Recovery of adrenal function after chronic secondary adrenal insufficiency in patients with hypopituitarism

Munro, Vicki; Tugwell, Barna; Doucette, Steve; Clarke, David B.; Lacroix, André; Imran, Syed Ali

doi:10.1111/cen.13048

Cited by 18 publications

(11 citation statements)

References 36 publications

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“…Munro et al [94] reported that approximately one in six patients with secondary adrenal insufficiency recover adrenal function, even up to 5 years after surgery [94]. Regular re-evaluations should therefore be performed, at least during the first 6–12 months postoperatively, by using morning serum cortisol before first morning dose and provocative tests when needed to prevent unnecessary GC replacement therapy.…”

Section: Introductionmentioning

confidence: 99%

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management

et al. 2019

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Purpose Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs. Methods We searched Medline and the Cochrane Library for articles published in English with the following items “Pituitary neoplasms AND Surgery” and “Surgery AND Hypopituitarism”. Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed. Results Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence. Conclusions In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.

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Section: Introductionmentioning

confidence: 99%

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management

et al. 2019

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“…These therapies are lifelong. Interestingly, some investigators found that recovery of the adrenal function was not uncommon in secondary adrenal insufficiency even after a median of nearly 2 years …”

Section: Introductionmentioning

confidence: 99%

“…Interestingly, some investigators found that recovery of the adrenal function was not uncommon in secondary adrenal insufficiency even after a median of nearly 2 years. 10 Few studies have addressed the residual endogenous cortisol production in long-standing adrenal insufficiency during substitution therapy. This is difficult because the chemical composition of hydrocortisone tablets and endogenous cortisol is identical, and therefore, usually the strategy is chosen to temporarily withdraw hydrocortisone substitution.…”

Section: Introductionmentioning

confidence: 99%

Residual endogenous corticosteroid production in patients with adrenal insufficiency

Vulto

Bergthorsdottir

Faassen

et al. 2019

Clinical Endocrinology

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ObjectiveThis study aimed at comparing precursors of endogenous corticosteroid production in patients with primary adrenal insufficiency and in secondary adrenal insufficiency.DesignTwenty patients with primary adrenal insufficiency and matched controls and 19 patients with secondary adrenal insufficiency participated in this ancillary analysis of two different studies.Patients and measurementsPatients with primary adrenal insufficiency were on stable hydrocortisone and fludrocortisone therapy. Patients with secondary adrenal insufficiency received two different doses of hydrocortisone in a randomized crossover study. Main outcome measures were concentrations of precursors of cortisol and aldosterone measured by LC‐MS/MSResultsCompared to controls, progressively lower concentrations of the glucocorticoid precursors 11‐deoxycortisol, 11‐deoxycorticosterone and corticosterone concentrations were found in patients with secondary adrenal insufficiency on lower hydrocortisone dose, secondary adrenal insufficiency on higher hydrocortisone dose and primary adrenal insufficiency, respectively. Half of the primary adrenal insufficient patients showed evidence of residual endogenous cortisol or aldosterone synthesis, as determined by quantifiable 11‐deoxycortisol, 11‐deoxycorticosterone and corticosterone concentrations. In secondary adrenal insufficient patients with higher endogenous cortisol production, as indicated by 11‐deoxycortisol concentrations above the median, no increased cortisol exposure was observed both by plasma pharmacokinetic parameters and 24‐hour free cortisol excretion in urine.ConclusionsAdrenal corticosteroid production is likely to continue during treatment in a considerable percentage of patients with both primary and secondary adrenal insufficiency. In patients with secondary adrenal insufficiency, this synthesis appears to be sensitive to the dose of hydrocortisone. However, the residual corticosteroid concentrations were quantitatively low and its clinical significance remains therefore to be determined.

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“…The testing protocol for cortisol has previously been published. [10][11][12][13] Briefly, if serum AM cortisol is <130 nmol/L then GC is continued, if 130-250 nmol/L then adrenocorticotrophic (ACTH) stimulation testing is done and if the post-ACTH cortisol is >500 nmol/L, or if serum AM cortisol is >250 nmol/L, then GC therapy is discontinued at the 2-week visit. Patients are asked specifically about symptoms of DI and, if present, appropriate investigations are conducted and management is initiated.…”

Section: Methodsmentioning

confidence: 99%

In-Hospital Endocrinology Consultation After Transsphenoidal Surgery: Is It Always Necessary?

Clarke

Hebb

Massoud

et al. 2020

Can. J. Neurol. Sci.

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Background: Patients with sellar masses undergoing transsphenoidal surgery (TSS) frequently develop endocrine dysfunction; therefore, in-hospital endocrinology consultation (IHEC) is recommended. However, we wondered whether routine endocrinology assessment of all TSS patients is always necessary. Methods: We developed an IHEC Physician’s Guide to identify patients who would require peri-operative IHEC. An analysis of all patients undergoing TSS for a sellar mass over a 4-year period was conducted to assess the predictive value of the IHEC Physician’s Guide in identifying patients who required IHEC. Results: A total of 116 patients underwent TSS; 24 required IHEC. As expected, the risk of endocrine complications requiring peri-operative endocrine management was significantly higher in the IHEC group versus no-IHEC group (96% vs. 1%; p < 0.001). The negative predictive value of the IHEC Physician’s Guide in identifying patients who did not require IHEC was 0.99 (95% CI 0.9409–0.9997); Fisher’s exact test, p < 0.001), meaning that the IHEC Physician’s Guide successfully identified all but one patient who truly required IHEC. Conclusion: Results from our study show that most patients do not need IHEC after TSS and that those patients requiring IHEC can be reliably predicted at surgery by using a simple IHEC Physician’s Guide.

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Recovery of adrenal function after chronic secondary adrenal insufficiency in patients with hypopituitarism

Abstract: Results from our study show that approximately one in six patients with SAI recover adrenal function, even up to 5 years after diagnosis. We recommend that patients with SAI undergo regular testing to assess recovery in order to prevent unnecessary glucocorticoid therapy.

Cited by 18 publications

References 36 publications

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management

Residual endogenous corticosteroid production in patients with adrenal insufficiency

In-Hospital Endocrinology Consultation After Transsphenoidal Surgery: Is It Always Necessary?

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