AACE Clinical Conversation Series

The presence of benign tumors or adenomas in the anterior lobe of the pituitary gland may lead to a variety of endocrine symptoms and aberrant secretion of growth hormone (GH). Hypersecretion of GH in response to an adenoma results in acromegaly or gigantism, a condition observed in adults and associated with significant morbidity and mortality.

The primary goal for treating acromegaly is to reduce GH production to normal levels. Traditionally, transphenoidal neurosurgery, to excise the pituitary tumors that are causing excess GH secretion, has been considered first-line treatment. However, as medical treatment options have improved, especially as somatostatin analogues have become available and been refined, researchers have started to consider the potential benefits of using first-line pharmacologic treatment in some patients with acromegaly. Whereas, dopamine agonists were considered an inferior option to neurosurgery, treatment with somatostatin analogues seems promising. Given the fact that remnants of tumors often remain after surgery, there are numerous situations in which primary or adjuvant therapy with a somatostatin analogue may be indicated.

In this conversation, two endocrinologists, Dr. David M. Cook and Dr. Lawrence Katznelson, join Dr. Carlos Hamilton, Jr. to discuss the therapeutic goals for acromegaly.

Hypersecretion of growth hormone (GH) in response to an adenoma results in acromegaly or gigantism, a condition observed in adults and associated with significant morbidity and mortality. The estimated prevalence of acromegaly in the US is approximately 15,000 people, with men and women being equally affected.

Onset of symptoms of acromegaly is insidious and generally occurs between the ages of 40 and 60. Telltale physical signs include enlarged hands, feet, nose, and lips, as well as increased sweating, fatigue, and joint pain. Biochemically, acromegaly is associated with excessively high levels of circulating GH and insulin-like growth factor I (IGF-I).

GH-related disorders may be difficult to diagnose without a sound understanding of the underlying endocrinologic pathology. Affected patients who are not diagnosed or properly treated are at risk for increased morbidity and mortality, decreased quality of life, and potentially related psychosocial challenges.

In this conversation, two endocrinologists, Dr. David M. Cook and Dr. Lawrence Katznelson, join Dr. Carlos Hamilton, Jr. to discuss the clinical features, comorbidities and diagnosis of acromegaly.

Insulin-like growth factor 1 (IGF-1) is a potent growth and differentiation factor. It stimulates the multiple processes leading to statural growth and is normally secreted in response to stimulation by growth hormone (GH). IGF-1 deficiency (IGFD) can be caused by abnormalities of either the GH receptor or the GH signaling pathway. Though GH exerts direct effects on target tissues, many of its physiologic effects are mediated indirectly through IGF-1. Because IGF-1 is a critical factor in the growth of children, the availability of recombinant IGF-1 (rhIGF-1) has dramatically changed the long-term prognosis for children with IGFD.

In this conversation, two pediatric endocrinology specialists, Dr. Naomi Neufeld and Dr. Paul Saenger, join Dr. Carlos Hamilton, Jr. to discuss current issues surrounding the role of IGF-1 in the treatment of growth failure.

Within the last decade, there have been major advances in the understanding of growth hormone deficiency and its impact on stature, especially short stature. Experts suggest that up to 75% of the cases of growth hormone (GH) deficiency may be reversible. Physicians and endocrinologists now recognize that the growth effects of GH are mediated by a substance called insulin-like growth factor 1 (IGF-1). IGF-1, a potent growth and differentiation factor, stimulates the multiple processes leading to statural growth and is normally secreted in response to stimulation by GH.

In this conversation, two pediatric endocrinology specialists, Dr. Naomi Neufeld and Dr. Paul Saenger, join Dr. Carlos Hamilton, Jr. to discuss current issues surrounding the evaluation and treatment of growth failure in children.

Diabetes, hypertension, and hyperlipidemia are interrelated disorders conferring an increased risk of vascular events and endothelial dysfunction. Patients with type 2 diabetes (T2DM) are often diagnosed with some form of cardiovascular disease (CVD) such as myocardial infarction, atrial fibrillation, heart failure, peripheral arterial disease, and coronary artery disease. Evidence from randomized controlled clinical trials points to the need for comprehensive risk management and aggressive treatment for patients with concomitant diabetes and CVD.

In this conversation, three endocrinologists, Dr. Paul Jellinger, Dr. Joseph Torre and Dr. Vijay Nambi, join Dr. Carlos Hamilton, Jr. to discuss current issues primarily surrounding the prevention of vascular complications in diabetic patients.

In diabetic patients, the presence of one or more of cardiovascular disease (CVD) conditions such as myocardial infarction, heart failure, peripheral arterial disease, or coronary artery disease, increases their risk of developing renal compromise and eventual renal failure. Patients with diabetes and end stage renal disease (ESRD) have a very poor prognosis, and despite the availability of dialysis, most die prematurely of cardiovascular disease (DVD). Diligent and consistent monitoring and appropriate interventions are required to delay progression of renal disease and to forestall cardiovascular and renal events.

In this conversation, two endocrinologists, Dr. Joseph Torre and Dr. Addison Taylor, join Dr. Carlos Hamilton, Jr. to discuss current issues surrounding the effects of renal disease in the management of diabetes.

It is estimated that 25% of the US population have 3 or more clustered risk factors for the development of cardiovascular disease (CVD), including obesity, insulin resistance, sedentary lifestyle, smoking, excessive use of alcohol, and hyperlipidemia. These risk factors are even more prevalent in persons with co-existing hypertension and type 2 diabetes mellitus (T2DM). A simple paradigm suggests that inflammatory conditions increase insulin resistance contributing to obesity and leading to T2DM, hypertension, prothrombic derangements, and dyslipidemia. Reducing risk factors for CVD in persons with T2DM is a formidable task for clinicians and patients, requiring the administration of multiple medications, close monitoring and good communication.

In this conversation, three endocrinologists, Dr. Paul Jellinger, Dr. Joseph Torre and Dr. Vijay Nambi, join Dr. Carlos Hamilton, Jr. to discuss current issues primarily surrounding the non-pharmacological management and control of hyperlipidemia in diabetic patients.

Hypertension is a critical risk factor in the development of macrovascular and microvascular complications in diabetic patients. The task of controlling blood pressure is challenged by recommendations for lower blood pressure goals, and the need for long-term use of a regimen of two or more antihypertensive agents. Moreover, there is still some controversy regarding the optimal antihypertensive agents to use in patients with diabetes.

In this conversation, two endocrinologists, Dr. Joseph Torre and Dr. Addison Taylor, join Dr. Carlos Hamilton, Jr. to discuss current issues surrounding the management of hypertension in diabetic patients.

Almost 1/3 of all hospitalized patients and 2/3 of critically ill patients have hyperglycemia or diabetes. In the inpatient setting, insulin is the best management option, in lieu of hypoglycemic agents, which are often contraindicated. Tight glycemic control should be an ongoing goal in this population.

In this conversation, two diabetes experts, Dr. Andrew Ahmann and Dr. Etie Moghissi, join Dr. Carlos Hamilton to discuss overcoming barriers to glucose control in the inpatient setting.

Controlling hyperglycemia in the inpatient setting should be a multidisciplinary team effort, with medical and nursing staffs, the pharmacy, and the patient all playing key roles.

In this conversation, two diabetes experts, Dr. Andrew Ahmann and Dr. Etie Moghissi, join Dr. Carlos Hamilton to discuss issues related to optimizing glycemic control in the inpatient setting.

New treatment agents for type 2 diabetes include drugs from the following classes: the incretin mimetics, the DPP-4 inhibitors, and snew long-acting insulin.

In this conversation, two diabetes experts, Dr. Brian Tulloch and Dr. Naveed Igbal, join Dr. Carlos Hamilton to discuss the role of these new therapies in the management of diabetes.

Tight glycemic control benefits patients in inpatient and outpatient settings. Insulin regimens comprised of long-acting insulins as the foundation, combined with short-acting and inhaled insulins at mealtimes, as well as premixed analog insulins, can help achieve target glycohemoglobin levels of 6.5% or lower.

In this conversation, two diabetes experts, Dr. Alan Garber and Dr. Glenn Cunningham, join Dr. Carlos Hamilton to discuss current issues regarding insulin therapy.

Achieving optimal glycemic control involves monitoring blood glucose levels, advising on lifestyle modificaiton, and instituting pharmacologic intervention. Metformin and the thiazolidenediones are clinically proven first-line treatment agents for at-risk patients. Eventually, most patients will require insulin to achieve glycemic control.
In this conversation, two diabetes experts, Dr. Brian Tulloch and Dr. Naveed Iqbal, join Dr. Carlos Hamilton to discuss issues related to educating newly diagnosed patients with diabetes.

Treatment of type 2 diabetes begins with efforts to improve lifestyle factors, including diet and exercise. However, the majority of patients with type 2 diabetes will require medication over the course of their diabetes.In this conversation, two diabetes experts, Dr Alan Garber and Dr Glenn Cunningham, join Dr Carlos Hamilton to discuss current issues surrounding initial treatment for Type 2 diabetes mellitus.

In addition to lifestyle modifications, oral monotherapy is often initiated as first-line therapy in type 2 diabetes mellitus, however, its initial effectiveness commonly wanes over time, and HbA1c levels gradually climb.Join this conversation as Dr Carlos Hamilton, Dr Philip Orlander and Dr Dale Hamilton discuss treatment strategies in type 2 diabetic patients with recurring hyperglycemia.

Diabetes mellitus is a chronic condition that can lead to complications over time. The long-term complications of diabetes result from the effects of hyperglycemia on blood vessels, causing microvascular and macrovascular disease.In this program, Dr Carlos Hamilton, Dr Philip Orlander and Dr Dale Hamilton discuss the importance of maintaining optimal glycemic control in patients with type 1 or type 2 diabetes mellitus. Included in this discussion are optimal targets for blood glucose levels, issues related to glucose monitoring and a review of the long-term complications of hyperglycemia.

Current recommendations of the American Diabetes Association (ADA), which have been used predominantly in the United States, present goals for fasting/preprandial and bedtime glucose levels but do not define a target for postprandial glucose. The ADA guidelines also present a glycated hemoglobin (A1C) goal of <7%. The International Diabetes Federation (IDF) and the American College of Endocrinology (ACE) have each published guidelines that define targets for both fasting/preprandial and 2-h postprandial blood glucose and present 6.5% as their A1C goal for glycemic control.

Joining Dr Carlos Hamilton to discuss the importance of diet and weight management in diabetes care are Dr Eric Orzek and Dr Philip Levy, both clinical endocrinologist and specialist in the treatment of diabetes.