Contexto: la pasireotida ha demostrado eficacia en el tratamiento de pacientes con enfermedad de Cushing y acromegalia; sin embargo, es frecuente que los pacientes tratados con pasireotida presenten hiperglucemia.

Objetivo: proporcionar lineamientos y recomendaciones en Colombia para el control y el manejo de hiperglucemia secundaria a pasireotida en pacientes con enfermedad de Cushing y acromegalia.

Metodología: se utilizó la metodología de panel de expertos. Previo al panel se hizo una revisión de la evidencia disponible para las preguntas de interés formuladas por especialistas en Endocrinología, la cual fue actualizada posterior a la reunión. Participaron especialistas de diferentes zonas del país, quienes discutieron las preguntas y formularon recomendaciones para el control y el tratamiento de la hiperglucemia secundaria a pasireotida en enfermedad de Cushing y acromegalia.

Resultados: se formularon 16 recomendaciones para el control y manejo de la hiperglucemia secundaria al uso de pasireotida en pacientes con enfermedad de Cushing y 7 para pacientes con acromegalia. Las recomendaciones fueron formuladas y validadas por un panel de expertos, a partir de evidencia y de su experiencia clínica.

Conclusiones: es frecuente que pacientes con acromegalia o enfermedad de Cushing tratados con pasireotida presenten alteraciones en el metabolismo de la glucosa como consecuencia de la terapia. Existe poca evidencia de alto nivel para la formulación de recomendaciones para el manejo de la hiperglucemia secundaria al uso de pasireotida en ambas patologías, aquí las recomendaciones generadas fueron con base en opinión de expertos y son las primeras publicadas para Colombia.

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Henry RR, Ciaraldi TP, Armstrong D, Burke P, Ligueros-Saylan M, Mudaliar S. Hyperglycemia associated with pasireotide: Results from a mechanistic study in healthy volunteers. J Clin Endocrinol Metab. 2013;98(8):3446–53.

Kumar U, Sasi R, Suresh S, Patel A, Thangaraju M, Metrakos P, et al. Subtype-selective expression of the five somatostatin receptors (hSSTR1-5) in human pancreatic islet cells: a quantitative double-label immunohistochemical analysis. Diabetes. 1999 Jan;48(1):77–85.

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Reznik Y, Bertherat J, Borson-chazot F, Brue T, Chanson P, Cortet-rudelli C. Management of hyperglycaemia in Cushing ’ s disease?: Experts ’ proposals on the use of pasireotide. Diabetes Metab. 2013;39(1):34–41.

Colao A, Block C De, Sonia M, Sudhesh G, Seufert J, Casanueva FF. Managing hyperglycemia in patients with Cushing ’ s disease treated with pasireotide?: medical expert recommendations. Pituitary. 2014;17:180–6.

Lindholm J, Juul S, Jørgensen JOL, Astrup J, Bjerre P, Feldt-Rasmussen U, et al. Incidence and Late Prognosis of Cushing’s Syndrome: A Population-Based Study 1. J Clin Endocrinol Metab. 2001 Jan;86(1):117–23.

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Faggiano A, Pivonello R, Spiezia S, De Martino MC, Filippella M, Di Somma C, et al. Cardiovascular risk factors and common carotid artery caliber and stiffness in patients with Cushing’s disease during active disease and 1 year after disease remission. J Clin Endocrinol Metab. 2003 Jun;88(6):2527–33.

Mancini T, Kola B, Mantero F, Boscaro M, Arnaldi G. High cardiovascular risk in patients with Cushing’s syndrome according to 1999 WHO/ISH guidelines. Clin Endocrinol (Oxf). 2004 Dec;61(6):768–77.

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Enfermedad de Cushing
Acromegalia
Hiperglucemia
Pasireotide

Introducción: los inhibidores de punto de control inmunitario (IPCI) han revolucionado el tratamiento de los pacientes con cáncer, incrementando la supervivencia libre de enfermedad y son terapias con aval para el manejo de neoplasias sólidas. Entre los eventos adversos frecuentes se encuentran los que ocurren a nivel del sistema endocrino y se reporta el caso de una paciente tratada con anti CTLA-4 y anti PD-1 que desarrolló hipofisitis y adrenalitis.

Objetivo: describir el caso de una paciente que presentó endocrinopatías (hipofisitis y adrenalitis) asociadas al uso de IPCI, en una clínica en la ciudad de Medellín, Colombia.

Presentación del caso: mujer de 74 años con antecedente de carcinoma de células renales tratada con ipilimumab y nivolumab, suspendidos por neumonitis. Tres meses después acudió a urgencias por disminución de clase funcional y somnolencia, el examen físico mostró hipotensión y se evidenció hiponatremia, hipotónica y cortisol basal disminuido. Por ello, se solicitó perfil hipofisario, encontrando somatomedina y hormona folículo estimulante (FSH) bajas y hormona adrenocorticotropa ACTH elevada, además, se realizó resonancia de silla turca sin alteración estructural y se concluyó hipofisitis con imagen normal e insuficiencia adrenal primaria secundaria a adrenalitis.

Discusión y conclusión: los inhibidores del punto de control inmunitario son medicamentos actualmente utilizados para diferentes tipos de neoplasias, estos medicamentos se asocian en un porcentaje significativo con endocrinopatías, sin embargo, encontrar la afectación de dos glándulas endocrinas es inusual, este es el segundo caso reportado en la literatura con hipofisitis y adrenalitis.

Se deben reconocer las manifestaciones clínicas de las endocrinopatías asociadas a la inmunoterapia, teniendo en cuenta el uso creciente de estas terapias para diferentes neoplasias. El compromiso de más de una glándula endocrina es infrecuente, sin embargo, se debe sospechar y reconocer. Además, es importante establecer en cada centro un protocolo para el abordaje y el seguimiento de estos pacientes.

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hipófisis
hipofisitis
adrenalitis
inmunoterapia
silla turca

Contexto: La osteosarcopenia es un nuevo síndrome geriátrico con graves consecuencias en el anciano. Se ha descrito su relación con el riesgo de caídas, fracturas, dependencia funcional y mortalidad. Se define como la coexistencia de baja masa mineral ósea u osteoporosis y sarcopenia. Desde hace varios años estas condiciones clínicas en el adulto mayor han sido diagnosticadas y tratadas por separado, sin embargo, es claro que los mejores resultados se evidencian realizando diagnóstico e intervención en conjunto. En Colombia no existe información científica que estudie o describa este fenotipo en nuestra población de adultos mayores.

Objetivo: El objetivo principal de esta revisión es realizar una descripción del fenotipo denominado osteosarcopenia, los mecanismos fisiopatológicos, factores de riesgo y las implicaciones clínicas de esta entidad en la población adulta mayor, así como describir lo que se conoce en la actualidad acerca de su diagnóstico, tratamiento e intervenciones.

Metodología: se realizó una búsqueda no sistemática de la literatura en osteosarcopenia, osteoporosis, osteopenia y sarcopenia, incluyendo literatura acerca de la epidemiología, fisiopatología y diagnóstico.

Resultados: la evidencia en osteosarcopenia es escasa, sin embargo, hay literatura creciente sobre el tema de interés, así como la relación de la osteoporisis y la sarcopenia por separado. Se logran reunir los conceptos más importantes de la actualidad.

Conclusiones: A pesar del impacto que tiene esta condición en los pacientes y el sistema de salud, aún se encuentra en progreso la búsqueda e intervención simultánea y sistémica de la osteoporosis/osteopenia asociada a sarcopenia.

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osteosarcopenia
envejecimiento
sarcopenia
osteoporosis
anciano
adultos mayores

Contexto: el manejo de los pacientes con acromegalia actualmente incluye cirugía, radioterapia y terapia farmacológica. Aunque la cirugía es el tratamiento de primera línea, un gran porcentaje de pacientes van a requerir manejo adicional con radioterapia y farmacoterapia.

Objetivo: revisar las características farmacológicas y los estudios clínicos de pegvisomant.

Metodología: se revisaron las bases de datos electrónicas como Medline y Pubmed con el término pegvisomant y se analizaron los estudios clínicos y los datos relevantes de este medicamento en el manejo de acromegalia.

Resultados: los análogos de somatostatina constituyen el tratamiento farmacológico de primera línea indicado en las guías de práctica la de esta entidad, no obstante, estudios recientes han reportado niveles muy variables de control de la enfermedad. Para lograr un mejor control se introdujo el pegvisomant, un análogo de la hormona de crecimiento que se une al receptor pero no induce cambios conformacionales para la transducción de señales y, por tanto, no inhibe la secreción de la hormona de crecimiento, sino sus efectos fisiológicos en los tejidos diana. Hasta la fecha, ha demostrado eficacia para normalizar los niveles séricos del IGF-1 tanto en monoterapia como en terapia combinada.

Conclusiones: si no logramos el control de la enfermedad a pesar de estos medicamentos, debemos considerar terapias de segunda línea como pasireotide o pegvisomant. Las características clínicas individuales del paciente permitirán elegir cuál es la mejor opción para nuestros pacientes. El pegvisomant es un medicamento eficaz para el control del paciente con acromegalia.

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pegvisomant
acromegalia
antagonista de GH
IGF-1
lanreotide
octreotide
pasireotide

Contexto. La disfunción tiroidea y la diabetes mellitus se consideran dos de los desórdenes endocrinos más frecuentes en la población mundial y por ende en la práctica clínica. La diabetes y las enfermedades de la glándula tiroides están muy relacionadas entre sí. (1) 

Objetivo. Determinar la prevalencia de disfunciones tiroideas en pacientes con diabetes mellitus tipo 2 en diferentes regiones del mundo a través de una revisión sistemática de la evidencia disponible en la actualidad.

Metodología. Se realizó una revisión sistemática de estudios que estiman la prevalencia de disfunciones tiroideas en pacientes diagnosticados con Diabetes Mellitus tipo 2. Se llevó a cabo conforme a las recomendaciones del Preferred Reporting Ítems for Systematic Reviews and Meta-Analyses (PRISMA).  A partir de 55 artículos inicialmente identificados se pudieron incluir en este estudio 16, que corresponde a un 32% de los mismos. Los artículos seleccionados en su mayoría fueron escritos en idioma inglés, el 25% de estos estudios fueron realizados en India (4/16) y la base de datos que más contribuyó fue PubMed (93%). Los artículos seleccionados fueron en su mayoría estudios de tipo transversal, con un tamaño de muestra que va desde 50 hasta 1677 participantes.

Resultados. Se encontró una prevalencia de disfunción tiroidea con alta variabilidad que va desde 8,4% a 48%, con predominio en el sexo femenino, en personas mayores de 50 años y en aquellos con control glucémico deficiente.

Conclusiones. La disfunción tiroidea representa un grupo de afecciones frecuentes en pacientes con diabetes mellitus tipo 2 que puede tener una prevalencia variada, identificada en diferentes estudios que alcanzan a medir variables de género, diagnóstico y progresión de la disfunción.

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Disfunción tiroidea
Diabetes mellitus
Hipertiroidismo
hipotiroidismo
hormonas tiroideas