Medication Summary
The goal of pharmacotherapy is to restore target hormones to physiologic levels. Medications used in hypopituitarism vary depending on the specific hormone deficiency that exists. As previously stated, patients with hypopituitarism are usually maintained on hormone replacement therapies for life. These patients are generally asymptomatic but require increased doses of glucocorticoids following any form of stress, emotional or physical. The most common stressor is infection. Not matching glucocorticoid dose to stress causes acute decompensation.
Corticosteroids
Class Summary
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 glucocorticoid and mineralocorticoid activity. [30] In the past, these agents were used in a higher-than-physiological dose. Presently, a dose equivalent to 15-20 mg/day of hydrocortisone is recommended in adults.
Hydrocortisone (Hydrocortone, A-Hydrocort, Solu-Cortef, Cortef)
Hydrocortisone is used as replacement therapy in adrenocortical deficiency states and may be used for its anti-inflammatory effects. For hypotensive patients and acute management, use intravenous (IV) preparation.
Prednisone
This is an alternative to hydrocortisone in patients with adrenal insufficiency.
Thyroid hormones
Class Summary
These agents are used in hypothyroidism.
Levothyroxine (Synthroid, Levoxyl, Levothroid, Tirosint, Unithroid)
In active form, levothyroxine influences the growth and maturation of tissues. It is involved in normal growth, metabolism, and development. Endocrinologists can monitor and adjust the doses to optimal effect. A serum free thyroxine value in the upper third of normal range is the goal.
Antidiuretic hormone replacements
Class Summary
These agents are used for the replacement of vasopressin.
Vasopressin (Pitressin)
This is an intramuscular or subcutaneous injection of an ADH analog that has vasopressor and ADH activity. It increases water resorption at the distal renal tubular epithelium (ADH effect) and promotes smooth-muscle contraction throughout the vascular bed of the renal tubular epithelium (vasopressor effects). It is rarely used today for long-term therapy.
Desmopressin acetate (DDAVP, Stimate)
This agent is a longer-acting ADH derivative that can be used intranasally (also orally and sublingually); it increases the cellular permeability of the collecting ducts, resulting in the resorption of water by the kidneys.
Growth hormones
Class Summary
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, Saizen)
This is produced by recombinant deoxyribonucleic acid (DNA) technology. It stimulates the growth of linear bone, skeletal muscle, and organs and stimulates erythropoietin, increasing red blood cell mass. Actions are either direct or from the hepatic production of IGF-1.
Estrogens/Progestins
Class Summary
These hormones are used for replacement therapy in hypogonadism associated with a deficiency or absence of endogenous testosterone or estrogen.
Estrogens, conjugated (Premarin)
Estrogen is important in the development and maintenance of the female reproductive system and secondary sex characteristics, promoting the growth and development of the vagina, uterus, fallopian tubes, and breasts. It affects the release of pituitary gonadotropins; causes capillary dilatation, fluid retention, and protein anabolism; increases the water content of cervical mucus; and inhibits ovulation. Metabolic effects include maintenance of bone density. Estrogen is predominantly produced by the ovaries.
Estradiol (Alora, Climara, Elestrin, Vivelle-Dot, Estrace, Estraderm, EstroGel)
Estradiol increases synthesis of DNA, RNA, and many proteins in target tissues. It may be given transdermally by patch or gel, or orally in micronized form.
Medroxyprogesterone (Provera, Depo-Provera)
Administer cyclically 12 d/mo to prevent endometrial hyperplasia that unopposed estrogen may cause. In young women, regular withdrawal bleeding is preferable because even young women with premature ovarian failure have a 5-10% chance of spontaneous pregnancy (unlike postmenopausal women). If an expected withdrawal bleeding is absent, perform a pregnancy test (and a timely diagnosis of pregnancy will not be missed). Other causes of amenorrhea may also remit spontaneously and result in an unexpected pregnancy.
Progesterone (Prometrium)
This agent is used to prevent endometrial hyperplasia.
Desogestrel and ethinyl estradiol (Desogen, Ortho-Cept, Velivet, Azurette, Cyclessa)
The combination of desogestrel and ethinyl estradiol reduces the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones (GnRHs). This is one example of an oral contraceptive pill (OCP). All the modern formulations are equally efficacious, although some of the newer (so-called third-generation) pills have a larger progestin effect and may offer greater efficacy.
Norgestimate and ethinyl estradiol (Ortho Cyclen, Sprintec, TriNessa, Ortho Tri-Cyclen)
The combination of norgestimate and ethinyl estradiol reduces the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing the amount of gonadotropin-releasing hormones (GnRHs).
Androgens
Class Summary
Androgens are used for replacement therapy in hypogonadism associated with a deficiency or absence of endogenous testosterone.
Testosterone (Depo-Testosterone, Androderm, AndroGel, Testim, Andriol)
Testosterone is an anabolic steroid that promotes and maintains secondary sex characteristics in androgen-deficient males. Physiological amounts may be given by intramuscular injection every 1-2 weeks, daily by transdermal patch or gel, or several times daily by oral testosterone undecanoate, the latter of which is not available in all countries.
