Abstract
Hypopituitarism is deficiency of one or more pituitary hormones, of which adrenocorticotrophic hormone (ACTH) deficiency is the most serious and potentially life-threatening. It may occur in isolation or, more commonly as part of more widespread pituitary failure. Diagnosis requires demonstration of subnormal cortisol rise in response to stimulation with hypoglycemia, glucagon, ACTH(1-24) or in the setting of acute illness. The choice of diagnostic test should be individualised for the patient and clinical scenario. A random cortisol and ACTH level may be adequate in making a diagnosis in an acutely ill patient with a suspected adrenal crisis e.g. pituitary apoplexy. Often however, dynamic assessment of cortisol reserve is needed. The cortisol response is both stimulus and assay- dependent and normative values should be derived locally. Results must be interpreted within clinical context and with understanding of potential pitfalls of the test used.
Highlights
Hypopituitarism is a clinical syndrome of deficiencies in one or more pituitary hormones of which adrenocorticotrophic hormone (ACTH) deficiency resulting in adrenal failure is the most serious and potentially life-threatening feature
POMC gene expression, processing to ACTH and ACTH secretion are stimulated by corticotropin releasing factor (CRF) which is secreted in the hypothalamus [1]
The choice of test used to interrogate the HPA axis should be individualised for each patient and the results interpreted within clinical context and with understanding of potential pitfalls of the test used
Summary
Hypopituitarism is a clinical syndrome of deficiencies in one or more pituitary hormones of which adrenocorticotrophic hormone (ACTH) deficiency resulting in adrenal failure is the most serious and potentially life-threatening feature. Testing for central hypoadrenalism Interrogation of the HPA axis is performed as part of a formal screening process for hypopituitarism in patients with organic hypothalamic-pituitary disease such as those with sellar/parasellar tumours, post pituitary surgery or apoplexy, history of cranial irradiation or traumatic brain injury. Pituitary surgery/apoplexy All patients with sellar/parasellar tumours should be subjected to an assessment of HPA axis function, with perhaps the exception of those with pituitary microadenomas who are at a very low risk of ACTH deficiency. Patients with a 08.00 h unstressed cortisol of >400 nmol/ L have an extremely low risk of ACTH deficiency and no further dynamic testing of the HPA axis is required [18, 19].
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