Hemorrhagic Pituitary Macroadenoma

Hemorrhagic Pituitary Macroadenoma:

Sx: Headache, diplopia (if affects optic chiasm)

  • Consult Neurosurgery for recommendations
  • Medications:
    • Start Dexamethosone (Decadrone) 4mg IV q6hr
    • Start Levothyroxine:
      • Overt disease: 1.6mg/kg
      • Subclinical disease: 1mg/kg
      • If elderly, CAD: Start with lower dose and then titrate up.
    • If hemorrhagic: Control BP to mitigate bleed and likely headache too.
      • Caution: Patient may be prone to hypotension due to decrease in cortisol levels, so start with PRN Clonidine/Hydralazine initially. May need to go home on antihypertensive if requiring throughout admission.
        • Ex: Clonidine 0.1mg PO q6hr PRN SBP > 140.
  • Elevate had of bed to 30 degrees
  • Neuro checks q2hr X 2, then q4hr X 2, then q6hrs.

Order endocrine (pituitary hormone) evaluation: [Expect all to be low to low normal.]

  • Cortisol level @ 8am (N: 4.5 – 22.7)
  • TSH (N: 0.465 – 4.68)
  • Free T4 (N: 0.78 – 2.19)
  • Prolactin level (N: 4.0 – 15.2)
  • ACTH
  • LH (N: 1.7 – 8.6)
  • FSH (N: 1.5 – 12.4)
  • Insulin like growth factor 1 (growth hormone)

Discharge medications:

  • Hydrocortisone 5mg tabs: Take 4 tablets (20mg) PO qAM, and take 1 tab (5mg) qPM.
  • Levothyroxine 0.125mg PO qd
  • Antihypertensive medication if necessary: Ex – Norvasc 5mg PO qd PLUS order BP cuff with instructions to measure BP daily and to stop taking medication if SBP<120 for multiple days and to F/U with PCP.

Discharge instructions:

F/U: PCP 1 week, Endocrinology consult, Neurosurgery consult

Amlodipine for blood pressure: Please check blood pressure at home, and if it is below 120/70 or if you feel dizzy/lightheaded, stop taking amlodipine and follow up with your Primary Care Provider.

Hydrocortisone – Take 20 mg in the morning when you wake up, and take 5 mg 2hours after lunch. Please do not miss any dose as this medication is very important. If you do not take it, you can have serious complications even death. If you get sick, you will need to take a higher dose of this medication, so you need to call your Primary Care Provider immediately for further instructions.

Levothyroxine – Take it every morning on an empty stomach at least 30 min to 1hour prior to breakfast, and do not take it at same time with other meds.

 

*** Suggest finding patient instructions/information on UpToDate about Adrenal Insufficiency ***

 

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