Medication Summary
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
Class Summary
These agents are used to treat disorders associated with acromegaly. Recent work suggests the use of pegvisomant; however, no definite guideline indication has been determined. [16]
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.
Dopamine agonists
Class Summary
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.
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.
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Pergolide was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation.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 For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.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.
Corticosteroids
Class Summary
These agents are used in the management of adrenocortical insufficiency.
Hydrocortisone (Cortef, Solu-Cortef, Hydrocort)
DOC because of mineralocorticoid activity and glucocorticoid effects.
Thyroid products
Class Summary
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.
Estrogen derivatives
Class Summary
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.
Androgens
Class Summary
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.
Growth Hormone
Class Summary
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.
Vasopressin analogs
Class Summary
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.
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This is a characteristic bitemporal hemianopic visual field defect.
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This contrast-enhanced coronal MRI was obtained in a patient who complained of visual loss.
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This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
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Coronal T1 precontrast MRI A (left panel), B postcontrast (middle panel) and T2 (right panel) showing a sellar mass causing obvious left and upward displacement of the optic chiasm. The mass is a histologically proven pituitary macroadenoma, which presented initially with a large cystic subfrontal extension that was successfully resected in April of 2006. This patient has been observed closely for 2.5 years and despite obvious mass effect, he has no visual complaints and the neuro-ophthalmologic evaluation is normal. Although infrequent, clinicians should be aware of this possibility. Close follow-up is required.
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Axial, sagittal, and coronal MRI of the sellae in a patient with a severe headache, normal neuro-ophthalmologic examination, and no evidence of endocrine failure. A hyperintense mass is observed in the sella with suprasellar extension. This case illustrates the clinical spectrum of pituitary apoplexy. Transsphenoidal resection confirmed the diagnosis of pituitary apoplexy.
