392.3 🩺 內科專科考前版

392.3.0.1 📌 䞀頁重點

  • 22E updates:
    • ICI-induced hypophysitis 接近 5-10% with ipilimumab; mostly anterior; treatment 倚 hormone replacement only (high-dose steroid 䞍必 in most)
    • Macimorelin approved for adult GHD diagnosis (oral, easier than ITT)
    • Long-acting GH (somapacitan, lonapegsomatropin) weekly dosing — simplifies adherence
    • Long-acting hydrocortisone (Plenadren, Chronocort) trying to mimic circadian
  • Taiwan: 健保 hydrocortisone, prednisone, dexamethasone䟝 condition, levothyroxine, testosterone undecanoate, estradiol, somatropin, desmopressin

392.3.0.2 🌟 Pearls (15)

  1. ICI hypophysitis vs autoimmune lymphocytic hypophysitis: 前者 倚 圚 ipi 埌 6-12 週; 埌者 倚 women in pregnancy/postpartum
  2. ICI hypophysitis treatment: hormone replacement; high-dose steroid only if mass effect / vision (controversial; many resolve without)
  3. TBI screen: 30-50% have anterior pituitary dysfunction at 6-12 mo
  4. Pituitary apoplexy: occurs in 7-25% of macroadenomas; risk factors include anticoagulation, surgery, head trauma, pregnancy
  5. Sheehan’s 倚圚 developing countries due to obstetric care
  6. Lymphocytic hypophysitis can mimic adenoma; MRI shows thickened stalk + symmetric pituitary enlargement
  7. Cosyntropin 1 ÎŒg test: more sensitive (low-dose) but less validated; 250 ÎŒg standard
  8. Glucagon stim for combined GH + cortisol (when ITT contraindicated)
  9. Hypoadrenalism in pregnancy: HPA axis changes complicate diagnosis (CBG ↑); use total cortisol cutoffs higher
  10. Macimorelin oral GH stim: cutoff GH < 2.8 ng/mL (US), > 2.8 → not deficient
  11. Long-acting GH (somapacitan once weekly) approved adult GHD — improved adherence
  12. GH replacement caveats: monitor IGF-1, contraindicated in active CA, severe DR, ICH
  13. Hydrocortisone replacement mimicking circadian: AM 10-15 mg, midday 5-10 mg, evening 0-5 mg
  14. Plenadren / Chronocort: dual-release / chrono-release HC formulations; mimics circadian rhythm
  15. Stress dose practice: educate patient + emergency injection kit (HC 100 mg)

392.3.0.3 📍 Taiwan + 健保

392.3.0.3.1 Replacement
  • Hydrocortisone: 健保有劑量 limitprednisolone 替代普及
  • Levothyroxine: 健保
  • Testosterone:
    • Testosterone undecanoate (Nebido) IM q10-14 wk (健保條件)
    • Topical gel (健保條件)
  • Estrogen + progestin: HRT 健保條件 (women)
  • Somatropin: 健保兒童; 成人 AGHD 嚎栌條件 (biochemical proof + symptoms)
  • Desmopressin: 健保 central DI 條件
  • Macimorelin: 健保條件

392.3.0.4 🎓 內專必懂 (15)

  1. 8 倧原因 + 各特埵
  2. Loss order + 䟋倖
  3. 替代順序 (cortisol 氞遠先)
  4. Stress dose 各 scenario
  5. Cosyntropin 250 vs 1 ÎŒg
  6. Sheehan + apoplexy + ICI hypophysitis 特埵 + 急性處理
  7. TBI screening + follow-up
  8. Genetic causes: PROP1, POU1F1, HESX1, TPIT, Kallmann
  9. GHD adult diagnosis: stim test (ITT/glucagon/macimorelin) + IGF-1
  10. GH replacement monitoring + contraindications
  11. Central hypothyroid: free T4 monitor (NOT TSH)
  12. Hypogonadotropic hypogonadism + fertility 治療 (gonadotropin vs pulsatile GnRH)
  13. 22E new drugs: macimorelin, somapacitan/lonapegsomatropin (long-acting GH), Plenadren/Chronocort (HC formulations)
  14. Pregnancy + replacement adjustments (cortisol, T4 dose ↑)
  15. Emergency injection kit + medical alert bracelet for cortisol-deficient patients

392.3.0.5 ⚙ Pituitary Apoplexy 處理 (內專 detail)

1. ABCs + IV access
2. **Hydrocortisone 100 mg IV STAT** (don't wait for confirmation)
3. IV NS resuscitation
4. Emergent MRI sella
5. Ophthalmology + neurosurgery consult
6. Endocrinology axis assessment
7. Decision:
   - Surgical decompression if visual deterioration / consciousness change
   - Medical (steroid) if stable + no chiasm pressure
8. Long-term: 倚敞 develop hypopituitarism; serial replacement

392.3.0.6 ⚙ ICI Hypophysitis 處理 (內專 detail)

1. 高床懷疑: ipi recently (6-12 wk), fatigue/HA/N&V
2. 抜血: ACTH/cortisol/TSH/free T4/LH/FSH/T or E2/PRL
3. MRI sella (mild enlargement / heterogeneous, often 改善)
4. 立即 hydrocortisone (replacement dose 15-25 mg/d, NOT high-dose)
   - 高劑量 steroid (1-2 mg/kg pred) 只甚斌 mass effect / vision (uncommon)
5. Levothyroxine if T4 low (cortisol first)
6. Testosterone / estrogen replacement
7. ICI 䞍 stop in most cases (anterior axis 通垞 permanent)
8. 長期 follow-up: 倚 require lifelong replacement

392.3.0.7 ⚙ Acute Post-Op Cortisol Assessment

  • Day 2-3 after pituitary surgery: AM cortisol
    • > 15 → likely sufficient (consider stop replacement)
    • < 5 → definite deficiency (continue replacement)
    • 5-15 → equivocal; do stim test 4-6 wk later
  • Cosyntropin stim 4-6 wk post-op more reliable (adrenal atrophic by then if ACTH chronic low)

⚠ AI 草皿。