Hypopituitarism medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
Line 9: Line 9:
*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>
*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>
*Management usually involves orally-administered target organ hormone replacement except for GH and ADH
*Management usually involves orally-administered target organ hormone replacement except for GH and ADH
=== ACTH deficiency ===
=== 1.ACTH deficiency ===
<ref name="pmid9156031">{{cite journal |vauthors=Peacey SR, Guo CY, Robinson AM, Price A, Giles MA, Eastell R, Weetman AP |title=Glucocorticoid replacement therapy: are patients over treated and does it matter? |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=3 |pages=255–61 |year=1997 |pmid=9156031 |doi= |url=}}</ref><ref name="pmid12788587">{{cite journal |vauthors=Arlt W, Allolio B |title=Adrenal insufficiency |journal=Lancet |volume=361 |issue=9372 |pages=1881–93 |year=2003 |pmid=12788587 |doi=10.1016/S0140-6736(03)13492-7 |url=}}</ref><ref name="pmid9156032">{{cite journal |vauthors=Howlett TA |title=An assessment of optimal hydrocortisone replacement therapy |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=3 |pages=263–8 |year=1997 |pmid=9156032 |doi= |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="pmid3256">{{cite journal |vauthors=Besser GM, Jeffcoate WJ |title=Endocrine and metabolic diseases. Adrenal diseases |journal=Br Med J |volume=1 |issue=6007 |pages=448–51 |year=1976 |pmid=3256 |pmc=1638946 |doi= |url=}}</ref><ref name="pmid8321791">{{cite journal |vauthors=Peacey SR, Pope RM, Naik KS, Hardern RD, Page MD, Belchetz PE |title=Corticosteroid therapy and intercurrent illness: the need for continuing patient education |journal=Postgrad Med J |volume=69 |issue=810 |pages=282–4 |year=1993 |pmid=8321791 |pmc=2399661 |doi= |url=}}</ref>
<ref name="pmid9156031">{{cite journal |vauthors=Peacey SR, Guo CY, Robinson AM, Price A, Giles MA, Eastell R, Weetman AP |title=Glucocorticoid replacement therapy: are patients over treated and does it matter? |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=3 |pages=255–61 |year=1997 |pmid=9156031 |doi= |url=}}</ref><ref name="pmid12788587">{{cite journal |vauthors=Arlt W, Allolio B |title=Adrenal insufficiency |journal=Lancet |volume=361 |issue=9372 |pages=1881–93 |year=2003 |pmid=12788587 |doi=10.1016/S0140-6736(03)13492-7 |url=}}</ref><ref name="pmid9156032">{{cite journal |vauthors=Howlett TA |title=An assessment of optimal hydrocortisone replacement therapy |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=3 |pages=263–8 |year=1997 |pmid=9156032 |doi= |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="pmid3256">{{cite journal |vauthors=Besser GM, Jeffcoate WJ |title=Endocrine and metabolic diseases. Adrenal diseases |journal=Br Med J |volume=1 |issue=6007 |pages=448–51 |year=1976 |pmid=3256 |pmc=1638946 |doi= |url=}}</ref><ref name="pmid8321791">{{cite journal |vauthors=Peacey SR, Pope RM, Naik KS, Hardern RD, Page MD, Belchetz PE |title=Corticosteroid therapy and intercurrent illness: the need for continuing patient education |journal=Postgrad Med J |volume=69 |issue=810 |pages=282–4 |year=1993 |pmid=8321791 |pmc=2399661 |doi= |url=}}</ref>


==== Acute setting ====
==== 1.1.Acute setting ====
* Preferred regimen: [[Hydrocortisone]] 100 mg IV bolus, then 300 mg/day IV divided q8hr '''or''' continuous [[infusion]] for 48 hours
* 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
** 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'''   
'''1.2.Chronic setting'''   
* Preferred regimen: [[Hydrocortisone]] 15-25 mg/day PO divided q8-12hr (20 mg on awakening and 10 mg in the early evening)
* Preferred regimen: [[Hydrocortisone]] 15-25 mg/day PO divided q8-12hr (20 mg on awakening and 10 mg in the early evening)
* Altered regimen: [[Prednisone]] (5 mg on awakening and 2.5 mg in the early evening)
* Altered regimen: [[Prednisone]] (5 mg on awakening and 2.5 mg in the early evening)
Line 24: Line 24:
*[[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'''===
==='''2.TSH deficiency'''===


====Mild hypothyroidism====
====2.1.Mild hypothyroidism====
* [[Levothyroxine]] 1.7 mcg/kg qDay '''or''' 100-125 mcg PO qDay<ref name="pmid9672293">{{cite journal |vauthors=Lamberts SW, de Herder WW, van der Lely AJ |title=Pituitary insufficiency |journal=Lancet |volume=352 |issue=9122 |pages=127–34 |year=1998 |pmid=9672293 |doi= |url=}}</ref>
* [[Levothyroxine]] 1.7 mcg/kg qDay '''or''' 100-125 mcg PO qDay<ref name="pmid9672293">{{cite journal |vauthors=Lamberts SW, de Herder WW, van der Lely AJ |title=Pituitary insufficiency |journal=Lancet |volume=352 |issue=9122 |pages=127–34 |year=1998 |pmid=9672293 |doi= |url=}}</ref>


==== Severe hypothyroidism ====
==== 2.2.Severe hypothyroidism ====
* [[Levothyroxine]] 12.5-25 mcg PO qDay and later on dose can be adjusted by 25 mcg/day q2-4 Week PRN
* [[Levothyroxine]] 12.5-25 mcg PO qDay and later on dose can be adjusted by 25 mcg/day q2-4 Week PRN


Line 36: Line 36:
*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'''===
==='''3.Gonadotropin deficiency'''===
*[[Gonadotropin]] deficiency may be confirmed by measuring serum [[estradiol]], [[testosterone]], [[FSH]]/[[LH]] levels<ref name="pmid7705324">{{cite journal |vauthors=Matsumoto AM |title=Hormonal therapy of male hypogonadism |journal=Endocrinol. Metab. Clin. North Am. |volume=23 |issue=4 |pages=857–75 |year=1994 |pmid=7705324 |doi= |url=}}</ref<nowiki><ref name="pmid9253305"></nowiki>{{cite journal |vauthors=Behre HM, Kliesch S, Leifke E, Link TM, Nieschlag E |title=Long-term effect of testosterone therapy on bone mineral density in hypogonadal men |journal=J. Clin. Endocrinol. Metab. |volume=82 |issue=8 |pages=2386–90 |year=1997 |pmid=9253305 |doi=10.1210/jcem.82.8.4163 |url=}}</ref><ref name="pmid11401611">{{cite journal |vauthors=Torgerson DJ, Bell-Syer SE |title=Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials |journal=JAMA |volume=285 |issue=22 |pages=2891–7 |year=2001 |pmid=11401611 |doi= |url=}}</ref><ref name="pmid12864790">{{cite journal |vauthors=Armitage M, Nooney J, Evans S |title=Recent concerns surrounding HRT |journal=Clin. Endocrinol. (Oxf) |volume=59 |issue=2 |pages=145–55 |year=2003 |pmid=12864790 |doi= |url=}}</ref><ref name="pmid12007911">{{cite journal |vauthors=Braunstein GD |title=Androgen insufficiency in women: summary of critical issues |journal=Fertil. Steril. |volume=77 Suppl 4 |issue= |pages=S94–9 |year=2002 |pmid=12007911 |doi= |url=}}</ref><ref name="pmid9758439">{{cite journal |vauthors=Büchter D, Behre HM, Kliesch S, Nieschlag E |title=Pulsatile GnRH or human chorionic gonadotropin/human menopausal gonadotropin as effective treatment for men with hypogonadotropic hypogonadism: a review of 42 cases |journal=Eur. J. Endocrinol. |volume=139 |issue=3 |pages=298–303 |year=1998 |pmid=9758439 |doi= |url=}}</ref><ref name="pmid1743320">{{cite journal |vauthors=Shoham Z, Balen A, Patel A, Jacobs HS |title=Results of ovulation induction using human menopausal gonadotropin or purified follicle-stimulating hormone in hypogonadotropic hypogonadism patients |journal=Fertil. Steril. |volume=56 |issue=6 |pages=1048–53 |year=1991 |pmid=1743320 |doi= |url=}}</ref><ref name="pmid3539644">{{cite journal |vauthors=Morris DV, Abdulwahid NA, Armar A, Jacobs HS |title=The response of patients with organic hypothalamic-pituitary disease to pulsatile gonadotropin-releasing hormone therapy |journal=Fertil. Steril. |volume=47 |issue=1 |pages=54–9 |year=1987 |pmid=3539644 |doi= |url=}}</ref>
*[[Gonadotropin]] deficiency may be confirmed by measuring serum [[estradiol]], [[testosterone]], [[FSH]]/[[LH]] levels<ref name="pmid7705324">{{cite journal |vauthors=Matsumoto AM |title=Hormonal therapy of male hypogonadism |journal=Endocrinol. Metab. Clin. North Am. |volume=23 |issue=4 |pages=857–75 |year=1994 |pmid=7705324 |doi= |url=}}</ref<nowiki><ref name="pmid9253305"></nowiki>{{cite journal |vauthors=Behre HM, Kliesch S, Leifke E, Link TM, Nieschlag E |title=Long-term effect of testosterone therapy on bone mineral density in hypogonadal men |journal=J. Clin. Endocrinol. Metab. |volume=82 |issue=8 |pages=2386–90 |year=1997 |pmid=9253305 |doi=10.1210/jcem.82.8.4163 |url=}}</ref><ref name="pmid11401611">{{cite journal |vauthors=Torgerson DJ, Bell-Syer SE |title=Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials |journal=JAMA |volume=285 |issue=22 |pages=2891–7 |year=2001 |pmid=11401611 |doi= |url=}}</ref><ref name="pmid12864790">{{cite journal |vauthors=Armitage M, Nooney J, Evans S |title=Recent concerns surrounding HRT |journal=Clin. Endocrinol. (Oxf) |volume=59 |issue=2 |pages=145–55 |year=2003 |pmid=12864790 |doi= |url=}}</ref><ref name="pmid12007911">{{cite journal |vauthors=Braunstein GD |title=Androgen insufficiency in women: summary of critical issues |journal=Fertil. Steril. |volume=77 Suppl 4 |issue= |pages=S94–9 |year=2002 |pmid=12007911 |doi= |url=}}</ref><ref name="pmid9758439">{{cite journal |vauthors=Büchter D, Behre HM, Kliesch S, Nieschlag E |title=Pulsatile GnRH or human chorionic gonadotropin/human menopausal gonadotropin as effective treatment for men with hypogonadotropic hypogonadism: a review of 42 cases |journal=Eur. J. Endocrinol. |volume=139 |issue=3 |pages=298–303 |year=1998 |pmid=9758439 |doi= |url=}}</ref><ref name="pmid1743320">{{cite journal |vauthors=Shoham Z, Balen A, Patel A, Jacobs HS |title=Results of ovulation induction using human menopausal gonadotropin or purified follicle-stimulating hormone in hypogonadotropic hypogonadism patients |journal=Fertil. Steril. |volume=56 |issue=6 |pages=1048–53 |year=1991 |pmid=1743320 |doi= |url=}}</ref><ref name="pmid3539644">{{cite journal |vauthors=Morris DV, Abdulwahid NA, Armar A, Jacobs HS |title=The response of patients with organic hypothalamic-pituitary disease to pulsatile gonadotropin-releasing hormone therapy |journal=Fertil. Steril. |volume=47 |issue=1 |pages=54–9 |year=1987 |pmid=3539644 |doi= |url=}}</ref>


=== Men: ===
=== 3.1.Men: ===
* Testosterone esters (for example, [[Sustanon]]'')  250 mg IM every 2–3 weeks''
* Testosterone esters (for example, [[Sustanon]]'')  250 mg IM every 2–3 weeks''
* [[Transdermal]] [[testosterone]]  
* [[Transdermal]] [[testosterone]]  
Line 50: Line 50:
* Intramuscular route administration may result in a transient increase in serum testosterone concentrations leading to low HDL-cholesterol levels. Transdermal route administration may result in achieving normal physiologic levels but it is being tested.<ref name="pmid3793849">{{cite journal |vauthors=Findlay JC, Place VA, Snyder PJ |title=Transdermal delivery of testosterone |journal=J. Clin. Endocrinol. Metab. |volume=64 |issue=2 |pages=266–8 |year=1987 |pmid=3793849 |doi=10.1210/jcem-64-2-266 |url=}}</ref><ref name="pmid3379703">{{cite journal |vauthors=Carey PO, Howards SS, Vance ML |title=Transdermal testosterone treatment of hypogonadal men |journal=J. Urol. |volume=140 |issue=1 |pages=76–9 |year=1988 |pmid=3379703 |doi= |url=}}</ref>
* Intramuscular route administration may result in a transient increase in serum testosterone concentrations leading to low HDL-cholesterol levels. Transdermal route administration may result in achieving normal physiologic levels but it is being tested.<ref name="pmid3793849">{{cite journal |vauthors=Findlay JC, Place VA, Snyder PJ |title=Transdermal delivery of testosterone |journal=J. Clin. Endocrinol. Metab. |volume=64 |issue=2 |pages=266–8 |year=1987 |pmid=3793849 |doi=10.1210/jcem-64-2-266 |url=}}</ref><ref name="pmid3379703">{{cite journal |vauthors=Carey PO, Howards SS, Vance ML |title=Transdermal testosterone treatment of hypogonadal men |journal=J. Urol. |volume=140 |issue=1 |pages=76–9 |year=1988 |pmid=3379703 |doi= |url=}}</ref>


=== Women: ===
=== 3.2.Women: ===
* [[Conjugated estrogens (oral)|Conjugated equine estrogens]]  0.625–1.25 mg daily orally
* [[Conjugated estrogens (oral)|Conjugated equine estrogens]]  0.625–1.25 mg daily orally
or
or
Line 68: Line 68:
** For further information regarding the indications, contraindications and adverse effects of gonadotropin replacement therapy click [[Hypogonadism medical therapy#Medical Therapy|here]].
** For further information regarding the indications, contraindications and adverse effects of gonadotropin replacement therapy click [[Hypogonadism medical therapy#Medical Therapy|here]].


=== '''Androgen replacement:''' ===
=== '''3.3.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'''===  
==='''4.Growth hormone replacement'''===  
*[[Growth hormone]] 0.27–0.7 mg subcutaneously in the evening
*[[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>
Line 83: Line 83:
**[[Diabetes mellitus]] due to [[insulin resistance]].
**[[Diabetes mellitus]] due to [[insulin resistance]].


=== ADH deficiency: ===
=== 5.ADH deficiency: ===
* [[Desmopressin]]  300–600 μg daily in 2–3 divided doses orally or 10–40 μg daily in 2–3 divided doses [[intranasally]]
* [[Desmopressin]]  300–600 μg daily in 2–3 divided doses orally or 10–40 μg daily in 2–3 divided doses [[intranasally]]


=== '''Prolactin deficiency:''' ===
=== '''6.Prolactin deficiency:''' ===
* There is no synthetic commercial preparation available to replace [[prolactin]].
* There is no synthetic commercial preparation available to replace [[prolactin]].
* 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 20:58, 25 September 2017

Hypopituitarism Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hypopituitarism from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Hypopituitarism medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Hypopituitarism medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Hypopituitarism medical therapy

CDC on Hypopituitarism medical therapy

Hypopituitarism medical therapy in the news

Blogs on Hypopituitarism medical therapy

Directions to Hospitals Treating Hypopituitarism

Risk calculators and risk factors for Hypopituitarism medical therapy

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

Overview

The mainstay of treatment is hormone replacement therapy and treating the underlying cause. ACTH deficiency is treated with glucocorticoids. Gonadotropin deficiency is treated with testosterone in men and estrogen with or without progesterone in women. Hypothyroidism is treated with levothyroxine. Growth hormone is usually replaced in children and replaced in adults only if symptomatic and after replacement of all other pituitary hormones.

Medical Therapy

1.ACTH deficiency

[15][16][17][7][18][19]

1.1.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

1.2.Chronic setting

  • Preferred regimen: Hydrocortisone 15-25 mg/day PO divided q8-12hr (20 mg on awakening and 10 mg in the early evening)
  • Altered regimen: Prednisone (5 mg on awakening and 2.5 mg in the early evening)

Note:

2.TSH deficiency

2.1.Mild hypothyroidism

2.2.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:

3.Gonadotropin deficiency

3.1.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
  • Intramuscular route administration may result in a transient increase in serum testosterone concentrations leading to low HDL-cholesterol levels. Transdermal route administration may result in achieving normal physiologic levels but it is being tested.[29][30]

3.2.Women:

or

Note:

  • 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.
    • For further information regarding the indications, contraindications and adverse effects of gonadotropin replacement therapy click here.

3.3.Androgen replacement:

4.Growth hormone replacement

5.ADH deficiency:

  • Desmopressin 300–600 μg daily in 2–3 divided doses orally or 10–40 μg daily in 2–3 divided doses intranasally

6.Prolactin deficiency:

References

  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. ↑ 7.0 7.1 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. ↑ Peacey SR, Guo CY, Robinson AM, Price A, Giles MA, Eastell R, Weetman AP (1997). "Glucocorticoid replacement therapy: are patients over treated and does it matter?". Clin. Endocrinol. (Oxf). 46 (3): 255–61. PMID 9156031.
  16. ↑ Arlt W, Allolio B (2003). "Adrenal insufficiency". Lancet. 361 (9372): 1881–93. doi:10.1016/S0140-6736(03)13492-7. PMID 12788587.
  17. ↑ Howlett TA (1997). "An assessment of optimal hydrocortisone replacement therapy". Clin. Endocrinol. (Oxf). 46 (3): 263–8. PMID 9156032.
  18. ↑ Besser GM, Jeffcoate WJ (1976). "Endocrine and metabolic diseases. Adrenal diseases". Br Med J. 1 (6007): 448–51. PMC 1638946. PMID 3256.
  19. ↑ Peacey SR, Pope RM, Naik KS, Hardern RD, Page MD, Belchetz PE (1993). "Corticosteroid therapy and intercurrent illness: the need for continuing patient education". Postgrad Med J. 69 (810): 282–4. PMC 2399661. PMID 8321791.
  20. ↑ 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.
  21. ↑ Lamberts SW, de Herder WW, van der Lely AJ (1998). "Pituitary insufficiency". Lancet. 352 (9122): 127–34. PMID 9672293.
  22. ↑ Matsumoto AM (1994). "Hormonal therapy of male hypogonadism". Endocrinol. Metab. Clin. North Am. 23 (4): 857–75. PMID 7705324.</ref<ref name="pmid9253305">Behre HM, Kliesch S, Leifke E, Link TM, Nieschlag E (1997). "Long-term effect of testosterone therapy on bone mineral density in hypogonadal men". J. Clin. Endocrinol. Metab. 82 (8): 2386–90. doi:10.1210/jcem.82.8.4163. PMID 9253305.
  23. ↑ Torgerson DJ, Bell-Syer SE (2001). "Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials". JAMA. 285 (22): 2891–7. PMID 11401611.
  24. ↑ Armitage M, Nooney J, Evans S (2003). "Recent concerns surrounding HRT". Clin. Endocrinol. (Oxf). 59 (2): 145–55. PMID 12864790.
  25. ↑ Braunstein GD (2002). "Androgen insufficiency in women: summary of critical issues". Fertil. Steril. 77 Suppl 4: S94–9. PMID 12007911.
  26. ↑ Büchter D, Behre HM, Kliesch S, Nieschlag E (1998). "Pulsatile GnRH or human chorionic gonadotropin/human menopausal gonadotropin as effective treatment for men with hypogonadotropic hypogonadism: a review of 42 cases". Eur. J. Endocrinol. 139 (3): 298–303. PMID 9758439.
  27. ↑ Shoham Z, Balen A, Patel A, Jacobs HS (1991). "Results of ovulation induction using human menopausal gonadotropin or purified follicle-stimulating hormone in hypogonadotropic hypogonadism patients". Fertil. Steril. 56 (6): 1048–53. PMID 1743320.
  28. ↑ Morris DV, Abdulwahid NA, Armar A, Jacobs HS (1987). "The response of patients with organic hypothalamic-pituitary disease to pulsatile gonadotropin-releasing hormone therapy". Fertil. Steril. 47 (1): 54–9. PMID 3539644.
  29. ↑ Findlay JC, Place VA, Snyder PJ (1987). "Transdermal delivery of testosterone". J. Clin. Endocrinol. Metab. 64 (2): 266–8. doi:10.1210/jcem-64-2-266. PMID 3793849.
  30. ↑ Carey PO, Howards SS, Vance ML (1988). "Transdermal testosterone treatment of hypogonadal men". J. Urol. 140 (1): 76–9. PMID 3379703.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ "Consensus guidelines for the diagnosis and treatment of adults with growth hormone deficiency: summary statement of the Growth Hormone Research Society Workshop on Adult Growth Hormone Deficiency". J. Clin. Endocrinol. Metab. 83 (2): 379–81. 1998. doi:10.1210/jcem.83.2.4611. PMID 9467545.
  34. ↑ de Boer H, Blok GJ, Van der Veen EA (1995). "Clinical aspects of growth hormone deficiency in adults". Endocr. Rev. 16 (1): 63–86. doi:10.1210/edrv-16-1-63. PMID 7758433.
  35. ↑ Carroll PV, Christ ER, Bengtsson BA, Carlsson L, Christiansen JS, Clemmons D, Hintz R, Ho K, Laron Z, Sizonenko P, Sönksen PH, Tanaka T, Thorne M (1998). "Growth hormone deficiency in adulthood and the effects of growth hormone replacement: a review. Growth Hormone Research Society Scientific Committee". J. Clin. Endocrinol. Metab. 83 (2): 382–95. doi:10.1210/jcem.83.2.4594. PMID 9467546.
  36. ↑ Beshyah SA, Johnston DG (1999). "Cardiovascular disease and risk factors in adults with hypopituitarism". Clin. Endocrinol. (Oxf). 50 (1): 1–15. PMID 10341850.
  37. ↑ Vance ML, Mauras N (1999). "Growth hormone therapy in adults and children". N. Engl. J. Med. 341 (16): 1206–16. doi:10.1056/NEJM199910143411607. PMID 10519899.
  38. ↑ "Critical evaluation of the safety of recombinant human growth hormone administration: statement from the Growth Hormone Research Society". J. Clin. Endocrinol. Metab. 86 (5): 1868–70. 2001. doi:10.1210/jcem.86.5.7471. PMID 11344173.
  39. ↑ Jørgensen JO, Pedersen SA, Thuesen L, Jørgensen J, Ingemann-Hansen T, Skakkebaek NE, Christiansen JS (1989). "Beneficial effects of growth hormone treatment in GH-deficient adults". Lancet. 1 (8649): 1221–5. PMID 2566779.
  40. ↑ Salomon F, Cuneo RC, Hesp R, Sönksen PH (1989). "The effects of treatment with recombinant human growth hormone on body composition and metabolism in adults with growth hormone deficiency". N. Engl. J. Med. 321 (26): 1797–803. doi:10.1056/NEJM198912283212605. PMID 2687691.
  41. ↑ Cuneo RC, Salomon F, Wiles CM, Hesp R, Sönksen PH (1991). "Growth hormone treatment in growth hormone-deficient adults. I. Effects on muscle mass and strength". J. Appl. Physiol. 70 (2): 688–94. PMID 2022560.
  42. ↑ Cuneo RC, Salomon F, Wiles CM, Hesp R, Sönksen PH (1991). "Growth hormone treatment in growth hormone-deficient adults. II. Effects on exercise performance". J. Appl. Physiol. 70 (2): 695–700. PMID 2022561.
  43. ↑ Jørgensen JO, Pedersen SA, Thuesen L, Jørgensen J, Møller J, Müller J, Skakkebaek NE, Christiansen JS (1991). "Long-term growth hormone treatment in growth hormone deficient adults". Acta Endocrinol. 125 (5): 449–53. PMID 1759534.
  44. ↑ Bowlby DA, Rapaport R (2004). "Safety and efficacy of growth hormone therapy in childhood". Pediatr Endocrinol Rev. 2 Suppl 1: 68–77. PMID 16456485.
  45. ↑ 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.

Template:WH Template:WS

References

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Hypopituitarism_medical_therapy&oldid=1367010"