Important Management Considerations In Patients With Pituitary Disorders During The Time Of The Covid-19 Pandemic

Abstract

Objective: In December 2019, a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of coronavirus disease 2019 (COVID-19) that resulted in a global pandemic with substantial morbidity and mortality. Currently, there is no specific treatment or approved vaccine against COVID-19. The underlying associated comorbidity and diminished immune function of some pituitary patients (whether caused by the disease and its sequelae or treatment with excess glucocorticoids) increases their risk of contracting and developing complications from COVID-19 infection. Methods: A review of studies in PubMed and Google Scholar published between January 2020 to the time of writing (May 1, 2020) was conducted using the search terms ‘pituitary,’ ‘coronavirus,’ ‘COVID-19’, ‘2019-nCoV’, ‘diabetes mellitus’, ‘obesity’, ‘adrenal’ and ‘endocrine.’ Results: Older age, and pre-existing obesity, hypertension, cardiovascular disease and diabetes mellitus increases the risk of hospitalization and death in COVID-19 patients. Men tend to be more severely affected than women; fortunately, most men, particularly of younger age, survive the infection. In addition to general comorbidities that may apply to many pituitary patients, they are also susceptible due to the following pituitary disorder-specific features: hypercortisolemia and adrenal suppression with Cushing disease, adrenal insufficiency and diabetes insipidus with hypopituitarism, and sleep-apnea syndrome and chest wall deformity with acromegaly. Conclusion: This review aims to focus on the impact of COVID-19 in patients with pituitary disorders. As most countries are implementing mobility restrictions, we also discuss how this pandemic has affected patient attitudes, and impacted our decision-making on management recommendations for these patients. Abbreviations: ACE = angiotensin-converting enzyme; ACTH = adrenocorticotropic hormone; ARBs = angiotensin receptor blockers; AI = adrenal insufficiency; ARDS = acute respiratory disease syndrome; CDC = Centers for Disease Control and Prevention; COVID-19 = coronavirus disease 2019; CPAP = continuous positive airway pressure; CYP3A4 = cytochrome P450 3A4; DI = diabetes insipidus; DM = diabetes mellitus; HPA = hypothalamic-pituitary adrenal; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

COVID-19 and the pituitary

“…At the beginning of the pandemic period, several regulatory bodies and Specialty Societies recommended to defer elective surgical procedures [ 138 ]. As a matter of fact, also in neurosurgical units urgent interventions were prioritized whereas those for benign lesions, as usually are pituitary adenomas [ 139 ], were postponed with much longer than usual waiting times or even cancelled [ 139 ].…”

“…Patients with incidental and asymptomatic tumors, non-functioning adenomas without mass effect or functioning tumors controlled with medical therapy, were classified as elective and the intervention could be postponed [ 134 ]. For patients with Cushing disease and acromegaly medical therapy can be first-line treatment, in order to postpone surgery [ 138 ].…”

“…Adding a chest CT scan to the nasal swab in high risk of infection surgeries during the pandemic period, was suggested due to the not infrequent false negativity of testing [142][143][144]. In a patient with COVID-19 that requires emergent surgery, alternative transcranial approaches may be considered, avoiding drilling, and full personal protective equipment for surgeons is recommended [138,141].…”

Endocrine risk factors for COVID-19: Endogenous and exogenous glucocorticoid excess

“…In response to the SARS-CoV-2 pandemic, several recommendations for the clinical guidance of patients with endogenous CS were published [45,[58][59][60]. These include preventive factors such as video consultations and adherence to social distancing to reduce the risk of infection, as well as diagnostic and treatment recommendations when extensive differential diagnostic testing and/or surgery is not possible [58].…”

Advances in the study of nervous system infections in COVID‐19

“…Furthermore, the hypercoagulability of COVID-19 patients may lead to a potential high risk of stroke [38]. Patients with pituitary disease who contracted COVID-19 tended to feature hypercortisolemia and adrenal depression with Cushing's disease, adrenal insufficiency with diabetes insipidus and hypopituitary dysfunction, sleep apnea syndrome, and chest wall deformities with acrometropy [39]. The prognosis for neurological involvement is poor.…”