Hypophysitis with headache

Management escalation pathway

• Withhold ICPi
• Oral prednisolone 0.5-1 mg/kg 1x/day after sending pituitary axis assessment
• If no improvement within 48h, treat with i.v. (methyl)prednisolone
• if signs of adrenal crisis, manage per standard guidelines Initial replacement advice for cortisol and thyroxine: 1)
• If 9 am cortisol < 250 or random cortisol < 150 and vague symptoms: Replace with hydrocortisone: 20/10/10 mg If thyroid function tests normal: 1–2 weekly monitoring initially (always replace cortisol for 1 week prior to thyroxine initiation) 2)
• If low FT4: Consider need for thyroxine replacement (guide is 0.5-1.5 µg/kg) based on symptoms +/- check 9 am weekly cortisol See Thyroid Guidelines for further information regarding interpretation of an abnormal TSH/T4
• Longterm: Wean steroids based on symptoms over 2-4 weeks to 5 mg prednisolone
• Refer to or consult endocrinologist
• Monitor thyroid function tests (TFTs)

Assessment and Investigations

ENDOCRINE LAB measurements:
• 9 am cortisol (or random if unwell and treatment cannot be delayed) + CBG (to exclude CBG-deficiency)
• Oestradiol if premenopausal,
• Testosterone in men + SHBG +/- albumin for evaluation of free testosterone
• IGF-1 (cave: long T1/2: acute GH-deficiency might me missed) • Blood glucose level imaging
• MRI hypophysis (hypophysitis is typically associated with swollen hypophysis)
• include whole brain imaging to exclude metastases to the brain and/or leptomeninges