eMedicine Specialties > Neurology > Neuro-oncology
Pituitary Tumors: Treatment & Medication
Updated: Jan 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Prolactinomas: The majority of these lesions respond to dopamine receptor agonists. Improvement in visual field abnormalities, resolution of symptoms associated with hyperprolactinemia, and visible diminution of the actual mass can result with treatment.
- Acromegaly: Somatostatin analogues (octreotide) can be helpful in the treatment of increased postoperative levels of GH. In some cases, the tumor may shrink modestly. Gallstones are a frequent complication of somatostatin-analogue therapy. Dopamine agonists also have been used.
- Replacement therapy for decreased or absent hormones should be instituted as needed.
- All hormone-based treatment should be directed by a consulting endocrinologist.
Surgical Care
- Transsphenoidal surgery
- Transsphenoidal microscopic surgery is the most frequent surgical approach for the resection of pituitary tumors. With larger lesions, a transfrontal approach may become necessary to decompress the visual pathways.
- Minimally invasive endoscopic surgery using a 4-mm endoscope through a nostril is a possibility in selective cases.
- Open low-field intraoperative MRI monitoring for transsphenoidal surgical resection is gaining acceptance to monitor the precise extent of tumor resection.
- Null cell tumors and gonadotrophinomas are best treated with transsphenoidal surgery.
- The main complication after transsphenoidal surgery (from the endocrine standpoint) is hypopituitarism.
- Prolactinomas
- Microprolactinomas: Transsphenoidal resection of the tumor offers a chance for a cure without the need for long-standing dopamine agonist therapy; however, many patients choose dopaminergic therapy.
- Macroadenomas that secrete prolactin are best treated with dopamine agonists.
- Acromegaly
- Transsphenoidal surgery decreases GH levels to less than 5 mcg/L in 60% of cases.
- Normal pulsatile secretion of GH is not always regained, and 20% of patients continue to have increased GH levels in response to TRH.
- Radiotherapy is an alternative, although GH levels may not decrease for 2-4 years.
- Elevated GH levels may be treated with somatostatin analogues and dopamine agonists, if tolerated.
- Cushing disease
- Transsphenoidal tumor resection is the first line of treatment in patients with basophilic adenomas of the pituitary gland. It is curative in 80% of cases.
- Pituitary irradiation is required in the remaining cases to prevent the development of Nelson syndrome.
- In children, pituitary irradiation and adrenalectomy are highly effective.
Consultations
- The treatment team should consist of any or all of the following specialists: ophthalmologist or neuro-ophthalmologist, neuroradiologist, endocrinologist, gynecologist, neurosurgeon, neuropathologist, and radiation medicine specialist.
- Different specialists may be involved as indicated by the patient's specific symptoms.
Diet
- Dietary factors are important in patients with acromegaly or Cushing disease.
- Patients with hypothyroidism, hypoadrenalism, or hypopituitarism have specific dietary needs.
Activity
- Activities of daily living (ADLs) generally are not restricted in these patients.
- Exercise tolerance may be limited in some cases.
Medication
All hormone-related therapy should be initiated and directed by a consulting endocrinologist. The specific disorders are treated as follows:
Pituitary disorders associated with hormonal excess
Prolactinomas - Dopamine agonists (eg, bromocriptine, cabergoline)
Acromegaly - Octreotide (somatostatin analogue), dopamine agonists
Syndromes associated with hormonal deficiency and hypopituitarism
Hypothyroidism - Synthroid
Adrenocorticosteroid deficiency - Cortisol
Male hypogonadism - Testosterone
Female hypogonadism - Estrogen/progesterone
Growth hormone deficiency - GH replacement may be needed, more often in children than in adults
Many patients who have undergone surgery may experience posterior pituitary hypofunction with resultant diabetes insipidus and may require transnasal arginine vasopressin (DDAVP).
Somatostatin analogues
These agents are used to treat disorders associated with acromegaly.
Octreotide (Sandostatin)
Hypothalamic polypeptide that inhibits production of GH. Acts primarily on somatostatin receptor subtypes II and V. Has multitude of other endocrine and nonendocrine effects, including inhibition of glucagon, VIP, and GI peptides.
More effective than dopamine agonists in acromegaly.
Adult
100-500 mcg SC tid
Pediatric
Administer lower limit of adult dosing range
May reduce effects of cyclosporine; patients on insulin, oral hypoglycemics, beta-blockers, or calcium channel blockers may need dosage adjustments
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adverse effects related primarily to altered GI motility and include nausea, abdominal pain, diarrhea, increased incidence of gallstones, and biliary sludge; because of alteration in counter-regulatory hormones (ie, insulin, glucagon, GH), hypoglycemia or hyperglycemia may be seen; bradycardia, cardiac conduction abnormalities, and arrhythmias have been reported; because of inhibition of TSH secretion, hypothyroidism may occur; use caution in patients with renal impairment; cholelithiasis may occur
Dopamine agonists
Dopamine receptors in the hypothalamus exert an inhibitory action on some pituitary cells, particularly those producing prolactin and, to a lesser extent, GH.
Bromocriptine (Parlodel)
Ergot alkaloid derivative with dopaminergic properties. Inhibits prolactin secretion.
Adult
2.5 mg PO tid
Pediatric
Not established
Ergot alkaloids may increase toxicity; amitriptyline, butyrophenones, imipramine, methyldopa, phenothiazines, and reserpine may decrease effects
Documented hypersensitivity; ischemic heart disease; peripheral vascular disorders
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic disease; many females with prolactinomas become pregnant while using dopamine-agonist therapy (once conception takes place, dopamine agonist may be discontinued 4 wk after confirmation of pregnancy); occasionally, enlargement of prolactinoma may occur with symptomatic visual loss, transient diabetes insipidus, and, rarely, pituitary apoplexy
Transsphenoidal surgery can be performed, if necessary, with continuation of pregnancy and successful full-term delivery; dopamine-agonist therapy may be reinitiated
Author has no experience with other dopamine agonists and pregnancy
Cabergoline (Quinazoline, Dostinex)
Formerly CV205-502. Long-acting dopamine receptor agonist with high affinity for D2 receptors. Prolactin secretion by anterior pituitary predominates under hypothalamic inhibitory control exerted through dopamine.
Adult
125 mcg to 1 mg PO twice weekly
Pediatric
Not established
May increase effects of antihypertensive medications (adjust dose accordingly); other dopamine agonists may reduce effects
Documented hypersensitivity; uncontrolled hypertension
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution when patient is taking hypertensives; do not use to inhibit physiologic lactation because of relatively high incidence of stroke, seizures, hypertension; monitor prolactin levels monthly; caution in hepatic impairment
Pergolide (Permax)
Pergolide was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to abruptly stop pergolide. Health care professionals should assess patients' need for dopamine agonist (DA) therapy and consider alternative treatment. If continued treatment with a DA is needed, another DA should be substituted for pergolide. For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.
Potent dopamine receptor agonist at both D1 and D2 receptor sites. Approximately 10-1000 times more potent than bromocriptine on mg per mg basis. Inhibits secretion of prolactin; causes transient rise in serum concentrations of GH and decrease in serum concentrations of LH.
Adult
50 mcg to 1 mg PO tid
Pediatric
Not established
Dopamine antagonists such as neuroleptics phenothiazines, butyrophenones, thioxanthines, or metoclopramide may diminish effectiveness; because pergolide mesylate is >90% bound to plasma proteins, use caution if coadministering with other drugs known to affect protein binding
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause valvular heart disease (yearly echocardiograms recommended for patients on chronic therapy); inhibits secretion of prolactin; causes transient rise in serum concentrations of growth hormone and decrease in serum concentrations of luteinizing hormone; adverse effects include nausea, hypotension, hallucinations, and somnolence; use caution in patients who have been treated for cardiac dysrhythmias; may cause or exacerbate preexisting states of confusion and hallucinations or dyskinesia
Corticosteroids
These agents are used in the management of adrenocortical insufficiency.
Hydrocortisone (Cortef, Solu-Cortef, Hydrocort)
DOC because of mineralocorticoid activity and glucocorticoid effects.
Adult
100 mg IV bolus, followed by continuous infusion of 100 mg q8h for 24-48 h; once patient is stable, initiate PO hydrocortisone (50 mg q8h for another 48 h; may taper dose to 30-50 mg/d in divided doses)
Pediatric
<12 years: 1-2 mg/kg IV bolus, followed by 25-150 mg/d divided q6-8h
>12 years: 1-2 mg/kg IV bolus, followed by 150-250 mg/d divided q6-8h
Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
Thyroid products
These agents are used as supplemental therapy in hypothyroidism.
Levothyroxine (Synthroid, Levoxyl, Levothroid)
DOC. Rapidly inhibits the release of thyroid hormones via a direct effect on the thyroid gland and inhibits the synthesis of thyroid hormones. Iodide also appears to attenuate cAMP-mediated effects of thyrotropin. In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development.
Adult
12.5-50 mcg/d PO and increase by 25-50 mcg/d q2-4 wk to a maximum of 100-200 mcg/d
Pediatric
Neonate to 6 months: 25-50 mcg/d PO
6-12 months: 50-75 mcg/d PO
1-5 years: 75-100 mcg/d PO
6-12 years: 100-150 mcg/d PO
>12 years: 150 mcg/d PO
Cholestyramine may decrease liothyronine absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants increased when administered with liothyronine; activity of some beta-blockers may decrease when hypothyroid patient is converted to a euthyroid state
Documented hypersensitivity; uncorrected adrenal insufficiency
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in angina pectoris or cardiovascular disease; monitor thyroid status periodically
Estrogen derivatives
These agents are used in the treatment of hypoestrogenism.
Estrogens (Premarin)
Contains a mixture of estrogens obtained exclusively from natural sources, occurring as the sodium salts of water-soluble estrogen sulfates blended to represent the average composition of material derived from pregnant mares' urine. Mixture of sodium estrone sulfate and sodium equilin sulfate. Contains as concomitant components, sodium sulfate conjugates, 17-alpha-dihydroequilenin, 17-alpha-estradiol, and 17-beta-dihydroequilenin.
Restores estrogen levels to concentrations that induce negative feedback at gonadotrophic regulatory centers, which, in turn, reduces release of gonadotropins from pituitary. Increases synthesis of DNA, RNA, and many proteins in target tissues.
Important in developing and maintaining female reproductive system and secondary sex characteristics; promotes growth and development of vagina, uterus, fallopian tubes, and breasts. Affects release of pituitary gonadotropins; causes capillary dilatation, fluid retention, and protein anabolism; increases water content of cervical mucus; and inhibits ovulation. Predominantly produced by the ovaries.
Adult
0.3-1.25 mg PO qd; may use higher doses depending on tissue response of patient
Pediatric
<12 years: Not established
>12 years: 0.3 mg PO qod for up to 6 mo, slowly (at 6-mo intervals) increasing to adult dose
May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins
Documented hypersensitivity; known or suspected pregnancy; breast cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis, or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, such as abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia
Androgens
These agents are used in the treatment of male hypogonadism.
Testosterone (Depo-Testosterone, Andro-LA, Delatest)
Promotes and maintains secondary sex characteristics in androgen-deficient males.
Adult
75-150 mg IM q7-10d or 100-200 mg IM q2wk
Buccal adhesive (Striant): Apply 1 buccal adhesive system (30 mg) to gum q12h
Pediatric
>13 years: 50-100 mg IM every mo initially followed by 50-100 mg IM q2wk after 1 y of treatment, with gradual increase to adult dose
May increase effects of anticoagulants
Documented hypersensitivity; severe cardiac or renal disease; benign prostatic hypertrophy with obstruction; males with carcinoma of the breast, undiagnosed genital bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Anabolic effects may enhance hypoglycemia; monitor hand and wrist every 6 mo to determine rate of bone maturation
Rotate buccal adhesive system application site; do not chew or swallow buccal adhesive system
Growth Hormone
These agents are used in the replacement of endogenous growth hormone in patients with adult growth hormone deficiency.
Human growth hormone (Genotropin, Humatrope, Nutropin)
Stimulates growth of linear bone, skeletal muscle, and organs. Stimulates erythropoietin, which increases red blood cell mass.
Currently widely available in SC injection form. Adjust dose gradually based on clinical and biochemical responses assessed at monthly intervals, including body weight, waist circumference, serum IGF-1, IGFBP-3, serum glucose, lipids, thyroid function, and whole body dual-energy x-ray absorptiometry. In children, assess response based on height and growth velocity. Continue treatment until final height or epiphysial closure or both have been recorded.
Adult
Usual starting dose is 2-5 mcg/kg/d or about 0.1-0.3 mg/d SC
Pediatric
0.15-0.3 mg/kg/wk SC initially; divide into equal doses to be given daily or 6 times/wk
Glucocorticoids may decrease growth promoting effects
Documented hypersensitivity; closed epiphyses; actively growing intracranial tumor; any underlying intracranial lesion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in diabetes; reconstitute with sterile water for injection if administering to newborns
Vasopressin analogs
These agents are used in the treatment of diabetes insipidus.
Desmopressin (DDAVP, Stimate)
Synthetic analogue of hypothalamic/posterior pituitary hormone 8-arginine vasopressin (antidiuretic hormone [ADH]). Has no effect on V1 receptors, which are responsible for vasopressin-induced vasoconstriction. Instead, acts on V2 receptors at renal tubuli, increasing cellular permeability of collecting ducts, which are responsible for antidiuretic effect. Effect is prevention of nocturnal diuresis and elevated BP in the mornings, resulting in reabsorption of water by kidneys. Formulated as a tab and a nasal spray. Tab is more convenient to administer.
Adult
2-4 mcg IV/SC divided bid
Pediatric
<3 months: Not established
3 months to 12 years: 5-30 mcg/d intranasally qd or divided bid
>12 years: Administer as in adults
Coadministration with demeclocycline and lithium decrease effects; fludrocortisone and chlorpropamide increase effects of desmopressin; loperamide increases bioavailability and absorption of desmopressin, thus potentially increasing effect
Documented hypersensitivity; platelet-type von Willebrand disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid overhydration in patients using desmopressin to benefit from its hemostatic effects
More on Pituitary Tumors |
| Overview: Pituitary Tumors |
| Differential Diagnoses & Workup: Pituitary Tumors |
 Treatment & Medication: Pituitary Tumors |
| Follow-up: Pituitary Tumors |
| Multimedia: Pituitary Tumors |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
pituitary adenoma, pituitary tumor, hormone deficiencies, hormone overproduction, prolactinoma, acromegaly, Cushing disease, Cushing syndrome, hormone therapy, pituitary mass
