eMedicine Specialties > Endocrinology > Pituitary Gland
Hypopituitarism (Panhypopituitarism): Treatment & Medication
Updated: Jul 20, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Medical care consists of hormone replacement as appropriate and treatment of the underlying cause.7
- Glucocorticoids are required if the ACTH-adrenal axis is impaired. This is particularly important in sudden collapse due to pituitary apoplexy or acute obstetric hemorrhage with pituitary insufficiency. In such circumstances, do not delay initiation of a possibly life-saving treatment pending a definitive diagnosis.
- Treat secondary hypothyroidism with thyroid hormone replacement.
- Treat gonadotropin deficiency with sex-appropriate hormones. In men, testosterone replacement is used and modified if the patient desires fertility. In women, estrogen replacement is used with or without progesterone as appropriate.
- GH is replaced in children as appropriate. GH is not routinely replaced in adults unless the patient is symptomatic.
Surgical Care
Surgical care depends on the underlying cause and the severity of hypopituitarism.
- In pituitary apoplexy, prompt surgical decompression may be life saving if head imaging reveals tumor mass effect.
- Extirpate macroadenomas that do not respond to medical therapy.
Consultations
Include an endocrinologist, a neurosurgeon, and a radiologist as appropriate.
Diet
No special diet is necessary unless dictated by an underlying disease process. Salt use in adrenal insufficiency may be liberalized in special circumstances (eg, excessive diaphoresis).
Activity
No restrictions are necessary unless dictated by an underlying disease process.
Medication
The goal of pharmacotherapy is to restore target hormones to physiologic levels.
Glucocorticoids
These agents are used in adrenal insufficiency. They cause profound and varied metabolic effects in addition to modifying the body's immune response to diverse stimuli. The naturally occurring glucocorticoids and many synthetic steroids have both glucocorticoid and mineralocorticoid activity.
Hydrocortisone (Hydrocortone, Hydrocort)
Used as replacement therapy in adrenocortical deficiency states and may be used for their anti-inflammatory effects.
Adult
20-30 mg/d PO divided bid (often 15 mg in the morning and 10 mg in the afternoon)
Pediatric
<12 years: 1-2 mg/kg/dose IV bolus, followed by 25-150 mg/d IV/IM divided q6-8h
>12 years: 1-2 mg/kg/dose IV bolus, followed by 150-250 mg/d IV/IM 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, and cirrhosis
Thyroid hormones
These agents are used in hypothyroidism.
Levothyroxine (Synthroid, Levoxyl, Levothroid)
In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development.
Adult
100-200 mcg/d PO
Pediatric
<6 months: 8-10 mcg/kg/d PO
6-12 months: 6-8 mcg/kg/d PO
1-5 years: 5-6 mcg/kg/d PO
6-12 years: 4-5 mcg/kg/d PO
>12 years: 2-3 mcg/kg/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, periodically monitor thyroid status
Growth hormones
These agents are used in the treatment of children who have growth failure associated with chronic renal insufficiency up to the time of renal transplantation. Use in conjunction with optimal management of chronic renal insufficiency.
Human growth hormone; somatropin (Humatrope, Genotropin)
Produced by recombinant DNA technology. Stimulates growth of linear bone, skeletal muscle, and organs. Stimulates erythropoietin, which increases red blood cell mass.
Adult
Genotropin or Humatrope: 6-125 mcg/kg/d SC
Pediatric
Genotropin: 160-240 mcg/kg SC qwk divided in 6-7 doses
Humatrope: 180 mcg/kg IM/SC qwk divided in 3-7 doses
Glucocorticoids reduce growth-promoting effects
Documented hypersensitivity; pediatric patients with closed epiphyses; evidence of tumor activity or active neoplasia (intracranial lesions must be inactive and antitumor therapy completed prior to instituting therapy; discontinue if evidence of tumor activity, recurrent tumor growth, or neoplasia)
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, epiphyseal closure, geriatric patients, transplant patients, and use with other hormones
Sex hormones
These hormones are used for replacement therapy in hypogonadism associated with a deficiency or absence of endogenous testosterone or estrogen.7
Testosterone (Andro-LA, Androderm, Depo-Testosterone)
Anabolic steroid that promotes and maintains secondary sex characteristics in androgen-deficient males.
Adult
50-400 mg IM q2-4wk
Pediatric
Initiation of pubertal growth: 40-50 mg/m2/dose IM qmo until growth rates fall to prepubertal levels
Terminal growth phase: 100 mg/m2/dose IM qmo until growth ceases
Maintenance virilizing dose: 100 mg/m2 IM 2 times/mo
May increase effects of anticoagulants
Documented hypersensitivity; severe cardiac or renal disease; benign prostatic hypertrophy with obstruction; males with carcinoma of the breast or prostate, undiagnosed genital bleeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Anabolic effects may enhance hypoglycemia in pediatric age group; monitor hand and wrist every 6 mo to determine rate of bone maturation
Estrogens, conjugated (Premarin)
Important in developing and maintaining the female reproductive system and secondary sex characteristics; promotes growth and development of the vagina, uterus, fallopian tubes, and breasts. Affect release of pituitary gonadotropins; cause capillary dilatation, fluid retention, and protein anabolism; increase water content of cervical mucus; and inhibit ovulation. Predominantly produced by the ovaries.
Adult
0.3-0.625 mg/d PO for 3 wk; off 1 wk, repeat cycle
Pediatric
Not established
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 P-450 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
More on Hypopituitarism (Panhypopituitarism) |
| Overview: Hypopituitarism (Panhypopituitarism) |
| Differential Diagnoses & Workup: Hypopituitarism (Panhypopituitarism) |
 Treatment & Medication: Hypopituitarism (Panhypopituitarism) |
| Follow-up: Hypopituitarism (Panhypopituitarism) |
| References |
| Further Reading |
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References
Clayton RN. Mortality, cardiovascular events and risk factors in hypopituitarism. Growth Horm IGF Res. Feb 1998;8 Suppl A:69-76. [Medline].
Santos A, Resmini E, Martínez MA, et al. Quality of life in patients with pituitary tumors. Curr Opin Endocrinol Diabetes Obes. Aug 2009;16(4):299-303. [Medline].
Fernandez A, Brada M, Zabuliene L, et al. Radiation-induced hypopituitarism. Endocr Relat Cancer. Jun 4 2009;[Medline].
de Graaff LC, De Bellis A, Bellastella A, et al. Antipituitary antibodies in Dutch patients with idiopathic hypopituitarism. Horm Res. Jan 2009;71(1):22-7. [Medline].
Fatemi N, Dusick JR, Mattozo C, et al. Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery. Oct 2008;63(4):709-18; discussion 718-9. [Medline].
Nakamoto J. Laboratory diagnosis of multiple pituitary hormone deficiencies: issues with testing of the growth and thyroid axes. Pediatr Endocrinol Rev. Jan 2009;6 Suppl 2:291-7. [Medline].
Walvoord E. Sex steroid replacement for induction of puberty in multiple pituitary hormone deficiency. Pediatr Endocrinol Rev. Jan 2009;6 Suppl 2:298-305. [Medline].
Constine LS, Woolf PD, Cann D, et al. Hypothalamic-pituitary dysfunction after radiation for brain tumors. N Engl J Med. Jan 14 1993;328(2):87-94. [Medline].
Dexter RN. Hypopituitarism. In: Becker KL, ed. Principles and Practice of Endocrinology and Metabolism. 1995. 2nd ed. Baltimore, Md: Williams and Wilkins; 1995:169-80.
Garcia-Heras J, Kilani RA, Martin RA, Lamp S. A deletion of proximal 20p inherited from a normal mosaic carrier mother in a newborn with panhypopituitarism and craniofacial dysmorphism. Clin Dysmorphol. Jul 2005;14(3):137-40. [Medline].
Harzallah L, Migaw H, Harzallah F, Kraiem Ch. Diabetes insipidus and panhypopituitarism revealing pituitary metastasis of small cell lung carcinoma: a case report. Ann Endocrinol (Paris). Apr 2005;66(2 Pt 1):117-20. [Medline].
Koh WJ, Kwon OJ. Mycobacterium avium complex lung disease and panhypopituitarism. Mayo Clin Proc. Jul 2005;80(7):961-2. [Medline].
Lasheen I, Doi SA, Al-Shoumer KA. Glucocorticoid replacement in panhypopituitarism complicated by myelinolysis. Med Princ Pract. Mar-Apr 2005;14(2):115-7. [Medline].
Thorner MO, Vance ML, Horvath E. The anterior pituitary. In: Williams Textbook of Endocrinology. 8th ed. Philadelphia, Pa: WB Saunders and Co; 1992:221-310.
Vance ML. Hypopituitarism. N Engl J Med. Jun 9 1994;330(23):1651-62. [Medline].
Wolfgang KHO. Hypopituitarism. In: Bardin CW, ed. Current Therapy in Endocrinology and Metabolism. 6th ed. St. Louis, Mo: Mosby-Year Book; 1997:27-31.
Yamakita N, Yasuda K. Pulmonary Mycobacterium avium complex infection in patients with panhypopituitarism not receiving hormone replacement therapy. Mayo Clin Proc. Feb 2005;80(2):291. [Medline].
Further Reading
Related eMedicine topics:
Growth Hormone Deficiency [Endocrinology]
Growth Hormone Deficiency [Pediatrics: General Medicine]
Growth Hormone Replacement in Older Men
Hypopituitarism [Emergency Medicine]
Hypopituitarism [Pediatrics: General Medicine]
Hyposomatotropism
Microphallus
Nelson Syndrome
Panhypopituitarism
Pituitary Adenoma
Pituitary Disease and Pregnancy
Pituitary Tumors
Post Head Injury Endocrine Complications
Prolactin Deficiency
Clinical guidelines:
ACR Appropriateness Criteria® neuroendocrine imaging. American College of Radiology - Medical Specialty Society. 1999 (revised 2006). 11 pages. [NGC Update Pending] NGC:005121
Evaluation and treatment of adult growth hormone deficiency: an Endocrine Society clinical practice guideline. The Endocrine Society - Disease Specific Society. 2006. 33 pages. NGC:004980
Stereotactic radiosurgery for patients with pituitary adenomas. IRSA - Professional Association. 2004 Apr. 12 pages. NGC:003598
Clinical trials:
Androgen Replacement Therapy in Women With Hypopituitarism
Assessment of Cardiovascular Risk Markers in Growth Hormone Deficient Patients With Nonsecreting Pituitary Adenomas
Detection and Treatment of Endocrine Abnormalities in Childhood Cancer Survivors
Endocrine Dysfunction and Growth Hormone Deficiency in Children With Optic Nerve Hypoplasia
Testosterone Gel Applied to Women With Pituitary Gland Problems
Keywords
hypopituitarism, panhypopituitarism, pituitary, human hormone, growth hormone, pituitary gland, endocrine system, hormone replacement, pituitary adenoma, hypothalamus, growth hormone deficiency, pituitary hormone, tumor pituitary gland, pituitary tumors, pituitary glands
adrenocorticotropic hormone, ACTH, corticotropin, follicle-stimulating hormone, FSH, luteinizing hormone, LH, prolactin, thyroid-stimulating hormone, TSH, thyrotropin, antidiuretic hormone, ADH, pituitary insufficiency, lack of trophic stimulus
