Patient handout

Hypopituitarism

PRODUCTION

1. Your condition

This handout is for hypopituitarism. Your care team identified this based on: pituitary / parasellar mass or stalk lesion on mri (fleseriu jcem 2016 es).

Other reasons your team may use this plan: low peripheral hormone with inappropriately low/normal trophic hormone (low cortisol + low/normal acth, low ft4 + low/normal tsh) (fleseriu jcem 2016 es); fatigue, hypotension, amenorrhea/low libido, cold intolerance, polyuria after pituitary insult (fleseriu jcem 2016 es); sellar surgery / cranial rt / apoplexy / sheehan / tbi-sah / checkpoint-inhibitor exposure (fleseriu jcem 2016 es; husebye lancet 2021).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
hydrocortisone	15–20 mg/day PO in 2–3 divided doses with the largest dose on waking (e.g., 10 mg AM + 5 mg early-PM ± 2.5 mg late-PM)	PO	BID-TID	Fleseriu JCEM 2016 ES — replaces cortisol mimicking diurnal rhythm; MUST be established before levothyroxine because thyroid hormone accelerates cortisol clearance and precipitates adrenal crisis; no reliable biomarker — titrate to clinical response avoiding over-replacement
prednisone	3–5 mg PO once daily (on waking)	PO	once daily	Fleseriu JCEM 2016 ES — once-daily alternative when adherence favors single dosing; less physiologic than divided hydrocortisone
hydrocortisone (parenteral stress dose)	100 mg IV/IM bolus then 50 mg IV q6h or 200 mg/24h infusion	IV	q6h or continuous	Fleseriu JCEM 2016 ES; Husebye Lancet 2021 — secondary AI decompensation is the life-threatening axis; do NOT delay for cortisol/ACTH result; route to adrenal-crisis pathway

Plan: Hypopituitarism replacement — glucocorticoid FIRST → levothyroxine → sex steroid → GH → desmopressin for central DI (Fleseriu JCEM 2016 ES)

3. When to call your provider

Contact your care team if any of the following happen:

Hypotension/hypoglycemia/hyponatremia → adrenal-crisis pathway + admit (Fleseriu JCEM 2016 ES)
New visual-field loss or thunderclap headache → urgent MRI + neurosurgery (apoplexy) (Fleseriu JCEM 2016 ES)
Severe symptomatic hyponatremia → admit + cautious correction (Fleseriu JCEM 2016 ES)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Secondary adrenal insufficiency decompensation: hypotension ± hypoglycemia ± hyponatremia in pituitary-failure substrate (Fleseriu JCEM 2016 ES; Husebye Lancet 2021)(life-threatening)
Concurrent central hypothyroidism AND ACTH-axis deficiency — levothyroxine started before glucocorticoid risks adrenal crisis (Fleseriu JCEM 2016 ES; Persani JCEM 2018)
Sodium <125 with neurologic symptoms (secondary AI, central hypothyroidism, or SIADH from pituitary disease) (Fleseriu JCEM 2016 ES)
Sellar/parasellar mass with bitemporal field loss or acute apoplexy (thunderclap headache + ophthalmoplegia) (Fleseriu JCEM 2016 ES)(life-threatening)
New central hormone deficiency (often hypocortisolism ± central hypothyroidism) in a patient on anti-CTLA-4 / PD-1 / PD-L1 therapy (Husebye Lancet 2021)
Central diabetes insipidus with impaired thirst access (unconscious / NPO / post-op) — rapid hypernatremic dehydration (Fleseriu JCEM 2016 ES)

5. Follow-up

Lifelong endocrine follow-up; stress-dosing / sick-day-rules education, emergency IM hydrocortisone kit, steroid card + MedicAlert; serial MRI for residual tumor; re-screen axes after RT (delayed hypopituitarism years later); fertility-induction referral if pregnancy desired (Fleseriu JCEM 2016 ES; Husebye Lancet 2021)

6. Sources

Guideline: 2016 Endocrine Society Hormonal Replacement in Hypopituitarism in Adults (Fleseriu JCEM 2016); 2021-2025 updates incl checkpoint-inhibitor hypophysitis (Husebye Lancet 2021); 2018 ETA central hypothyroidism (Persani); 2019 AACE/ACE adult GH deficiency (Yuen)