A 70-year-old male with past medical history of hypertension and headaches presents to the emergency department with a severe headache, double vision, nausea, and vomiting. Initial evaluation demonstrated hyponatremia, hyperkalemia, and intravascular volume depletion. Given concern for an intracranial process, an MRI was performed which demonstrated a hemorrhagic pituitary macroadenoma. You would like to initiate corticosteroid therapy.
Which of the following choices has the correct order of steroids from least to most potent?A. Hydrocortisone < cortisone < prednisone < dexamethasone
Correct Answer: C
This patient has pituitary apoplexy secondary to his hemorrhagic pituitary adenoma. As pressure inside the sella turcica rises, surrounding structures such as the optic nerve and contents of the cavernous sinus are compressed. This further decreases the blood supply to the pituitary, leading to tissue death and hypopituitarism.
Treatment involves stabilization of the circulatory system, as acute adrenal insufficiency can cause hypotension. Administration of a glucocorticoid replacement is required; for patients without a prior diagnosis of adrenal insufficiency, dexamethasone 4 mg IV bolus is preferred as it is not measured in serum cortisol assays. For patients with a known diagnosis of adrenal insufficiency who present with adrenal crisis, hydrocortisone 100 mg IV bolus or dexamethasone is recommended. In order of potency: cortisone < hydrocortisone < prednisone < dexamethasone.
The decision to surgically decompress the pituitary gland is mainly dependent on the severity of visual loss and defects. Surgery is most likely to improve vision if there was some remaining vision prior to surgery and if the surgery is performed within a week of onset of symptoms.