Hormonal Replacement in Hypopituitarism in Adults:
An Endocrine Society Clinical Practice Guideline
(chair) Maria Fleseriu, Ibrahim A. Hashim, Niki Karavitaki, Shlomo Melmed, M. Hassan Murad, Roberto Salvatori, and Mary H. Samuels
Received: May 16, 2016
Accepted: July 13, 2016
First Published Online: October 13, 2016
Link gehele richtlijn: http://press.endocrine.org/doi/pdf/10.1210/jc.2016-2118
Abstract
Objective:
To formulate clinical practice guidelines for hormonal replacement in hypopituitarism in adults.
Participants:
The participants include an Endocrine Society-appointed Task Force of six experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology co-sponsored this guideline.
Evidence:
The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Consensus Process:
One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines.
Conclusions:
Using an evidence-based approach, this guideline addresses important clinical issues regarding the evaluation and management of hypopituitarism in adults, including appropriate biochemical assessments, specific therapeutic decisions to decrease the risk of co-morbidities due to hormonal over-replacement or under-replacement, and managing hypopituitarism during pregnancy, pituitary surgery, and other types of surgeries.
Affiliations
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Een aantal (kleine) stukjes
Summary of Recommendations
1.0 Diagnosis of hypopituitarism
Central hypothyroidism
1.6 We recommend measuring serum free T4 (fT4) and TSH to evaluate central hypothyroidism (CH). An fT4
level below the laboratory reference range in conjunction with a low, normal, or mildly elevated TSH in the setting of pituitary disease usually confirms a CH diagnosis.(1QQQQ)
1.7 In patients with pituitary disease and low-normal fT4 levels suspected to have mild CH, we suggest starting
levothyroxine (L-T4) if suggestive symptoms are present or following fT4 levels over time and starting treatment if the fT4 level decreases by 20% or more. (2QEEE)
1.8 We suggest against using dynamic TSH-secretion testing to diagnose CH. (2QQQE)
2.0 Treatment
Hormonal replacement in panhypopituitarism
Thyroid hormone replacement
2.6 We recommend L-T4 in doses sufficient to achieve serum fT4 levels in the mid to upper half of the reference
range. Appropriate L-T4 doses inCHaverage 1.6g/kg/d, with dose adjustments based on clinical context, age, and
fT4 levels. (1QQQE)
2.7 We suggest against treating CH with levotriiodothyronine (L-T3), thyroid extracts, or other formulations
of thyroid hormones. (2QQEE)
2.8 We recommend against using serum TSH levels to adjust thyroid replacement dosing in patients with CH.
(1QQQE)
3.0 Special circumstances
Thyroid
3.20 We recommend that clinicians monitor fT4 or total T4 levels every 4–6 weeks for women with CH who
become pregnant, and that these women may require increased L-T4 doses to maintain levels within target ranges for pregnancy. (1QQEE
Central hypothyroidism
CH is caused by insufficient TSH stimulation of a normal thyroid gland due to the inadequate secretion or action
of TSH-releasing hormone and/or TSH (32, 33). Acquired CH is usually associated with other pituitary hormone deficiencies.
Table 1. Causes of Acquired Adult Hypopituitarism
Table 2. Clinical Manifestations of Hypopituitarism
Symptom/Sign > Pituitary Trophic Hormone Deficiency
- General
Fatigue, weakness > ACTH, TSH, LH/FSH, GH
Weight gain > TSH
Impaired sleep quality > TSH, LH/FSH, GH
Zie meerdere symptomen de tabel
_ Skin
Pallor > ACTH, LH/FSH
Dry skin > ACTH, TSH
Thinning hair, loss of body hair > ACTH, TSH, LH/FSH
- Cardiovascular/metabolic
- Pulmonary
- Gastrointestinal
- Musculoskeletal
- Renal
- Reproductive
Zie de symptomen in de tabel
Table 3. Dynamic Tests for Diagnosing Suspected Hypopituitarism
Hormone Test / Procedure / Interpretation--Expected Normal Response
Table 4. Dose Equivalence for GCs
Equivalent / Dose GCs
Table 5. GH Replacement Therapy for AGHD
Table 6. Patient Monitoring After Initiating Adult GH Replacement
Table 7. Dose Comparisons of Available Desmopressin Formulations
Appendix A or Supplemental Table 1: Assay Characteristics of Common Automated Immunoassays
Hormone / Assays Detectable Level / Sample Stability Remarks /
Mean Variability (% Imprecision) at Stated Concentrations > Within Method--Between Methods
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