0.001), TNF-α (ρ = 0.512; P = 0.010), and AUC(Cpeptide) (ρ = 0.715; p<0.001) and negatively with adiponectin (ρ = -0.766; P < 0.001), M value (ρ = -0.818; P < 0.001), and DIo (ρ = -0.512; P = 0.011). Patients with high VAI showed significantly higher basal GH levels (P = 0.018), AUC(GH) (P = 0.047), IGF-I (P = 0.047), AUC(Cpeptide) (P = 0.018), lower M value (P < 0.001), DIo (P = 0.006), and adiponectin levels (P < 0.001), despite the absence of a significantly higher prevalence in the overt metabolic syndrome and glucose tolerance abnormalities. AUC(GH) proved to be the main independent factor influencing VAI. Conclusions: In acromegaly, VAI appears to be associated with disease activity, adiponectin levels, and insulin sensitivity and secretion and is influenced independently by GH levels. VAI could therefore be used as an easy and useful new tool in daily clinical practice for the assessment of early metabolic risk associated with active acromegaly.     

The nadir growth hormone after an octreotide test dose predicts the long-term efficacy of somatostatin analogue therapy in acromegaly

OBJECTIVE: In the treatment of acromegaly, a 'test dose' of octreotide is recommended prior to the use of depot somatostatin analogue (SSA) therapy. However, there remains no consensus regarding the criteria that predict a response to treatment. The ability to select patients who may benefit most from medical therapy is potentially of great value in clinical practice. The aim of the study was to determine the predictive value of both the nadir GH and the mean GH following an octreotide test dose in identifying patients who subsequently achieved disease remission with depot SSA therapy. Remission was defined as a mean GH < 5 mU/l (< 2 microg/l). DESIGN: Retrospective case-control study. PATIENTS: A group of 41 patients with acromegaly underwent an octreotide test dose where GH was measured hourly for a total of 6 h following an injection of octreotide 50 microg subcutaneously. Nadir GH and mean GH following the octreotide test dose were determined. Thirty-three patients were subsequently treated with depot SSA therapy and mean GH and IGF-I levels were determined at follow-up. RESULTS: The nadir GH demonstrated superior predictive power to that of mean GH across a range of GH cut-off values. A nadir GH < 5 mU/l demonstrated 80% sensitivity and 83% specificity in predicting remission with depot SSA therapy. A nadir GH < 10 mU/l demonstrated 100% sensitivity and 56% specificity. CONCLUSIONS: The nadir GH following an octreotide test dose is a useful predictive marker of achieving disease remission with depot SSA therapy used as either a primary or an adjuvant agent.     

Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria.

The results of transsphenoidal surgery as initial therapy for GH-secreting pituitary adenomas in 57 acromegalic patients were analyzed retrospectively. Patients with prior surgery or radiation therapy were excluded from the study. Three different criteria were used to define remission: glucose-suppressed (nadir) GH less than 1.0 microg/liter, a normal sex- and age-adjusted IGF-I level, and postoperative random GH levels of 2.5 microg/liter or less. Additionally, we analyzed the neuropathological data, including immunohistochemistry and ultrastructural categorization, and the surgical complications. The short-term remission rate (6-wk postoperative follow-up visit), as determined by a random GH measurement of 2.5 microg/liter or less, was 48.8%; the remission rate, as determined by nadir GH, was 51.4%. For 57 patients followed for 12 months or more after surgery (mean, 37.7 months), surgical remission was achieved in 70.2%, 66.7%, and 61.1%, respectively, for patients assessed by normal IGF-I, random GH, and nadir GH. One patient (1.1%) developed recurrence of active acromegaly 81 months after initially successful surgical therapy. Extrasellar growth of the tumor (P = 0.04) and dural invasion by the adenoma (P = 0.008) were significant univariate predictors of a poor outcome. Tumor size was significantly greater in patients with persistent or recurrent acromegaly (P = 0.02). Patients with tumors of the ultrastructural categories of mixed GH/PRL cell and mammosomatotroph adenomas had the lowest remission rates (50% and 42.9%, respectively). There were no perioperative deaths, and there was no serious morbidity. The permanent complication rate was 3.3% (1 permanent DI and 2 nasal septal perforations). Surgical management of acromegaly currently provides prompt, effective, and satisfactory initial treatment for the majority of patients. Using stringent criteria for remission, primary transsphenoidal surgery for GH-secreting pituitary adenomas is effective and often definitive therapy for acromegaly. These results provide a benchmark for the contemporary results of surgical management as assessed by modern outcome criteria.     

Partial surgical removal of growth hormone-secreting pituitary tumors enhances the response to somatostatin analogs in acromegaly

CONTEXT: Surgery is a cornerstone in the treatment of acromegaly, but its efficacy in large, invasive tumors is scant. OBJECTIVE: The objective of this study was to investigate whether partial surgical removal of GH-secreting pituitary tumors enhances the response rate to somatostatin analogs (SSA; sc octreotide, slow-release octreotide, and lanreotide). DESIGN: This was a multicenter, open, retrospective study. SETTING: The study was performed at university hospitals. SUBJECTS AND METHODS: Eighty-six patients (42 women and 44 men; age, 42 +/- 14 yr) with acromegaly were studied. INTERVENTIONS: Patients underwent two courses of octreotide, lanreotide, or slow-release octreotide treatments before and after surgery of at least 6 months. MAIN OUTCOME MEASURE: The main outcome measure was normal IGF-I levels for age. RESULTS: Presurgical SSA treatment significantly decreased GH and IGF-I levels in all patients. GH levels were less than 2.5 microg/liter in 12 patients (14%); IGF-I levels normalized in nine (10%). After surgery, GH and IGF-I levels further decreased in all patients; tumor removal was greater than 75% in 50 (58%), 50.1-75% in 21 (24%), 25.1-50% in 10 (12%), and less than 25% in five patients (6%). Preoperatively, pituitary function was impaired in 12 patients (14%). Postsurgical SSA treatment lowered GH levels to less than 2.5 microg/liter in 49 (56%) and normalized IGF-I levels in 48 patients (55%). The success rate was significantly increased compared with that before surgery (P < 0.0001). GH (r = -0.48; P < 0.0001) and IGF-I levels (r = -0.38; P = 0.0003) after postsurgery SSA treatment correlated with the amount of tumor surgically removed. After surgery, pituitary function was impaired in 28 patients (32.6%) and was improved in 12 patients (13.9%). The cumulative prevalence of pituitary deficiency did not change during the study (normal function from 40 to 42%; deficiency from 60 to 58%). CONCLUSIONS: Surgical tumor removal (>75%) enhances the response to SSAs without impairing pituitary function. Our data indicate that surgical debulking has a significant place in the treatment algorithm of acromegaly.     

Therapeutic efficacy of the somatostatin analog SMS 201-995 (octreotide) in acromegaly. Effects of dose and frequency and long-term safety

STUDY OBJECTIVE: To determine the efficacy of stepwise incremental doses, to compare twice- with thrice-daily administration of the same total daily dosage of the long-acting somatostatin analog SMS 201-995 (octreotide, Sandoz Australia, Sydney, Australia), and to evaluate the risk for cholelithiasis after long-term therapy for acromegaly. DESIGN: Nonrandomized, controlled trial. SETTING: Tertiary care center at a medical research institute. PATIENTS: Sequential sample of 19 patients with active acromegaly. Twenty-five age-matched normal subjects were also studied to establish the normal range for growth hormone (GH) and insulin-like growth factor 1 (IGF-1). INTERVENTIONS: Eight patients (group 1) were treated with 100, 250, and 500 micrograms twice daily of octreotide, then switched to 333 micrograms three times daily, whereas 11 patients (group 2) were treated with 100, 200, 300, and 500 micrograms three times daily. Each treatment stage lasted 6 to 12 weeks. MEASUREMENTS AND MAIN RESULTS: Octreotide, 100 micrograms administered twice or thrice daily, significantly reduced mean 12-hour and nadir GH (P less than 0.01), IGF-1 (P less than 0.05), and hand volume (P less than 0.05). Dose increment to 500 micrograms in both groups did not further reduce mean 12-hour GH, nadir GH, or hand volume. Switching from 500 micrograms twice daily to 333 micrograms thrice daily resulted in significant (P less than 0.05) reduction of mean 12-hour GH, IGF-1, and hand volume. Normalization of mean 12-hour GH and IGF-1 occurred in 8 of 19 patients; 7 of the 8 patients had pretherapy mean 12-hour GH below 20 mIU/L. The pretherapy mean blood glucose was a significant negative predictor (r = -0.89) of the change in mean blood glucose during therapy. Gallstones were present in 9 of 18 patients after therapy. CONCLUSION: Thrice-daily was more effective than twice-daily administration of octreotide, and dose increments above 100 micrograms thrice daily did not confer additional benefit. Biochemical remission was achieved in 40% of patients and was dependent on the GH concentration at initiation of treatment. Cholelithiasis is a risk of octreotide therapy. Octreotide is effective and can be considered as a first-line therapy in patients with acromegaly with mean pretherapy GH concentrations below 20 mIU/L. In patients with mean GH over 20 mIU/L, octreotide may be used as an adjuvant to surgery or radiotherapy.     

Relationship between disease-related morbidity and biochemical markers of activity in patients with acromegaly

The criteria for biochemical control of acromegaly that will best reduce disease-related morbidity in acromegaly are debated. We therefore studied the relationship of biochemical markers with an important metabolic parameter, insulin sensitivity, and clinical parameters reflecting disease activity in acromegaly. Newly diagnosed and postoperative patients with acromegaly underwent assessment of fasting IGF-I and fasting and postoral glucose tolerance test GH and insulin levels and completed a numeric signs and symptoms questionnaire. Insulin sensitivity was estimated by the quantitative insulin sensitivity check index (QUICKI) and the composite insulin sensitivity index. Patients were divided into three groups: group I, normal IGF-I and nadir GH less than 0.14 mug/liter (n = 21); group II, normal IGF-I and nadir GH 0.14 mug/liter or more (n = 20); group III (active), elevated IGF-I (n = 25). Age, sex, and body mass index were comparable in these groups. Insulin sensitivity was reduced in group III (QUICKI: 0.33 +/- 0.01 and composite index: 3.44 +/- 0.54), compared with group II (0.38 +/- 0.01, P = 0.002 and 8.18 +/- 1.21, P = 0.0008), group I (0.38 +/- 0.01, P = 0.0008 and 8.91 +/- 1.34, P = 0.00001), and healthy controls (0.37 +/- 0.008, P = 0.009). When other nadir GH cut-offs were analyzed, insulin sensitivity remained relatively reduced in the elevated IGF-I group. IGF-I was a significant predictor for decreasing insulin sensitivity as calculated by QUICKI (r = 0.6, P < 0.0001) independently of nadir GH. Signs and symptom scores were higher in group III (mean 38.5 +/- 3.6%), compared with group II (mean 23.5 +/- 3.2%, P = 0.004) and group I (mean 20.5 +/- 3.7%, P = 0.0008) but not between the latter two groups. Our data indicate that overall and specifically in the presence of discordant serum IGF-I and nadir GH levels, IGF-I was more predictive than GH levels of insulin sensitivity and clinical symptom score in patients with acromegaly.     

Basal and Glucose-Suppressed GH Levels Less Than 1 μg/L in Newly Diagnosed Acromegaly

The development of highly sensitive and specific GH assays has necessitated a critical re-evaluation of the biochemical criteria needed for the diagnosis of acromegaly. Use of these assays has revealed that GH levels after oral glucose in healthy subjects and postoperative patients with active acromegaly can be significantly less than previously recognized with older GH assays. In order to assess GH criteria for newly diagnosed acromegaly with a modern assay we have evaluated GH levels in 25 patients referred to our Neuroendocrine Unit for evaluation of untreated acromegaly. All patients underwent measurement of basal GH and IGF-I levels and 15 of these patients also underwent oral glucose tolerance testing for GH suppression (OGTT). Basal GH levels were < 1.0 microg/L at diagnosis in 5 of these 25 patients. Nadir GH levels were less than 1 microg/L also in 5 of 15 patients, and as low as 0.42 microg/L. All patients had elevated IGF-I levels preoperatively and pathological confirmation of a GH secreting pituitary tumor at the time of transsphenoidal surgery. The clinical presentations of these patients was variable. Most patients presented with classical manifestations of acromegaly, but 3 of the 5 patients with low nadir GH values had only very subtle signs of acromegaly. Although most newly diagnosed patients have classically elevated GH levels and obvious clinical features of acromegaly, early recognition of disease may uncover patients with milder biochemical and clinical abnormalities. The diagnosis should not be discounted in patients who have elevated IGF-I levels, but have basal or nadir GH levels less than 1 microg/L. Conventional GH criteria for the diagnosis of acromegaly cannot be applied to the use of modern sensitive and specific GH assays.     

Long-term effects of depot long-acting somatostatin analog octreotide on hormone levels and tumor mass in acromegaly

The effects of a 12- to 24-month treatment with depot long-acting octreotide (OCT-LAR) on hormone profile, tumor mass, and clinical symptoms were reported in 36 patients with active acromegaly [GH, 34.2 +/- 5.6 microg/L; insulin-like growth factor I (IGF-I), 784.5 +/- 40.4 microg/L]. Fifteen patients were de novo whereas 21 had previously undergone unsuccessful surgery. Serum GH (P < 0.0001) and IGF-I levels (P < 0.0001) significantly decreased as early as after the first injection of OCT-LAR and progressively declined during the 12-24 months of treatment both in de novo and in operated patients. At the last follow-up, GH hypersecretion was controlled (< or =2.5 microg/L) in 69.4% whereas normal IGF-I levels were achieved in 61.1% of patients. GH and IGF-I suppression during OCT-LAR treatment was similar in de novo and operated patients as shown by nadir GH (2.3 +/- 0.6 vs. 2.2 +/- 0.6 microg/L) and IGF-I (323.1 +/- 34.9 vs. 275.5 +/- 33.0 microg/L), percent suppression of GH (92.7 +/- 2.0 vs. 85.9 +/- 3.3%) and IGF-I (57.4 +/- 4.9 vs. 61.5 +/- 4.6%), and prevalence of GH (73.3 vs. 76.2%) and IGF-I (53.3 vs. 71.4%) control. A decrease in tumor volume was observed in 12 of 15 de novo patients, whereas no shrinkage was detected in 4 of 9 operated patients. No patient had tumor reexpansion during OCT-LAR treatment. Significant clinical improvement was obtained in all patients; heart rate, systolic blood pressure, and diastolic blood pressure significantly decreased in the entire population. A mild but significant increase of blood glucose levels, followed by a decrease of serum insulin levels, was observed after 3 months of treatment: this effect subsided with treatment continuation. OCT-LAR treatment was well tolerated by most patients. In conclusion, long-term treatment with OCT-LAR was effective in controlling GH and IGF-I hypersecretion in most patients with acromegaly, when applied either as primary therapy or as adjunctive therapy after surgery. Tumor shrinkage was observed in de novo patients during OCT-LAR treatment, suggesting that it can be successfully applied as primary therapy in patients bearing invasive tumors, who are less likely to be cured after surgery.     

Gender- and age-related differences in the endocrine parameters of acromegaly

Acromegaly is a severe slow-developing disease associated with a poor prognosis for cardiovascular disease. To evaluate the impact of age and gender on the severity of the disease, 151 de novo patients with acromegaly (79 women, 72 men, age range 19-77 yr) were included in this open retrospective multi-center cohort study. Basal GH and IGF-I levels, GH response after glucose load and maximal tumor diameter at MRI were measured in all patients at diagnosis. Fasting GH levels and maximal tumor diameter were similar in women and men, while serum IGF-I levels were lower (664.9+/-24.9 vs 755.9+/-32 microg/l; p=0.02) and GH nadir after glucose load was higher (27.5+/-3.7 vs 18.5+/-2.2 microg/l; p=0.04) in women than in men. In both sexes, patients' age was negatively correlated with basal and nadir GH, IGF-I levels and tumor size; fasting GH levels were positively correlated with IGF-I levels and nadir GH after glucose. No interaction between age and gender was found on biochemical and morphological parameters. At diagnosis, elderly patients with acromegaly have lower GH and IGF-I levels, lower GH nadir after glucose load and smaller adenomas than young patients. Women have lower IGF-I levels but higher GH nadir after glucose load than men. These age and gender differences should be considered to appropriately evaluate the activity of acromegaly throughout a life-span.     

Acromegaly with apparently normal GH secretion: implications for diagnosis and follow-up

The biochemical diagnosis of acromegaly is conventionally based on elevated plasma GH levels that fail to suppress after an oral glucose load. We studied 16 newly diagnosed patients with acromegaly with normal mean plasma GH but elevated age and gender-adjusted plasma IGF-I concentrations (476 +/- 29 microg/liter, mean +/- SE). Plasma GH was sampled every 10 min for 24 h, and an oral glucose tolerance test was performed. The control group included 46 healthy subjects. All patients had 24-h mean GH values that overlapped with those of the healthy controls. Mean plasma GH was less than 2.5 microg/liter in 12 patients. Patients had higher 24-h nadir GH values than healthy controls (P < 0.001). During the oral glucose tolerance test, nadir plasma GH was less than 1 micro g/liter in eight patients. Plasma IGF-I normalized in 11 of 14 patients after transsphenoidal surgery. Four patients with normal IGF-I after transsphenoidal surgery were restudied. Mean and nadir GH decreased in all of them. In our experience in many patients with acromegaly, the diagnosis could be missed if only the existing GH-based criteria are used. Revised GH criteria in combination with plasma IGF-I should be used for the diagnosis and follow-up of acromegaly.