How should I manage a patient with hypopituitarism who presents with adrenal insufficiency?

Management of a patient with hypopituitarism presenting with adrenal insufficiency involves:

• Immediate treatment of adrenal crisis: Administer intravenous or intramuscular hydrocortisone immediately (100 mg for adults) without delay, as there is no risk of overdose in emergency situations. If intramuscular injection is used, it can be self-administered or given by anyone with an emergency kit. Concurrently, give 1 litre of 0.9% sodium chloride intravenous infusion over 30 minutes to stabilize the patient. Monitor blood pressure, heart rate, electrolytes, and glucose frequently during the crisis. Advise urgent hospital admission by ambulance without referral delay ¹,².
• Glucocorticoid replacement therapy: After stabilization, maintain physiological glucocorticoid replacement, typically hydrocortisone 15–25 mg daily in divided doses for adults, adjusted according to clinical response and stress levels. Avoid abrupt cessation of glucocorticoids ¹,².
• Mineralocorticoid replacement: Usually not required in secondary adrenal insufficiency due to hypopituitarism, as aldosterone secretion is preserved. Focus is on glucocorticoid replacement ¹.
• Patient education and support: Provide information on sick-day rules to increase glucocorticoid doses during physiological or psychological stress, how to self-administer emergency hydrocortisone, and the importance of carrying emergency steroid cards and medical alert identification. Discuss workplace or educational adjustments and psychological support options ¹.
• Follow-up and monitoring: Regularly review symptoms of under- or over-replacement, and adjust doses accordingly in collaboration with endocrinology specialists. Provide a management plan for other healthcare providers and carers ¹,².