Pituitary disease

Who to refer:

Patients with an incidental diagnosis of a pituitary adenoma

These patients do not necessarily need surgery and should be evaluated by an endocrinologist prior to neurosurgical referral.

At the time of referral, please check the following:

• Prolactin
• TSH and Free T4
• Gonadotrophins and testosterone in males
• Gonadotrophins and oestradiol in females only if amenorrhoeic
• 9am cortisol

Patients requiring urgent endocrine assessment:

• Patients with visual field defect
• Patients with any suggestion of ACTH/glucocorticoid deficiency (hypotension, hyponatraemia, significant  lethargy)
• 9am cortisol is <270 or fT4 <9

Patients with hypotension, hyponatraemia or hypoglycaemia in the context of suspected pituitary/adrenal insufficiency, should, if not requiring urgent admission via the medical registrar (bleep 6006), be discussed with the endocrine consultant on call via Diabetes and Endocrine email inbox (dr@borders.scot.nhs.uk) or bleep 6698 if urgent concerns.

Patients with galactorrhoea

• Ensure not pregnant
• Check prolactin and thyroid function
• Exclude iatrogenic causes such as antiemetics, antidepressants, antipsychotic medication, frequent checking/breast stimulation
• If prolactin and thyroid function are normal and patient has regular periods these patients do not need to be seen in endocrine clinic

Hyperprolactinaemia

• Ensure patient is not pregnant
• Consider iatrogenic causes such as antiemetics, antidepressants and antipsychotics
• Refer patients with a single elevated prolactin >3000
• For patients with prolactin more than upper limit of normal but <3000, please recheck the prolactin on at least one occasion to confirm it remains high prior to referral
• If prolactin is high on at least two occasions, please check bedside visual fields to confrontation and send bloods for remainder of pituitary function as above

Patients with clinical features of acromegaly

Patients with features of Cushing’s syndrome not explained by steroid therapy

Patients with a past history of irradiation including the pituitary and those with hypopituitarism on hormone replacement therapy. 

• These patients usually require lifelong follow-up
• Please re-refer if they have been lost to follow-up or have transferred here from another region.
• Growth Hormone replacement and somatostatin analogue therapy are managed under shared care protocols (see resources and links for information)

Suspected AVP Deficiency/Resistance (previously known as cranial/nephrogenic diabetes insipidus)

• Please refer patients who have symptoms of polyuria and polydipsia with normal glucose and calcium
• Refer patients with urine output of >3L/day with symptoms
• Refer patients with persistently elevated sodium
• Patients who are on or have been on Lithium are at higher risk of AVP resistance

Who not to refer

We are happy to review all patients with pituitary disease in the endocrine clinic.

How to refer

Please send referrals to Endocrinology through SciGateway:

Borders General Hospital -> Endocrinology & Diabetes -> Borders General Referral

If any queries please contact the endocrinology email advice on: diabetes.endocrinology@borders.scot.nhs.uk

Pituitary disease is a broad and potentially complex area which should be investigated and managed in secondary care. If steps should be taken in primary care prior to the patient’s attendance at clinic, consultants will be able to advise when triaging the referral. Do not hesitate to contact us via the diabetes and endocrine email inbox with queries.

Most pituitary investigations should happen in secondary care.  Specifically, patients should not have a pituitary MRI requested until there is a firm biochemical diagnosis – MRI’s will be arranged from secondary care.

If a patient has secondary hypothyroidism (ie hypothyroidism secondary to pituitary disease and TSH deficiency) please do not commence levothyroxine until the patient has been assessed or at least discussed with secondary care.  If the patient also has co-existing ACTH deficiency, an Addisonian crisis can be precipitated if levothyroxine is commenced before the patient is established on hydrocortisone.

If thyroid function is being checked in primary care for a patient with hypothyroidism secondary to pituitary disease, please be mindful that TSH is generally not helpful as it is likely to be low and titration of levothyroxine is on the basis of the fT4.

Sick Day Rules for Hydrocortisone and Desmopressin: https://www.pituitary.org.uk/information/emergency-information/

Patient information is available on the following website:

https://www.pituitary.org.uk/

diabetes.endocrinology@borders.scot.nhs.uk