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The prognosis depends on the primary cause Hypopituitarism resulting from a pituitary tumor may be reversible with dopamine agonists or with careful selective resection of the tumor Spontaneous recovery from hypopituitarism associated with pituitary stalk thickening has been reported Patients can also recover from functional hypopituitarism, eg, hypogonadism due to starvation or severe illness, suppression of ACTH by corticosteroids, or suppression of TSH by hyperthyroidism Functionally, most patients with hypopituitarism do very well with hormone replacement Men with infertility who are treated with hCG/FSH or GnRH are likely to resume spermatogenesis if they have a history of sexual maturation, descended testicles, and a baseline serum inhibin level over 60 pg/mL Women under age 40 years, with infertility due to hypogonadotropic hypogonadism, can usually have successful induction of ovulation
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Agha A et al Conventional glucocorticoid replacement overtreats adult hypopituitary patients with partial ACTH deficiency Clin Endocrinol (Oxf) 2004 Jun;60(6):688 93 [PMID: 15163331] Agha A et al The long-term predictive accuracy of the short synacthen (corticotropin) stimulation test for assessment of the hypothalamic-pituitary-adrenal axis J Clin Endocrinol Metab 2006 Jan;91(1):43 7 [PMID: 16249286] Brooke AM et al Dehydroepiandrosterone improves psychological well-being in male and female hypopituitary patients on maintenance growth hormone replacement J Clin Endocrinol Metab 2006 Oct;91(10):3773 9 [PMID: 16849414] Leal-Cerro A et al Prevalence of hypopituitarism and growth hormone deficiency in adults long-term after severe traumatic brain injury Clin Endocrinol (Oxf) 2005 May;62(5): 525 32 [PMID: 15853820] Maison P et al Impact of growth hormone (GH) treatment of cardiovascular risk factors in GH-deficient adults: a Metaanalysis of Blinded, Randomized, Placebo-Controlled Trials J Clin Endocrinol Metab 2004 May;89(5):2192 9 [PMID: 15126541] Smith JC Hormone replacement therapy in hypopituitarism Expert Opin Pharmacother 2004 May;5(5):1023 31 [PMID: 15155105]
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POSTERIOR HYPOPITUITARISM
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Antidiuretic hormone (ADH) deficiency causes central diabetes insipidus with polyuria (2 20 L/d) and
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Clinical Findings
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A Symptoms and Signs
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The symptoms of the disease are intense thirst, especially with a craving for ice water, and polyuria, the volume of ingested fluid varying from 2 L to 20 L daily, with correspondingly large urine volumes Partial diabetes insipidus presents with less intense symptoms and should be suspected in patients with unremitting enuresis Most patients with diabetes insipidus are able to maintain fluid balance by continuing to ingest large volumes of water However, diabetes insipidus may present with hypernatremia and dehydration in patients without free access to water, or with a damaged hypothalamic thirst center and altered thirst sensation Diabetes insipidus is aggravated by administration of high-dose corticosteroids, which increases renal free water clearance
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Complications
If water is not readily available, the excessive output of urine will lead to severe dehydration Patients with an impaired thirst mechanism are very prone to hypernatremia, particularly since they usually also have impaired mentation and forget to take their desmopressin All the complications of the primary disease may eventually become evident In patients who are receiving desmopressin acetate therapy, there is a danger of induced water intoxication
Treatment
A Diabetes Insipidus
Desmopressin acetate is the treatment of choice for central diabetes insipidus It is also useful in diabetes insipidus associated with pregnancy or the puerperium, since desmopressin is resistant to degradation by the circulating vasopressinase Desmopressin is available as an oral preparation (01 or 02 mg tablets) that is given in a starting dose of 005 mg twice daily and increased to a maximum of 04 mg every 8 hours, if required Oral desmopressin is particularly useful for patients with sinusitis from the nasal preparation Mild increases in hepatic enzymes can occur with the oral preparation Gastrointestinal symptoms and asthenia may also occur The nasal preparation (100 mcg/mL solution) is given every 12 24 hours as needed for thirst and polyuria It may be administered via metered-dose nasal inhaler containing 01 mL/spray or via a plastic calibrated tube Patients are started with 005 01 mL every 12 24 hours, and the dose is then individualized according to response Desmopressin is also available as a parenteral preparation containing 4 mcg/mL For central diabetes insipidus, it is given intravenously, intramuscularly, or subcutaneously in doses of 1 4 mcg every 12 24 hours as needed to treat thirst or hypernatremia Adverse reactions to desmopressin have included nasal irritation, occasional agitation, and erythromelalgia Hyponatremia is uncommon if minimum effective doses are used and the patient allows thirst to occur periodically Mild cases of diabetes insipidus require no treatment other than adequate fluid intake Reduction of aggravating factors (eg, corticosteroids, which directly increase renal free water clearance) will improve polyuria Both central and nephrogenic diabetes insipidus respond partially to hydrochlorothiazide, 50 100 mg/d orally (with potassium supplement or amiloride) Nephrogenic diabetes insipidus may respond to combined treatments of indomethacin-hydrochlorothiazide, indomethacin-desmopressin, or indomethacin-amiloride Indomethacin, 50 mg orally every 8 hours, is effective in acute cases Psychotherapy is required for most patients with compulsive water drinking Thioridazine and lithium are best avoided if drug therapy is needed, since they cause polyuria
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