Sheehan's syndrome medical therapy: Difference between revisions

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==Medical Therapy==
==Medical Therapy==
*Treatment involves appropriate hormone replacement therapy, which must be taken for the rest of your life that results in significant improvement and reversal of not only the physical symptoms but also the [[psychological]] symptoms.<ref name="pmid27034575">{{cite journal |vauthors=Parikh R, Buch V, Makwana M, Buch HN |title=The price of a 15-year delay in diagnosis of Sheehan's syndrome |journal=Proc (Bayl Univ Med Cent) |volume=29 |issue=2 |pages=212–3 |year=2016 |pmid=27034575 |pmc=4790577 |doi= |url=}}</ref><ref name="pmid19697029">{{cite journal |vauthors=Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH |title=Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review) |journal=Ann. Hematol. |volume=89 |issue=3 |pages=305–8 |year=2010 |pmid=19697029 |doi=10.1007/s00277-009-0804-9 |url=}}</ref><ref name="pmid15921942">{{cite journal |vauthors=Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F |title=Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome |journal=Growth Horm. IGF Res. |volume=15 |issue=3 |pages=231–7 |year=2005 |pmid=15921942 |doi=10.1016/j.ghir.2005.03.005 |url=}}</ref><ref name="pmid9059561">{{cite journal |vauthors=Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM |title=Increased cerebrovascular mortality in patients with hypopituitarism |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=1 |pages=75–81 |year=1997 |pmid=9059561 |doi= |url=}}</ref><ref name="pmid12675508">{{cite journal |vauthors=Arafah BM |title=Medical management of hypopituitarism in patients with pituitary adenomas |journal=Pituitary |volume=5 |issue=2 |pages=109–17 |year=2002 |pmid=12675508 |doi= |url=}}</ref><ref name="pmid20719838">{{cite journal |vauthors=Grossman AB |title=Clinical Review#: The diagnosis and management of central hypoadrenalism |journal=J. Clin. Endocrinol. Metab. |volume=95 |issue=11 |pages=4855–63 |year=2010 |pmid=20719838 |doi=10.1210/jc.2010-0982 |url=}}</ref><ref name="pmid1986026">{{cite journal |vauthors=Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL |title=Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry |journal=J. Clin. Endocrinol. Metab. |volume=72 |issue=1 |pages=39–45 |year=1991 |pmid=1986026 |doi=10.1210/jcem-72-1-39 |url=}}</ref><ref name="pmid16584509">{{cite journal |vauthors=Arlt W, Rosenthal C, Hahner S, Allolio B |title=Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements |journal=Clin. Endocrinol. (Oxf) |volume=64 |issue=4 |pages=384–9 |year=2006 |pmid=16584509 |doi=10.1111/j.1365-2265.2006.02473.x |url=}}</ref><ref name="pmid17437510">{{cite journal |vauthors=Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM |title=Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=66 |issue=6 |pages=789–96 |year=2007 |pmid=17437510 |doi=10.1111/j.1365-2265.2007.02812.x |url=}}</ref><ref name="pmid4182323">{{cite journal |vauthors=Martin MM |title=Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication |journal=Arch. Intern. Med. |volume=123 |issue=4 |pages=409–16 |year=1969 |pmid=4182323 |doi= |url=}}</ref><ref name="pmid2019265">{{cite journal |vauthors=Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y |title=Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium |journal=Endocrinology |volume=128 |issue=5 |pages=2534–9 |year=1991 |pmid=2019265 |doi=10.1210/endo-128-5-2534 |url=}}</ref><ref name="pmid8015573">{{cite journal |vauthors=White PC |title=Disorders of aldosterone biosynthesis and action |journal=N. Engl. J. Med. |volume=331 |issue=4 |pages=250–8 |year=1994 |pmid=8015573 |doi=10.1056/NEJM199407283310408 |url=}}</ref>
*Treatment involves appropriate hormone replacement therapy, which must be taken for the rest of your life that results in significant improvement and reversal of not only the physical symptoms but also the [[psychological]] symptoms.<ref name="pmid27034575">{{cite journal |vauthors=Parikh R, Buch V, Makwana M, Buch HN |title=The price of a 15-year delay in diagnosis of Sheehan's syndrome |journal=Proc (Bayl Univ Med Cent) |volume=29 |issue=2 |pages=212–3 |year=2016 |pmid=27034575 |pmc=4790577 |doi= |url=}}</ref><ref name="pmid19697029">{{cite journal |vauthors=Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH |title=Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review) |journal=Ann. Hematol. |volume=89 |issue=3 |pages=305–8 |year=2010 |pmid=19697029 |doi=10.1007/s00277-009-0804-9 |url=}}</ref><ref name="pmid15921942">{{cite journal |vauthors=Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F |title=Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome |journal=Growth Horm. IGF Res. |volume=15 |issue=3 |pages=231–7 |year=2005 |pmid=15921942 |doi=10.1016/j.ghir.2005.03.005 |url=}}</ref><ref name="pmid9059561">{{cite journal |vauthors=Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM |title=Increased cerebrovascular mortality in patients with hypopituitarism |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=1 |pages=75–81 |year=1997 |pmid=9059561 |doi= |url=}}</ref><ref name="pmid12675508">{{cite journal |vauthors=Arafah BM |title=Medical management of hypopituitarism in patients with pituitary adenomas |journal=Pituitary |volume=5 |issue=2 |pages=109–17 |year=2002 |pmid=12675508 |doi= |url=}}</ref><ref name="pmid20719838">{{cite journal |vauthors=Grossman AB |title=Clinical Review#: The diagnosis and management of central hypoadrenalism |journal=J. Clin. Endocrinol. Metab. |volume=95 |issue=11 |pages=4855–63 |year=2010 |pmid=20719838 |doi=10.1210/jc.2010-0982 |url=}}</ref><ref name="pmid1986026">{{cite journal |vauthors=Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL |title=Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry |journal=J. Clin. Endocrinol. Metab. |volume=72 |issue=1 |pages=39–45 |year=1991 |pmid=1986026 |doi=10.1210/jcem-72-1-39 |url=}}</ref><ref name="pmid16584509">{{cite journal |vauthors=Arlt W, Rosenthal C, Hahner S, Allolio B |title=Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements |journal=Clin. Endocrinol. (Oxf) |volume=64 |issue=4 |pages=384–9 |year=2006 |pmid=16584509 |doi=10.1111/j.1365-2265.2006.02473.x |url=}}</ref><ref name="pmid17437510">{{cite journal |vauthors=Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM |title=Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=66 |issue=6 |pages=789–96 |year=2007 |pmid=17437510 |doi=10.1111/j.1365-2265.2007.02812.x |url=}}</ref><ref name="pmid4182323">{{cite journal |vauthors=Martin MM |title=Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication |journal=Arch. Intern. Med. |volume=123 |issue=4 |pages=409–16 |year=1969 |pmid=4182323 |doi= |url=}}</ref><ref name="pmid2019265">{{cite journal |vauthors=Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y |title=Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium |journal=Endocrinology |volume=128 |issue=5 |pages=2534–9 |year=1991 |pmid=2019265 |doi=10.1210/endo-128-5-2534 |url=}}</ref><ref name="pmid8015573">{{cite journal |vauthors=White PC |title=Disorders of aldosterone biosynthesis and action |journal=N. Engl. J. Med. |volume=331 |issue=4 |pages=250–8 |year=1994 |pmid=8015573 |doi=10.1056/NEJM199407283310408 |url=}}</ref><ref name="pmid11158009">{{cite journal |vauthors=Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A |title=Androgen deficiency in women with hypopituitarism |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=2 |pages=561–7 |year=2001 |pmid=11158009 |doi=10.1210/jcem.86.2.7246 |url=}}</ref><ref name="pmid16478814">{{cite journal |vauthors=Miller KK, Biller BM, Beauregard C, Lipman JG, Jones J, Schoenfeld D, Sherman JC, Swearingen B, Loeffler J, Klibanski A |title=Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study |journal=J. Clin. Endocrinol. Metab. |volume=91 |issue=5 |pages=1683–90 |year=2006 |pmid=16478814 |doi=10.1210/jc.2005-2596 |url=}}</ref>
'''ACTH deficiency:'''
'''ACTH deficiency:'''
*Cortisol deficiency is replaced with 15-25mg of hydrocortisone per day with increased doses in patients with severe deficiency, increased body weight and in times of surgery, illness, procedures and other stresses.
*Cortisol deficiency is replaced with 15-25mg of hydrocortisone per day with increased doses in patients with severe deficiency, increased body weight and in times of surgery, illness, procedures and other stresses.

Revision as of 17:00, 28 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Treatment involves appropriate hormone replacement therapy that results in complete recovery and reversal of symptoms.

Medical Therapy

ACTH deficiency:

  • Cortisol deficiency is replaced with 15-25mg of hydrocortisone per day with increased doses in patients with severe deficiency, increased body weight and in times of surgery, illness, procedures and other stresses.
  • Unfortunately, there is no established test to assess adequate hormonal replacement. Plasma ACTH measurement and serum/salivary/urinary cortisol values are all unreliable. So assessment of adequate hormonal replacement is based on clinical basis with Cushingoid features showing excessive replacement while symptoms of adrenal insufficiency suggesting insufficient hormonal replacement.
  • Glucocorticoid relacement can cause polyuria due to unmasking of underlying central diabetes insipidus.
  • Mineralocorticoids are rarely required as aldosterone secretion is primarily regulated by angiotensin II and potassium not by ACTH.

TSH deficiency:

  • In patients with combined hypothyroidism and hypocortisolism, glucocorticoids (physiologic doses and increased doses in stress) are replaced first than thyroid hormone replacement because treating the hypothyroidism alone by levothyroxine can worsen the severity of cortisol deficiency by increasing the clearance of cortisol. So, it is important to assess adrenal function first including corticotropin (ACTH) reserve before adminstering T4 (levothyroxine).
  • T4 (Levothyroxine) replacement therapy is usually started with  weight-based T4 dose of 1.6 mcg/kg.
  • American Thyroid Association (ATA) recommends dose adjustment to keep serum free T4 concentration in upper half of reference range.

LH and FSH deficiency:

  • If fertility required:
    • Such women are offered ovulation induction. Pregnancy can be made possible by giving exogenous gonadotropins or pulsatile GnRH.
    • Women with GnRH deficiency can be offered either pulsatile GnRH or gonadotropin therapy
    • Women with gonadotropin deficiency are given gonadotropins only
  • If fertility not required:
    • Such women are treated with estrogen-progestin replacement therapy by using the traditional regimen  of estradiol on days 1 through 25 of each month and progesterone on days 16 through 25 of each month
    • Another regimen includes continuous transdermal estradiol throughout the month, with progestin added days 1 to 10 of the calendar month

Androgens replacement:

  • Androgens can be given to females having low libido.[15]
  • DDAVP is the treatment of choice for patients with DI.[16]
  • GH is replaced on case to case basis starting with a low dose(0.1-0.3mg/day) and titrated upwards by 0.1mg/d/month with repeated measurement of hormone levels every month initially for the first 6 months followed by yearly measurements and is replaced once all other hormones have been replaced.[17]

Medical Therapy

  1. ↑ Parikh R, Buch V, Makwana M, Buch HN (2016). "The price of a 15-year delay in diagnosis of Sheehan's syndrome". Proc (Bayl Univ Med Cent). 29 (2): 212–3. PMC 4790577. PMID 27034575.
  2. ↑ Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH (2010). "Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review)". Ann. Hematol. 89 (3): 305–8. doi:10.1007/s00277-009-0804-9. PMID 19697029.
  3. ↑ Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F (2005). "Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome". Growth Horm. IGF Res. 15 (3): 231–7. doi:10.1016/j.ghir.2005.03.005. PMID 15921942.
  4. ↑ Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM (1997). "Increased cerebrovascular mortality in patients with hypopituitarism". Clin. Endocrinol. (Oxf). 46 (1): 75–81. PMID 9059561.
  5. ↑ Arafah BM (2002). "Medical management of hypopituitarism in patients with pituitary adenomas". Pituitary. 5 (2): 109–17. PMID 12675508.
  6. ↑ Grossman AB (2010). "Clinical Review#: The diagnosis and management of central hypoadrenalism". J. Clin. Endocrinol. Metab. 95 (11): 4855–63. doi:10.1210/jc.2010-0982. PMID 20719838.
  7. ↑ Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL (1991). "Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry". J. Clin. Endocrinol. Metab. 72 (1): 39–45. doi:10.1210/jcem-72-1-39. PMID 1986026.
  8. ↑ Arlt W, Rosenthal C, Hahner S, Allolio B (2006). "Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements". Clin. Endocrinol. (Oxf). 64 (4): 384–9. doi:10.1111/j.1365-2265.2006.02473.x. PMID 16584509.
  9. ↑ Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM (2007). "Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency". Clin. Endocrinol. (Oxf). 66 (6): 789–96. doi:10.1111/j.1365-2265.2007.02812.x. PMID 17437510.
  10. ↑ Martin MM (1969). "Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication". Arch. Intern. Med. 123 (4): 409–16. PMID 4182323.
  11. ↑ Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y (1991). "Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium". Endocrinology. 128 (5): 2534–9. doi:10.1210/endo-128-5-2534. PMID 2019265.
  12. ↑ White PC (1994). "Disorders of aldosterone biosynthesis and action". N. Engl. J. Med. 331 (4): 250–8. doi:10.1056/NEJM199407283310408. PMID 8015573.
  13. ↑ Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A (2001). "Androgen deficiency in women with hypopituitarism". J. Clin. Endocrinol. Metab. 86 (2): 561–7. doi:10.1210/jcem.86.2.7246. PMID 11158009.
  14. ↑ Miller KK, Biller BM, Beauregard C, Lipman JG, Jones J, Schoenfeld D, Sherman JC, Swearingen B, Loeffler J, Klibanski A (2006). "Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study". J. Clin. Endocrinol. Metab. 91 (5): 1683–90. doi:10.1210/jc.2005-2596. PMID 16478814.
  15. ↑ Matsuzaki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata T, Kumasawa K, Yoshino K, Kimura T (2017). "A case of acute Sheehan's syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage". BMC Pregnancy Childbirth. 17 (1): 188. doi:10.1186/s12884-017-1380-y. PMC 5471854. PMID 28615049.
  16. ↑ Soares DV, Conceição FL, Vaisman M (2008). "[Clinical, laboratory and therapeutics aspects of Sheehan's syndrome]". Arq Bras Endocrinol Metabol (in Portuguese). 52 (5): 872–8. PMID 18797595.
  17. ↑ Tessnow AH, Wilson JD (2010). "The changing face of Sheehan's syndrome". Am. J. Med. Sci. 340 (5): 402–6. doi:10.1097/MAJ.0b013e3181f8c6df. PMID 20944496.

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