IGF-1 and GH are important assays used for the diagnosis of acromegaly. Normal IGF1 excludes acromegaly. In acromegalic patients after surgery, a hypointense T2-weighted MRI signal is associated with a better response to SSA treatment (Puig-Domingo M, et al. J Clin Endocrinol Metab. 2010;95(11):4973-8). Surgery is associated with a remission rate of 0.66 vs. medical treatment. Cavernous sinus invasion indicates unresectability. Surgical debulking is recommended. It improves response to somatostatin receptor ligand (SRL) therapy. Medical therapies for acromegaly – SRLs; Growth hormone receptor antagonist (GHRA); Dopamine agonists (for patients unresponsive to SRLs or as an adjunct to SRL therapy); Combination therapy (SRL and pegvisomant, cabergoline and SRL, cabergoline and pegvisomant, estrogens or selective estrogen receptor modulators and cabergoline or SRL). SRLs have 56% response for GH and 55% for IGF-1 control across studies. Dose titration increases responsiveness by 20%. Extend dosing interval after IGF-1 stabilizes. With GHRA therapy, tumor growth is a concern. Caution should be exercised with tumors near optic chiasm.