Hypophysitis

Symptom Grade

Silent hypophysitis

• asymptomatic or mild
• no headache

Assessment and Investigations

Hypophysitis is unlikely

• 8 am or random cortisol
• >160 µg/L

Hypophysitis cannot be excluded

• 8 am cortisol 70-160 µg/L or random cortisol 30-160 µg/L

Hypophysitis is very likely

• 8 am cortisol <70 µg/L or random cortisol <30 µg/L
• Perform MRI of the pituitary gland + whole brain imaging (exclude metastasis)

Management

• Await hormonal assessment (should be known within 24h)
• Start physiological substitution with hydrocortisone 10-5-5mg if hypophysitis possible or cannot be excluded
• Continue ICPI once adequately substituted
• Review for recent steroid use to exclude iatrogenic adrenal insufficiency.
• Educate and provide advice on ‘sick day rules’ (triple daily dosis) and a medical alert bracelet.

Symptom Grade

Serious hypophysitis

• Headache (usually severe, not always responding to analgesics)
• Severe fatigue
• Dehydration, hypotension, nausea, vomiting or abdominal pain, confusion

Assessment and Investigations

Hypophysitis is unlikely

• Random cortisol >160 µg/L

Hypophysitis is very likely

• Random cortisol <160 µg/L
• Rule out mass-effect symptoms of hypophysitis, adrenal crisis, rule out sepsis
• Perform MRI of the pituitary gland + whole brain imaging (exclude metastasis)

Management

• Urgent hydrocortisone stress dose: hydrocortisone 100mg IV (or IM)
• Intravenous hydration
• If low fT4 and low/normal TSH, first await 72h of hydrocortisone substitution before starting thyroxine replacement therapy.
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