From the Guidelines
Hypopituitarism treatment should prioritize hormone replacement therapy, with a focus on replacing deficient hormones, such as cortisol, thyroid hormone, growth hormone, sex hormones, and antidiuretic hormone, to address specific deficiencies caused by inadequate pituitary function, as recommended by the most recent guidelines 1.
Treatment Approach
The treatment approach for hypopituitarism involves identifying the deficient hormones through blood tests and replacing them with synthetic versions.
- For cortisol deficiency, hydrocortisone (15-25 mg daily in divided doses) or prednisone (3-5 mg daily) is prescribed, with dose increases during illness or stress, as suggested by 1.
- Thyroid deficiency requires levothyroxine (typically 1.6 mcg/kg/day), with a goal of achieving a free T4 level in the upper half of the reference range, as recommended by 1.
- Growth hormone deficiency in adults is treated with somatropin injections (0.2-1.0 mg daily), while children receive weight-based dosing.
- Sex hormone replacement includes testosterone for men (50-100 mg intramuscular injections every 1-2 weeks, or daily transdermal patches/gels) and estrogen with progesterone for women (varies by age and menopausal status).
- Antidiuretic hormone deficiency (diabetes insipidus) requires desmopressin as tablets, nasal spray, or injections.
Management of Hypophysitis
In patients with hypophysitis, management includes replacement of deficient hormones, with a preference for physiologic doses of steroids and thyroid hormone, as recommended by 1 and 1.
- In the presence of both adrenal insufficiency and hypothyroidism, steroids should always be started prior to thyroid hormone to avoid an adrenal crisis, as emphasized by 1 and 1.
- High doses of steroids are necessary in the setting of severe headaches, vision changes, or adrenal crisis, as suggested by 1.
- All patients with adrenal insufficiency should be instructed to obtain and carry a medical alert bracelet, as recommended by 1 and 1.
Monitoring and Adjustments
Regular monitoring with blood tests is essential to adjust dosages, and patients should understand how to adjust medications during illness, as recommended by 1.
- Treatment is typically lifelong, with the goal of restoring normal hormone levels and relieving symptoms while avoiding over-replacement complications.
- Patients should be educated on stress dosing, emergency injectable, and a medical alert or necklace accessory or system, as suggested by 1.
From the Research
Treatment of Hypopituitarism
The treatment of hypopituitarism involves the physiologic replacement of the individual end-organ hormone deficiencies and requires close lifelong monitoring 2, 3.
- Hormone replacement therapy should be individualized according to the specific needs of each patient, taking into account possible interactions 2.
- Adrenocorticotropic hormone deficiency replacement is best performed with the immediate-release oral glucocorticoid hydrocortisone (HC) in 2-3 divided doses, but novel once-daily modified-release HC targets a more physiological exposure of glucocorticoids 4.
- Growth hormone deficiency (GHD) is treated currently with daily subcutaneous GH, but current research is focusing on the development of once-weekly administration of recombinant GH 4.
- Hypogonadism is targeted with testosterone replacement in men and on estrogen replacement therapy in women; when fertility is wanted, replacement targets secondary or tertiary levels of hormonal settings 4.
- Thyroid-stimulating hormone replacement therapy follows the rules of primary thyroid gland failure with L-thyroxine replacement 4.
- Central diabetes insipidus is nowadays replaced by desmopressin 4.
Growth Hormone Replacement Therapy
Growth hormone replacement therapy in GH-deficient adults is associated with improved outcomes, including increased exercise capacity, improved cardiac function, and enhanced quality of life 5.
- GH replacement therapy is associated with a significant increase in mean serum dehydroepiandrosterone sulphate (DHEAS) only in adrenocorticotropic hormone (ACTH)-sufficient patients 6.
- The effects of GH replacement therapy on adrenal androgen secretion in adult onset hypopituitarism have been investigated, and the results suggest that GH might stimulate adrenocortical hormone secretion in the permissive presence of ACTH 6.
Management of Hypopituitarism
The management of hypopituitarism includes the replacement of target-hormone of hypothalamo-pituitary-endocrine gland axis with the exceptions of secondary hypogonadism when fertility is required, and growth hormone deficiency (GHD) 4.
- Certain clinical scenarios may have to be promptly managed to avoid short-term or long-term sequelae such as pregnancy in patients with hypopituitarism, pituitary apoplexy, adrenal crisis, and pituitary metastases 4.
- Long-term endocrinological follow-up of hypopituitary patients is important to monitor hormonal replacement regimes and avoid under- or overtreatment 2.