Treatment of hypopituitarism
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
Treatment of patients with hypopituitarism is the sum of the treatments of each of the individual pituitary hormonal deficiencies detected when a patient with a pituitary or hypothalamic disease is tested. The treatments of adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) deficiencies are in many ways the same as the treatments of primary deficiencies of the respective target glands, but in other ways they differ. Both the similarities and differences will be highlighted below. Treatment of growth hormone (GH) deficiency is unique to hypopituitarism.
The specifics of therapy for hypopituitarism will be reviewed here. The causes, clinical manifestations, and diagnosis of hypopituitarism, as well as GH deficiency in adults and the management of individual hormone deficiencies, are reviewed in more detail elsewhere. (See "Causes of hypopituitarism" and "Clinical manifestations of hypopituitarism" and "Diagnosis of hypopituitarism" and "Growth hormone deficiency in adults".)
IMPORTANCE OF TREATMENT
One reason to optimize treatment is that in a retrospective study of 344 patients who had hypopituitarism after pituitary surgery, the long-term mortality was about double that of the general population . Most of the excess mortality was due to cerebrovascular disease. The relationship between the hypopituitarism and the excess mortality remains unknown, and we do not know if even optimal treatment will improve mortality.
The primary consequence of lack of adrenocorticotropic hormone (ACTH) is cortisol deficiency. As a result, treatment consists of the administration of hydrocortisone or other glucocorticoid in an amount and timing to mimic the normal pattern of cortisol secretion. Because there is no test to assess the adequacy of the replacement, the optimal replacement glucocorticoid and the optimal doses are not known. Most authorities recommend replacement with hydrocortisone because that is the hormone the adrenal glands make normally, but others prefer prednisone or dexamethasone for their longer durations of action.
Preparation and dose — Most authorities recommend hydrocortisone doses of 15 to 25 mg/day [2,3] because those doses are similar to daily production rates . Patients who are more severely deficient or weigh more tend to need doses at the upper end of this range and vice versa. Some patients, however, need even larger doses to avoid severely symptomatic adrenal insufficiency, and others can get by on smaller amounts.
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- Miller KK, Biller BM, Beauregard C, et al. Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab 2006; 91:1683.
- Powe CE, Allen M, Puopolo KM, et al. Recombinant human prolactin for the treatment of lactation insufficiency. Clin Endocrinol (Oxf) 2010; 73:645.
- IMPORTANCE OF TREATMENT
- ACTH DEFICIENCY
- Preparation and dose
- - Assessment of dose adequacy
- Subjective health status
- Unmasking diabetes insipidus
- Need for mineralocorticoid coverage
- Adrenal androgen replacement
- TSH DEFICIENCY
- LH AND FSH DEFICIENCY
- - Androgen replacement
- GROWTH HORMONE DEFICIENCY
- PROLACTIN DEFICIENCY
- INFORMATION FOR PATIENTS