How is pituitary insufficiency treated?
The goal of therapy is to replace hormone deficits as close to the physiologic pattern as possible.
• ACTH deficiency: Hydrocortisone 15 to 20 mg per day, in two or three divided doses, or prednisone 5 mg per day, is commonly used to replace cortisol. Patients using divided doses of hydrocortisone should take 10 to 15 mg in the morning upon awakening and 5 to 10 mg in the afternoon (two-dose regimen), or 10 to 15 mg in the morning and 5 to 10 mg at lunch and again in the late afternoon (three-dose regimen). Because ACTH is not the main regulator of aldosterone secretion, patients with central adrenal insufficiency do not need fludrocortisone. Although it has been suggested that some women with decreased libido and muscle weakness may benefit from taking low doses of dehydroepiandrosterone (DHEA), recent guidelines recommend against its use because of limited data concerning its efficacy and safety. Patients should be educated about stress dosing and emergency glucocorticoid administration, and instructed about obtaining an emergency card/bracelet/necklace regarding adrenal insufficiency.
• TSH deficiency: Levothyroxine (LT 4 ) in doses sufficient to achieve and maintain serum free T 4 levels in the mid- to upper half of the reference range should be used to treat central hypothyroidism. Treatment with liothyronine (LT 3 ) or desiccated thyroid extracts should be discouraged.
• Gonadotropin deficiency:
• If no contraindications are present, men should be treated with testosterone to alleviate hypogonadal symptoms, improve bone mineral density (BMD), and prevent anemia related to testosterone deficiency. The choice of testosterone formulations depends on patient preference, cost, and risk of specific adverse effects.
• If no contraindications are present, premenopausal women should be treated with hormone replacement therapy until age 45 to 55 years to alleviate vasomotor symptoms of hypoestrogenism, improve vaginal atrophy and dysuria, prevent bone loss, and reduce the risk of cardiovascular disease and mortality. Unopposed estrogens are given to women who have undergone a hysterectomy and combined estrogen–progesterone preparations are used for those with an intact uterus to prevent endometrial hyperplasia.
• GH deficiency: GH replacement therapy may be offered to adult patients with rigorously proven GH deficiency, no contraindications, and persistently reduced sense of well-being, energy, quality of life, muscle strength, and lean body mass, despite adequate replacement of other pituitary deficiencies. The starting dose for patients age < 60 years is 0.2 to 0.4 mg per day and that for patients age > 60 years is 0.1 to 0.2 mg per day. GH replacement results in improved body composition, BMD, muscle strength, and lipoprotein metabolism. Side effects associated with GH replacement include fluid retention, arthralgias and myalgias, carpal tunnel syndrome, paresthesias, and sleep apnea.