Sheehan's syndrome medical therapy: Difference between revisions

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*Treatment involves appropriate [[hormone replacement therapy]], which must be taken for the rest of your life that results in significant improvement and reversal of not only the physical symptoms but also the [[psychological]] symptoms.<ref name="pmid27034575">{{cite journal |vauthors=Parikh R, Buch V, Makwana M, Buch HN |title=The price of a 15-year delay in diagnosis of Sheehan's syndrome |journal=Proc (Bayl Univ Med Cent) |volume=29 |issue=2 |pages=212–3 |year=2016 |pmid=27034575 |pmc=4790577 |doi= |url=}}</ref><ref name="pmid19697029">{{cite journal |vauthors=Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH |title=Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review) |journal=Ann. Hematol. |volume=89 |issue=3 |pages=305–8 |year=2010 |pmid=19697029 |doi=10.1007/s00277-009-0804-9 |url=}}</ref><ref name="pmid15921942">{{cite journal |vauthors=Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F |title=Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome |journal=Growth Horm. IGF Res. |volume=15 |issue=3 |pages=231–7 |year=2005 |pmid=15921942 |doi=10.1016/j.ghir.2005.03.005 |url=}}</ref><ref name="pmid9059561">{{cite journal |vauthors=Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM |title=Increased cerebrovascular mortality in patients with hypopituitarism |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=1 |pages=75–81 |year=1997 |pmid=9059561 |doi= |url=}}</ref><ref name="pmid12675508">{{cite journal |vauthors=Arafah BM |title=Medical management of hypopituitarism in patients with pituitary adenomas |journal=Pituitary |volume=5 |issue=2 |pages=109–17 |year=2002 |pmid=12675508 |doi= |url=}}</ref><ref name="pmid20719838">{{cite journal |vauthors=Grossman AB |title=Clinical Review#: The diagnosis and management of central hypoadrenalism |journal=J. Clin. Endocrinol. Metab. |volume=95 |issue=11 |pages=4855–63 |year=2010 |pmid=20719838 |doi=10.1210/jc.2010-0982 |url=}}</ref><ref name="pmid1986026">{{cite journal |vauthors=Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL |title=Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry |journal=J. Clin. Endocrinol. Metab. |volume=72 |issue=1 |pages=39–45 |year=1991 |pmid=1986026 |doi=10.1210/jcem-72-1-39 |url=}}</ref><ref name="pmid16584509">{{cite journal |vauthors=Arlt W, Rosenthal C, Hahner S, Allolio B |title=Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements |journal=Clin. Endocrinol. (Oxf) |volume=64 |issue=4 |pages=384–9 |year=2006 |pmid=16584509 |doi=10.1111/j.1365-2265.2006.02473.x |url=}}</ref><ref name="pmid17437510">{{cite journal |vauthors=Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM |title=Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=66 |issue=6 |pages=789–96 |year=2007 |pmid=17437510 |doi=10.1111/j.1365-2265.2007.02812.x |url=}}</ref><ref name="pmid4182323">{{cite journal |vauthors=Martin MM |title=Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication |journal=Arch. Intern. Med. |volume=123 |issue=4 |pages=409–16 |year=1969 |pmid=4182323 |doi= |url=}}</ref><ref name="pmid2019265">{{cite journal |vauthors=Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y |title=Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium |journal=Endocrinology |volume=128 |issue=5 |pages=2534–9 |year=1991 |pmid=2019265 |doi=10.1210/endo-128-5-2534 |url=}}</ref><ref name="pmid8015573">{{cite journal |vauthors=White PC |title=Disorders of aldosterone biosynthesis and action |journal=N. Engl. J. Med. |volume=331 |issue=4 |pages=250–8 |year=1994 |pmid=8015573 |doi=10.1056/NEJM199407283310408 |url=}}</ref><ref name="pmid11158009">{{cite journal |vauthors=Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A |title=Androgen deficiency in women with hypopituitarism |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=2 |pages=561–7 |year=2001 |pmid=11158009 |doi=10.1210/jcem.86.2.7246 |url=}}</ref><ref name="pmid16478814">{{cite journal |vauthors=Miller KK, Biller BM, Beauregard C, Lipman JG, Jones J, Schoenfeld D, Sherman JC, Swearingen B, Loeffler J, Klibanski A |title=Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study |journal=J. Clin. Endocrinol. Metab. |volume=91 |issue=5 |pages=1683–90 |year=2006 |pmid=16478814 |doi=10.1210/jc.2005-2596 |url=}}</ref>
*Treatment involves appropriate [[hormone replacement therapy]], which must be taken for the rest of your life that results in significant improvement and reversal of not only the physical symptoms but also the [[psychological]] symptoms.<ref name="pmid27034575">{{cite journal |vauthors=Parikh R, Buch V, Makwana M, Buch HN |title=The price of a 15-year delay in diagnosis of Sheehan's syndrome |journal=Proc (Bayl Univ Med Cent) |volume=29 |issue=2 |pages=212–3 |year=2016 |pmid=27034575 |pmc=4790577 |doi= |url=}}</ref><ref name="pmid19697029">{{cite journal |vauthors=Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH |title=Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review) |journal=Ann. Hematol. |volume=89 |issue=3 |pages=305–8 |year=2010 |pmid=19697029 |doi=10.1007/s00277-009-0804-9 |url=}}</ref><ref name="pmid15921942">{{cite journal |vauthors=Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F |title=Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome |journal=Growth Horm. IGF Res. |volume=15 |issue=3 |pages=231–7 |year=2005 |pmid=15921942 |doi=10.1016/j.ghir.2005.03.005 |url=}}</ref><ref name="pmid9059561">{{cite journal |vauthors=Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM |title=Increased cerebrovascular mortality in patients with hypopituitarism |journal=Clin. Endocrinol. (Oxf) |volume=46 |issue=1 |pages=75–81 |year=1997 |pmid=9059561 |doi= |url=}}</ref><ref name="pmid12675508">{{cite journal |vauthors=Arafah BM |title=Medical management of hypopituitarism in patients with pituitary adenomas |journal=Pituitary |volume=5 |issue=2 |pages=109–17 |year=2002 |pmid=12675508 |doi= |url=}}</ref><ref name="pmid20719838">{{cite journal |vauthors=Grossman AB |title=Clinical Review#: The diagnosis and management of central hypoadrenalism |journal=J. Clin. Endocrinol. Metab. |volume=95 |issue=11 |pages=4855–63 |year=2010 |pmid=20719838 |doi=10.1210/jc.2010-0982 |url=}}</ref><ref name="pmid1986026">{{cite journal |vauthors=Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL |title=Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry |journal=J. Clin. Endocrinol. Metab. |volume=72 |issue=1 |pages=39–45 |year=1991 |pmid=1986026 |doi=10.1210/jcem-72-1-39 |url=}}</ref><ref name="pmid16584509">{{cite journal |vauthors=Arlt W, Rosenthal C, Hahner S, Allolio B |title=Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements |journal=Clin. Endocrinol. (Oxf) |volume=64 |issue=4 |pages=384–9 |year=2006 |pmid=16584509 |doi=10.1111/j.1365-2265.2006.02473.x |url=}}</ref><ref name="pmid17437510">{{cite journal |vauthors=Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM |title=Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=66 |issue=6 |pages=789–96 |year=2007 |pmid=17437510 |doi=10.1111/j.1365-2265.2007.02812.x |url=}}</ref><ref name="pmid4182323">{{cite journal |vauthors=Martin MM |title=Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication |journal=Arch. Intern. Med. |volume=123 |issue=4 |pages=409–16 |year=1969 |pmid=4182323 |doi= |url=}}</ref><ref name="pmid2019265">{{cite journal |vauthors=Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y |title=Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium |journal=Endocrinology |volume=128 |issue=5 |pages=2534–9 |year=1991 |pmid=2019265 |doi=10.1210/endo-128-5-2534 |url=}}</ref><ref name="pmid8015573">{{cite journal |vauthors=White PC |title=Disorders of aldosterone biosynthesis and action |journal=N. Engl. J. Med. |volume=331 |issue=4 |pages=250–8 |year=1994 |pmid=8015573 |doi=10.1056/NEJM199407283310408 |url=}}</ref><ref name="pmid11158009">{{cite journal |vauthors=Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A |title=Androgen deficiency in women with hypopituitarism |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=2 |pages=561–7 |year=2001 |pmid=11158009 |doi=10.1210/jcem.86.2.7246 |url=}}</ref><ref name="pmid16478814">{{cite journal |vauthors=Miller KK, Biller BM, Beauregard C, Lipman JG, Jones J, Schoenfeld D, Sherman JC, Swearingen B, Loeffler J, Klibanski A |title=Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study |journal=J. Clin. Endocrinol. Metab. |volume=91 |issue=5 |pages=1683–90 |year=2006 |pmid=16478814 |doi=10.1210/jc.2005-2596 |url=}}</ref>
'''ACTH deficiency:'''
'''ACTH deficiency:'''
*15-25mg of [[hydrocortisone]] per day with increased doses in patients with severe deficiency, increased body weight and in times of [[surgery]], [[illness]], [[Procedure|procedures]] and other [[Stress|stresses]].
*[[Hydrocortisone]] 15-25mg per day with increased doses in patients with severe deficiency, increased body weight and in times of [[surgery]], [[illness]], [[Procedure|procedures]] and other [[Stress|stresses]].
*Unfortunately, there is no established test to assess adequate [[Hormone replacement therapy|hormonal replacement]]. Plasma [[Adrenocorticotropic hormone|ACTH]] measurement and [[serum]]/[[Saliva|salivary]]/[[urinary]] [[Cortisol|cortiso]]<nowiki/>l values are all unreliable. So assessment of adequate hormonal replacement is based on [[clinical]] basis with [[Cushingoid appearance|Cushingoid features]] showing excessive replacement while [[symptoms]] of [[adrenal insufficiency]] suggesting insufficient hormonal replacement.
*Unfortunately, there is no established test to assess adequate [[Hormone replacement therapy|hormonal replacement]]. Plasma [[Adrenocorticotropic hormone|ACTH]] measurement and [[serum]]/[[Saliva|salivary]]/[[urinary]] [[Cortisol|cortiso]]<nowiki/>l values are all unreliable. So assessment of adequate hormonal replacement is based on [[clinical]] basis with [[Cushingoid appearance|Cushingoid features]] showing excessive replacement while [[symptoms]] of [[adrenal insufficiency]] suggesting insufficient hormonal replacement.
*[[Glucocorticoid]] replacement can cause [[polyuria]] due to unmasking of underlying [[central diabetes insipidus]]. [[DDAVP]] is the treatment of choice for patients with [[Diabetes insipidus|DI]].<ref name="pmid18797595">{{cite journal |vauthors=Soares DV, Conceição FL, Vaisman M |title=[Clinical, laboratory and therapeutics aspects of Sheehan's syndrome] |language=Portuguese |journal=Arq Bras Endocrinol Metabol |volume=52 |issue=5 |pages=872–8 |year=2008 |pmid=18797595 |doi= |url=}}</ref>
*[[Glucocorticoid]] replacement can cause [[polyuria]] due to unmasking of underlying [[central diabetes insipidus]]. [[DDAVP]] is the treatment of choice for patients with [[Diabetes insipidus|DI]].<ref name="pmid18797595">{{cite journal |vauthors=Soares DV, Conceição FL, Vaisman M |title=[Clinical, laboratory and therapeutics aspects of Sheehan's syndrome] |language=Portuguese |journal=Arq Bras Endocrinol Metabol |volume=52 |issue=5 |pages=872–8 |year=2008 |pmid=18797595 |doi= |url=}}</ref>
Line 15: Line 15:
'''TSH deficiency:'''
'''TSH deficiency:'''
*In patients with combined [[hypothyroidism]] and [[hypocortisolism]], [[glucocorticoids]] ([[physiologic]] [[doses]] and increased doses in [[stress]]) are replaced first than [[thyroid hormone]] replacement because treating the [[hypothyroidism]] alone by [[levothyroxine]] can worsen the severity of [[Cortisol|cortiso]]<nowiki/>l deficiency by increasing the [[Clearance (medicine)|clearance]] of  [[cortisol]]. So, it is important to assess [[adrenal]] function first including [[corticotropin]] ([[Adrenocorticotropic hormone|ACTH]]) reserve before adminstering [[T4]] ([[levothyroxine]]).
*In patients with combined [[hypothyroidism]] and [[hypocortisolism]], [[glucocorticoids]] ([[physiologic]] [[doses]] and increased doses in [[stress]]) are replaced first than [[thyroid hormone]] replacement because treating the [[hypothyroidism]] alone by [[levothyroxine]] can worsen the severity of [[Cortisol|cortiso]]<nowiki/>l deficiency by increasing the [[Clearance (medicine)|clearance]] of  [[cortisol]]. So, it is important to assess [[adrenal]] function first including [[corticotropin]] ([[Adrenocorticotropic hormone|ACTH]]) reserve before adminstering [[T4]] ([[levothyroxine]]).
*[[T4]] ([[Levothyroxine]]) replacement therapy is usually started with  [[Weight|weigh]]<nowiki/>t-based [[T4]] dose of 1.6 mcg/kg.
*[[T4]] ([[Levothyroxine]]) 1.6 mcg/kg.
*American Thyroid Association (ATA) recommends dose adjustment to keep serum [[free T4]] [[concentration]] in upper half of [[reference range]].
*American Thyroid Association (ATA) recommends dose adjustment to keep serum [[free T4]] [[concentration]] in upper half of [[reference range]].
'''LH and FSH deficiency:'''
'''LH and FSH deficiency:'''

Revision as of 17:49, 30 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Treatment involves appropriate hormone replacement therapy that results in complete recovery and reversal of symptoms.

Medical Therapy

ACTH deficiency:

TSH deficiency:

LH and FSH deficiency:

Androgens replacement:

Growth hormone replacement:

  • GH is replaced on case to case basis starting with a low dose(0.1-0.3mg/day) and titrated upwards by 0.1mg/d/month with repeated measurement of hormone levels every month initially for the first 6 months followed by yearly measurements and is replaced once all other hormones have been replaced.[17]

Prolactin deficiency:

  • A study was done on 5 women with prolactin deficiency caused by Sheehan syndrome or other causes that showed increased milk production upon subcutaneous administration of r-hPRL(recombinant human prolactin) every 12 hours for 28 days.[18]

Medical Therapy

  1. Parikh R, Buch V, Makwana M, Buch HN (2016). "The price of a 15-year delay in diagnosis of Sheehan's syndrome". Proc (Bayl Univ Med Cent). 29 (2): 212–3. PMC 4790577. PMID 27034575.
  2. Laway BA, Bhat JR, Mir SA, Khan RS, Lone MI, Zargar AH (2010). "Sheehan's syndrome with pancytopenia--complete recovery after hormone replacement (case series with review)". Ann. Hematol. 89 (3): 305–8. doi:10.1007/s00277-009-0804-9. PMID 19697029.
  3. Tanriverdi F, Unluhizarci K, Kula M, Guven M, Bayram F, Kelestimur F (2005). "Effects of 18-month of growth hormone (GH) replacement therapy in patients with Sheehan's syndrome". Growth Horm. IGF Res. 15 (3): 231–7. doi:10.1016/j.ghir.2005.03.005. PMID 15921942.
  4. Bülow B, Hagmar L, Mikoczy Z, Nordström CH, Erfurth EM (1997). "Increased cerebrovascular mortality in patients with hypopituitarism". Clin. Endocrinol. (Oxf). 46 (1): 75–81. PMID 9059561.
  5. Arafah BM (2002). "Medical management of hypopituitarism in patients with pituitary adenomas". Pituitary. 5 (2): 109–17. PMID 12675508.
  6. Grossman AB (2010). "Clinical Review#: The diagnosis and management of central hypoadrenalism". J. Clin. Endocrinol. Metab. 95 (11): 4855–63. doi:10.1210/jc.2010-0982. PMID 20719838.
  7. Esteban NV, Loughlin T, Yergey AL, Zawadzki JK, Booth JD, Winterer JC, Loriaux DL (1991). "Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry". J. Clin. Endocrinol. Metab. 72 (1): 39–45. doi:10.1210/jcem-72-1-39. PMID 1986026.
  8. Arlt W, Rosenthal C, Hahner S, Allolio B (2006). "Quality of glucocorticoid replacement in adrenal insufficiency: clinical assessment vs. timed serum cortisol measurements". Clin. Endocrinol. (Oxf). 64 (4): 384–9. doi:10.1111/j.1365-2265.2006.02473.x. PMID 16584509.
  9. Thomson AH, Devers MC, Wallace AM, Grant D, Campbell K, Freel M, Connell JM (2007). "Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency". Clin. Endocrinol. (Oxf). 66 (6): 789–96. doi:10.1111/j.1365-2265.2007.02812.x. PMID 17437510.
  10. Martin MM (1969). "Coexisting anterior pituitary and neurohypophyseal insufficiency. A syndrome with diagnostic implication". Arch. Intern. Med. 123 (4): 409–16. PMID 4182323.
  11. Shibata H, Ogishima T, Mitani F, Suzuki H, Murakami M, Saruta T, Ishimura Y (1991). "Regulation of aldosterone synthase cytochrome P-450 in rat adrenals by angiotensin II and potassium". Endocrinology. 128 (5): 2534–9. doi:10.1210/endo-128-5-2534. PMID 2019265.
  12. White PC (1994). "Disorders of aldosterone biosynthesis and action". N. Engl. J. Med. 331 (4): 250–8. doi:10.1056/NEJM199407283310408. PMID 8015573.
  13. Miller KK, Sesmilo G, Schiller A, Schoenfeld D, Burton S, Klibanski A (2001). "Androgen deficiency in women with hypopituitarism". J. Clin. Endocrinol. Metab. 86 (2): 561–7. doi:10.1210/jcem.86.2.7246. PMID 11158009.
  14. Miller KK, Biller BM, Beauregard C, Lipman JG, Jones J, Schoenfeld D, Sherman JC, Swearingen B, Loeffler J, Klibanski A (2006). "Effects of testosterone replacement in androgen-deficient women with hypopituitarism: a randomized, double-blind, placebo-controlled study". J. Clin. Endocrinol. Metab. 91 (5): 1683–90. doi:10.1210/jc.2005-2596. PMID 16478814.
  15. Soares DV, Conceição FL, Vaisman M (2008). "[Clinical, laboratory and therapeutics aspects of Sheehan's syndrome]". Arq Bras Endocrinol Metabol (in Portuguese). 52 (5): 872–8. PMID 18797595.
  16. Matsuzaki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata T, Kumasawa K, Yoshino K, Kimura T (2017). "A case of acute Sheehan's syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage". BMC Pregnancy Childbirth. 17 (1): 188. doi:10.1186/s12884-017-1380-y. PMC 5471854. PMID 28615049.
  17. Tessnow AH, Wilson JD (2010). "The changing face of Sheehan's syndrome". Am. J. Med. Sci. 340 (5): 402–6. doi:10.1097/MAJ.0b013e3181f8c6df. PMID 20944496.
  18. Powe CE, Allen M, Puopolo KM, Merewood A, Worden S, Johnson LC, Fleischman A, Welt CK (2010). "Recombinant human prolactin for the treatment of lactation insufficiency". Clin. Endocrinol. (Oxf). 73 (5): 645–53. doi:10.1111/j.1365-2265.2010.03850.x. PMID 20718766.

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