Hypopituitarism medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
*The mainstay of treatment for [disease name] is [therapy]. | *The mainstay of treatment for [disease name] is [therapy]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
| Line 35: | Line 34: | ||
*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]]. | ||
=== ''' | === '''Gonadotropin deficiency:''' === | ||
=== Men: === | |||
* Testosterone esters (for example, Sustanon'') 250 mg IM every 2–3 weeks'' | |||
* Transdermal testosterone | |||
** Patch (for example, Andropatch) 2.5–7.5 mg/24 hours | |||
** Gel (for example, Testogel) 5–10 g gel/24 hours | |||
* Testosterone implant 600–800 mg every 4–6 months | |||
* Buccal testosterone (for example, Striant SR) 1 buccal tablet (30 mg) applied to the gum every 12 hours | |||
* Oral testosterone (for example, Restandol) 40–120 mg daily | |||
=== Women: === | |||
* Conjugated equine oestrogens 0.625–1.25 mg daily orally | |||
or | |||
* Estradiol valerate 1–2 mg daily orally | |||
* Transdermal estradiol (patch) 25–100 μg/24 hours | |||
* Oestrogen plus progesterone (cyclical/continuous): Dose depends on preparation—orally or transdermal | |||
==== NOTE: ==== | |||
* '''If fertility required:''' | * '''If fertility required:''' | ||
** Such women are offered [[ovulation]] induction. [[Pregnancy]] can be made possible by giving [[exogenous]] [[gonadotropins]] or [[Gonadotropin-releasing hormone|pulsatile GnRH]]. | ** Such women are offered [[ovulation]] induction. [[Pregnancy]] can be made possible by giving [[exogenous]] [[gonadotropins]] or [[Gonadotropin-releasing hormone|pulsatile GnRH]]. | ||
| Line 45: | Line 63: | ||
** Another regimen includes continuous [[transdermal]] [[estradiol]] throughout the month, with [[progestin]] added days 1 to 10 of the calendar month. | ** Another regimen includes continuous [[transdermal]] [[estradiol]] throughout the month, with [[progestin]] added days 1 to 10 of the calendar month. | ||
=== '''Androgen replacement''' === | === '''Androgen replacement:''' === | ||
*[[Androgens]] can be given to females having low [[libido]].<ref name="pmid28615049">{{cite journal |vauthors=Matsuzaki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata T, Kumasawa K, Yoshino K, Kimura T |title=A case of acute Sheehan's syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage |journal=BMC Pregnancy Childbirth |volume=17 |issue=1 |pages=188 |year=2017 |pmid=28615049 |pmc=5471854 |doi=10.1186/s12884-017-1380-y |url=}}</ref> | *[[Androgens]] can be given to females having low [[libido]].<ref name="pmid28615049">{{cite journal |vauthors=Matsuzaki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata T, Kumasawa K, Yoshino K, Kimura T |title=A case of acute Sheehan's syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage |journal=BMC Pregnancy Childbirth |volume=17 |issue=1 |pages=188 |year=2017 |pmid=28615049 |pmc=5471854 |doi=10.1186/s12884-017-1380-y |url=}}</ref> | ||
=== '''Growth hormone replacement''' === | === '''Growth hormone replacement:''' === | ||
* Growth hormone 0.27–0.7 mg subcutaneously in the evening | |||
*[[Growth hormone|GH]] is replaced on case to case basis starting with a low dose (0.1-0.3 mg/day) and [[Titrate|titrated]] upwards by 0.1 mg/d/month with repeated measurement of [[hormone]] levels every month, initially for the first 6 months followed by yearly measurements; replaced once all other [[hormones]] have been replaced.<ref name="pmid20944496">{{cite journal |vauthors=Tessnow AH, Wilson JD |title=The changing face of Sheehan's syndrome |journal=Am. J. Med. Sci. |volume=340 |issue=5 |pages=402–6 |year=2010 |pmid=20944496 |doi=10.1097/MAJ.0b013e3181f8c6df |url=}}</ref> | *[[Growth hormone|GH]] is replaced on case to case basis starting with a low dose (0.1-0.3 mg/day) and [[Titrate|titrated]] upwards by 0.1 mg/d/month with repeated measurement of [[hormone]] levels every month, initially for the first 6 months followed by yearly measurements; replaced once all other [[hormones]] have been replaced.<ref name="pmid20944496">{{cite journal |vauthors=Tessnow AH, Wilson JD |title=The changing face of Sheehan's syndrome |journal=Am. J. Med. Sci. |volume=340 |issue=5 |pages=402–6 |year=2010 |pmid=20944496 |doi=10.1097/MAJ.0b013e3181f8c6df |url=}}</ref> | ||
=== '''Prolactin deficiency''' === | === ADH deficiency: === | ||
* Desmopressin 300–600 μg daily in 2–3 divided doses orally or 10–40 μg daily in 2–3 divided doses intranasally | |||
=== '''Prolactin deficiency:''' === | |||
* A study was done on 5 women with [[prolactin]] deficiency caused by Sheehan's syndrome or other causes that showed increased milk production upon [[subcutaneous]] administration of r-hPRL ([[recombinant]] human [[prolactin]]) every 12 hours for 28 days.<ref name="pmid20718766">{{cite journal |vauthors=Powe CE, Allen M, Puopolo KM, Merewood A, Worden S, Johnson LC, Fleischman A, Welt CK |title=Recombinant human prolactin for the treatment of lactation insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=73 |issue=5 |pages=645–53 |year=2010 |pmid=20718766 |doi=10.1111/j.1365-2265.2010.03850.x |url=}}</ref> | * A study was done on 5 women with [[prolactin]] deficiency caused by Sheehan's syndrome or other causes that showed increased milk production upon [[subcutaneous]] administration of r-hPRL ([[recombinant]] human [[prolactin]]) every 12 hours for 28 days.<ref name="pmid20718766">{{cite journal |vauthors=Powe CE, Allen M, Puopolo KM, Merewood A, Worden S, Johnson LC, Fleischman A, Welt CK |title=Recombinant human prolactin for the treatment of lactation insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=73 |issue=5 |pages=645–53 |year=2010 |pmid=20718766 |doi=10.1111/j.1365-2265.2010.03850.x |url=}}</ref> | ||
Revision as of 01:14, 8 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
- The mainstay of treatment for [disease name] is [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.[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
ACTH deficiency
Acute setting
- Preferred regimen: Hydrocortisone 100 mg IV bolus, then 300 mg/day IV divided q8hr or continuous infusion for 48 hours
- Once patient is stable: 50 mg PO q8hr for 6 doses, later on tapered to 30-50 mg/day PO in divided doses
Chronic setting
- Preferred regimen: Hydrocortisone 15-25 mg/day PO divided q8-12hr
NOTE
- Dosage is increased 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
Mild hypothyroidism
- Levothyroxine 1.7 mcg/kg qDay or 100-125 mcg PO qDay
Severe hypothyroidism
- Levothyroxine 12.5-25 mcg PO qDay and later on dose can be adjusted by 25 mcg/day q2-4 Week PRN
NOTE
- In patients with combined hypothyroidism and hypocortisolism, glucocorticoids (physiologic doses and increased doses in stress) are replaced before 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, including corticotropin (ACTH) reserve, before administering T4 (levothyroxine).
- American Thyroid Association (ATA) recommends dose adjustment to keep serum free T4 concentration in upper half of reference range.
Gonadotropin deficiency:
Men:
- Testosterone esters (for example, Sustanon) 250 mg IM every 2–3 weeks
- Transdermal testosterone
- Patch (for example, Andropatch) 2.5–7.5 mg/24 hours
- Gel (for example, Testogel) 5–10 g gel/24 hours
- Testosterone implant 600–800 mg every 4–6 months
- Buccal testosterone (for example, Striant SR) 1 buccal tablet (30 mg) applied to the gum every 12 hours
- Oral testosterone (for example, Restandol) 40–120 mg daily
Women:
- Conjugated equine oestrogens 0.625–1.25 mg daily orally
or
- Estradiol valerate 1–2 mg daily orally
- Transdermal estradiol (patch) 25–100 μg/24 hours
- Oestrogen plus progesterone (cyclical/continuous): Dose depends on preparation—orally or transdermal
NOTE:
- 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.
Androgen replacement:
Growth hormone replacement:
- Growth hormone 0.27–0.7 mg subcutaneously in the evening
- GH is replaced on case to case basis starting with a low dose (0.1-0.3 mg/day) and titrated upwards by 0.1 mg/d/month with repeated measurement of hormone levels every month, initially for the first 6 months followed by yearly measurements; replaced once all other hormones have been replaced.[17]
ADH deficiency:
- Desmopressin 300–600 μg daily in 2–3 divided doses orally or 10–40 μg daily in 2–3 divided doses intranasally
Prolactin deficiency:
- A study was done on 5 women with prolactin deficiency caused by Sheehan's syndrome or other causes that showed increased milk production upon subcutaneous administration of r-hPRL (recombinant human prolactin) every 12 hours for 28 days.[18]
References
- ↑ 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.