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

Management of a patient with hypopituitarism presenting with adrenal insufficiency involves the following key steps:

• Immediate treatment of adrenal crisis: If adrenal crisis is suspected, administer intravenous or intramuscular hydrocortisone immediately without delay, as there is no risk of overdose in an emergency. The recommended dose for adults is 100 mg hydrocortisone intravenously or intramuscularly, followed by intravenous 0.9% sodium chloride infusion (1 litre over 30 minutes) to stabilize the patient. Frequent monitoring of blood pressure, heart rate, electrolytes, and glucose is essential during the crisis. Emergency admission to hospital should be arranged promptly, ideally by ambulance without delay for diagnostic tests NICE NG243,NICE CKS.
• Glucocorticoid replacement therapy: After stabilization, initiate or continue physiological glucocorticoid replacement. For adults, the typical daily dose of hydrocortisone is 15–25 mg, divided into two or three doses to mimic natural cortisol rhythm. Prednisolone or dexamethasone may be alternatives but hydrocortisone is preferred NICE NG243,NICE CKS.
• Mineralocorticoid replacement: In secondary adrenal insufficiency due to hypopituitarism, mineralocorticoid replacement is usually not required because aldosterone secretion is typically preserved. This contrasts with primary adrenal insufficiency where fludrocortisone is needed NICE NG243,NICE CKS.
• Sick-day rules and stress dosing: Educate the patient on increasing glucocorticoid doses during physiological stress (illness, surgery, trauma) and significant psychological stress to prevent adrenal crisis. Provide an emergency management plan and ensure the patient has access to an emergency hydrocortisone injection kit and a Steroid Emergency Card NICE NG243.
• Patient education and support: Inform the patient and carers about the importance of adherence to glucocorticoid therapy, recognition of symptoms of under- or over-replacement, and when to seek urgent medical help. Discuss psychological stress management and provide information on support groups and mental health services as needed NICE NG243.
• Follow-up and monitoring: Regular review in primary care and endocrinology is important to assess clinical response, adjust glucocorticoid doses, and monitor for complications. Screening for other pituitary hormone deficiencies and associated autoimmune conditions should be considered NICE NG243,NICE CKS.