Sheehan's syndrome medical therapy: Difference between revisions
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*[[Mineralocorticoids]] are rarely required as [[aldosterone]] secretion is primarily regulated by [[angiotensin II]] and [[potassium]] not by [[Adrenocorticotropic hormone|ACTH]]. | *[[Mineralocorticoids]] are rarely required as [[aldosterone]] secretion is primarily regulated by [[angiotensin II]] and [[potassium]] not by [[Adrenocorticotropic hormone|ACTH]]. | ||
'''TSH deficiency:''' | '''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|cortiso]]<nowiki/>l deficiency by increasing the [[Clearance (medicine)|clearance]] of cortisol. So, it is important to assess adrenal function first including corticotropin (ACTH) reserve before adminstering T4 (levothyroxine). | *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|cortiso]]<nowiki/>l deficiency by increasing the [[Clearance (medicine)|clearance]] of [[cortisol]]. So, it is important to assess [[adrenal]] function first including [[corticotropin]] ([[Adrenocorticotropic hormone|ACTH]]) reserve before adminstering [[T4]] ([[levothyroxine]]). | ||
*T4 (Levothyroxine) replacement therapy is usually started with | *[[T4]] ([[Levothyroxine]]) replacement therapy is usually started with [[Weight|weigh]]<nowiki/>t-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. | *American Thyroid Association (ATA) recommends dose adjustment to keep serum free T4 concentration in upper half of reference range. | ||
'''LH and FSH deficiency:''' | '''LH and FSH deficiency:''' | ||
Revision as of 18:55, 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
- 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.[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
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 replacement can cause polyuria due to unmasking of underlying central diabetes insipidus. DDAVP is the treatment of choice for patients with DI.[15]
- 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.[16]
Growth hormone replacement:
- 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]
Prolactin deficiency:
- A study was done on 5 women with prolactin deficiency caused by Sheehan syndrome or other causes that showed increased milk production upon subcutaneous administration of r-hPRL every 12 hours for 28 days.[18]
Medical Therapy
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Arafah BM (2002). "Medical management of hypopituitarism in patients with pituitary adenomas". Pituitary. 5 (2): 109–17. PMID 12675508.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Martin MM (1969). "Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication". Arch. Intern. Med. 123 (4): 409–16. PMID 4182323.
- ↑ 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.
- ↑ White PC (1994). "Disorders of aldosterone biosynthesis and action". N. Engl. J. Med. 331 (4): 250–8. doi:10.1056/NEJM199407283310408. PMID 8015573.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Powe CE, Allen M, Puopolo KM, Merewood A, Worden S, Johnson LC, Fleischman A, Welt CK (2010). "Recombinant human prolactin for the treatment of lactation insufficiency". Clin. Endocrinol. (Oxf). 73 (5): 645–53. doi:10.1111/j.1365-2265.2010.03850.x. PMID 20718766.