Guidance for pituitary disease management during COVID-19
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The COVID-19 pandemic presents substantial challenges for pituitary disease management, and clinicians should consider local conditions and hospital resources when opting for surgery vs. medical management, according to new guidance.
The clinical care of patients with pituitary disorders typically involves a multidisciplinary team working together to deliver timely, often complex disease investigation and management, including pituitary surgery, Maria Fleseriu, MD, FACE, professor of medicine and neurological surgery in the School of Medicine at Oregon Health & Science University and director of the OHSU Pituitary Center, and international colleagues with the Pituitary Society Professional Education Committee wrote in guidance published in Pituitary. COVID-19 has brought major disruption to such services, limiting access to care and opportunities for laboratory and radiologic testing, and dramatically reducing the ability to safely undertake transsphenoidal surgery, the researchers wrote.
“Working on this multidisciplinary guidance with four neurosurgeons and neuroendocrinologists from Europe, South America, the United Kingdom and the United States, it is now even more clear to me that one size does not fit all and everything depends on local circumstances, both for rates of active infection in the region and also for hospital resources for personal protective equipment,” Fleseriu, also an Endocrine Today Editorial Board Member, told Healio. “However, transsphenoidal pituitary surgery seems to have higher risk for infection for health professionals; thus, testing for COVID-19 before surgery is essential. In emergency cases, or when in doubt regarding virus presence, additional personal protective equipment during surgery is necessary. Furthermore, in areas with very high rates of infection, medical management can be temporarily used for all functioning pituitary tumors with no vision loss, even for cases where, in regular times, surgery would be first-line. Similarly, nonfunctioning tumors can be closely followed and surgery performed if vision loss ensues.”
Disease risk and management
When viral risk is decreasing in a specific geographic area, Fleseriu and colleagues advocate a “stepwise, but flexible normalization of activity” before any pituitary surgery:
All patients undergoing pituitary surgery should undergo screening for COVID-19.
Depending on COVID-19 activity in the community, isolation of patients for up to 2 weeks, testing and routine chest X-rays may be appropriate.
Among patients with COVID-19 for whom surgery is indicated, delaying surgery is recommended, ideally until patients no longer have symptoms and have a negative swab test result.
The guidance also recommends patients be stratified as “emergent, urgent or elective,” according to pituitary disease state, noting that patients presenting with pituitary apoplexy, acute severe visual loss or other significant mass effects should be operated on in an emergent fashion. Select patients with slowly progressive vision loss or functioning tumors with aggressive clinical features or those with an unclear diagnosis could be classified as urgent, with decisions for surgery made on a case-by-case basis. Those with incidental and asymptomatic tumors, known as nonfunctioning adenomas or functioning tumors, can be scheduled as elective cases, the researchers wrote.
Medication guidance
Many patients with pituitary disorders are at higher risk for contracting COVID-19 and developing complications from the novel coronavirus due to the presence of many comorbidities in Cushing’s disease and acromegaly, such as diabetes, hypertension, obesity and sleep apnea, Fleseriu said.
“With virtual visits across some state lines, we are able to effectively manage the large majority of patients with pituitary disease, which are patients with rare disease who benefit from being seen in a pituitary center of excellence,” Fleseriu said. “Repeat frequent clinical evaluation via virtual visits can help us monitor patients in the interim after changing doses of medications in Cushing’s disease and acromegaly, for example, without biochemical data, when risk of going to the lab is high.”
Fleseriu said some patients with acromegaly could benefit from an increased dose and extended time interval between injections of lanreotide (Somatuline Depot, Ipsen), which is approved for every 6 to 8 weeks, to reduce the number of nursing visits.
“For patients on combination treatment for acromegaly, I have also increased doses of pegvisomant [Somavert, Pfizer] to allow for extending the interval between somatostatin receptor ligands injections,” she said.
Titration of medications for Cushing’s disease is challenging and requires special fine-tuning to achieve eucortisolemia, Fleseriu noted.
“For patients with adrenal insufficiency who are under-replaced, we increase the glucocorticoid replacement doses to reduce risk for adrenal crisis and also ensure that patients have injectable glucocorticoid medications at home,” she said.
“Education is always the key in preventing adrenal crisis, but is even more important in a pandemic,” Fleseriu said. “Awareness of possible impulse control disorders and depression is also needed for patients starting on cabergoline for prolactinomas, as rates of depression are higher overall in a pandemic.”
Guidance may change
In the guidance, the researchers cautioned that the suggestions are not evidence-based due to the novelty and timing of the pandemic; reevaluation every few months in light of emerging data is recommended. Approaches will also likely vary from country to country depending on the risk for viral infection, local rules for lockdowns, and the capabilities of individual health care systems, they wrote.
“There are many unknowns, but hopefully, some of the changes we implement now are here to stay with respect to reducing patients’ visits to our pituitary centers and being able to manage chronic diseases from a distance, too,” Fleseriu said.
For more information:
Maria Fleseriu, MD, FACE, can be reached at the School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; email: fleseriu@ohsu.edu; Twitter: @MariaFleseriu.
Perspective
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Shlomo Melmed, MB, ChB, MACP
Dr. Fleseriu and her colleagues have provided a very timely guide from the Pituitary Society to assist caregivers and patients navigate the new clinical challenges of COVID-19 infection. Patients with pituitary disorders are particularly vulnerable to all stress-engendering situations, and continued vigilance — especially for adrenal steroid coverage — is vital. As hypersecreting pituitary tumors lead to deleterious peripheral comorbidities, surgery and medical treatments should not be delayed or postponed, and appropriate precautions are clearly enunciated by this rigorously crafted statement.
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