Patients undergoing pituitary adenoma or Rathke’s cleft cyst (RCC) removal are often administered peri-operative glucocorticoids regardless of lesion size and pre-operative ACTH/cortisol levels.

     To minimize unnecessary glucocorticoid therapy, we describe a protocol in which patients with normal pre-operative serum cortisol and ACTH levels are given glucocorticoids only if post-operative day 1 or 2 (POD1 or POD2) cortisol levels fall below normal.

     A total of 207 consecutive patients undergoing endonasal surgery for an adenoma or RCC were considered for study. Of these, 68 patients with pre-operative adrenal insufficiency or Cushing’s disease were excluded.  The 139 patients included 119 with macroadenomas, 14 microadenomas and 6 RCCs (follow-up 3-41 months; median 10 months).

     Glucocorticoids were withheld unless POD1/POD2 morning cortisol values were below normal (=4 µg/dL). Subsequent adrenal status was assessed through follow-up biochemical and clinical evaluations.

     Nine (6.5%) patients, all with macroadenomas (mean diameter 26±10 mm) had low POD1/POD2 cortisol values and received glucocorticoids; of these 5 were weaned off within 3-28 weeks of surgery. Overall, 12/139 (8.6%) patients were treated for early (n=9) or delayed (n=3) adrenal insufficiency but only 5 (3.6%) remain on glucocorticoid replacement. No patients experienced an adrenal crisis.

     This is a retrospective study.

     In patients with normal pre-operative cortisol levels undergoing endonasal removal of a pituitary adenoma or RCC, normal morning cortisol values on POD1/POD2 reliably predicts adequate and safe adrenal function in over 96% of patients.

     This simple protocol of withholding post-operative glucocorticoids avoids unnecessary steroid exposure and poses minimal risk to the well-informed closely monitored patient.