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Central hypothyroidism after pituitary surgery — SCE Endocrinology MCQ

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HardThyroidCentral hypothyroidism after pituitary surgerySCE Endocrinology

A 46-year-old woman has transsphenoidal surgery for a non-functioning pituitary macroadenoma. Two weeks later she is tired and cold. Free T4 is 7 pmol/L, TSH is 0.8 mU/L and 09:00 cortisol is 82 nmol/L. What is the most appropriate management?

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Correct answer: D — Start hydrocortisone before levothyroxine

Central hypothyroidism with possible ACTH deficiency requires glucocorticoid replacement before thyroxine to avoid precipitating adrenal crisis. TSH is not reliable for replacement titration in central hypothyroidism. The pearl is that pituitary patients are treated in endocrine-axis order.

Reference: Society for Endocrinology pituitary guidance, BNF