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 corticotropin (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 "Diagnostic testing for 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 corticotropin (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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bülow B, Hagmar L, Mikoczy Z, et al. Increased cerebrovascular mortality in patients with hypopituitarism. Clin Endocrinol (Oxf) 1997; 46:75.
- Arafah BM. Medical management of hypopituitarism in patients with pituitary adenomas. Pituitary 2002; 5:109.
- Grossman AB. Clinical Review#: The diagnosis and management of central hypoadrenalism. J Clin Endocrinol Metab 2010; 95:4855.
- Esteban NV, Loughlin T, Yergey AL, et al. Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry. J Clin Endocrinol Metab 1991; 72:39.
- Arlt W, Rosenthal C, Hahner S, Allolio B. Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements. Clin Endocrinol (Oxf) 2006; 64:384.
- Thomson AH, Devers MC, Wallace AM, et al. Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2007; 66:789.
- Hahner S, Loeffler M, Fassnacht M, et al. Impaired subjective health status in 256 patients with adrenal insufficiency on standard therapy based on cross-sectional analysis. J Clin Endocrinol Metab 2007; 92:3912.
- Martin MM. Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication. Arch Intern Med 1969; 123:409.
- Shibata H, Ogishima T, Mitani F, et al. Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium. Endocrinology 1991; 128:2534.
- White PC. Disorders of aldosterone biosynthesis and action. N Engl J Med 1994; 331:250.
- Miller KK, Sesmilo G, Schiller A, et al. Androgen deficiency in women with hypopituitarism. J Clin Endocrinol Metab 2001; 86:561.
- 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