How to Treat Anterior Hypopituitarism?

Things to note:
Surgery is required for large tumours, pituitary apoplexy, and hormone secreting tumours (prolactinoma excluded). Radiotherapy may be required in selected patients. A notification bracelet is needed.
Medical Treatment:
Acute crisis
Treat as for Acute crisis in Exclude sepsis.

• Hydrocortisone, IV, 200 mg 6 hourly.

Change to oral maintenance therapy once stable.
To maintain adequate intravascular volume guided by blood pressure:

• Sodium chloride 0.9%, IV.

The fluid deficit is often several litres.
Monitor glucose levels closely and treat hypoglycaemia if present.
Chronic
As maintenance therapy:
* Hydrocortisone, oral.

• Start with 10 mg in the morning and 5 mg at night.
• Increase the dose according to clinical response up to 20 mg in the morning and 10 mg at night.

OR
* Prednisone, oral.

• Start with 5 mg daily.
• Increase to maximum of 7.5 mg daily, if necessary.

For patients who remain symptomatically hypotensive:

• Fludrocortisone, oral, 50-100 mcg daily.

Monitor response to therapy with:

• Symptoms: improvement in fatigue and GIT disturbances.
• Blood pressure: normotensive and no postural drop.
• Electrolytes: normal Na+ and K+.

During times of severe stress i.e. acute illness, surgery, trauma, etc:

• Hydrocortisone, IV, 100 mg 6 hourly.

With minor stress maintenance therapy should be doubled for the duration of illness and gradually tapered to usual dose.
Hypoadrenalism
If TSH is normal or slightly elevated and T4 is low this suggests hypopituitarism. Take blood for cortisol and ACTH and then give hydrocortisone replacement before starting levothyroxine and investigate for hypopituitarism.
* Levothyroxine, oral, 100 mcg daily.

• If there is a risk of ischaemic heart disease, start at 25 mcg daily and increase by 25 mcg every 4 weeks.

Check TSH and T4 after 2-3 months and adjust dose if required. TSH levels will take several weeks to stabilise. Once stable check T4 and TSH annually.
Hypothyroidism in pregnancy
About 60% of hypothyroid pregnant women need an increase in levothyroxine therapy in the second and third trimesters. Check TSH monthly and increase levothyroxine doses to keep serum TSH levels low normal and free T4 levels in the high-normal range. After delivery, revert to preconception doses.
Hypogonadism
Individualise dosage and need for replacement according to age, symptoms, etc.
Women:
* Combined oral contraceptives for 6 months.
OR
* Medroxyprogesterone acetate, oral, 30 mg daily for at least 3 months.
Note: The recurrence of symptoms is common following cessation of treatment.
Men:
* Testosterone, IM, 200-300 mg every 3-4 weeks.
Screen hypogonadal men for prostate cancer before beginning testosterone replacement. Individualise dosage and review doses based on clinical response.
* Testosterone cyprionate, deep IM, 200-300 mg every 2-4 weeks. Monitor patients for prostate cancer during treatment as normal.
When to refer:

• All diagnosed patients for initial assessment.