Glucocorticoid replacement should be started after a successful pituitary adenomectomy (approx on d 5 after low or undetectable serum and urinary cortisol levels have been obtained). The action is undertaken because in those patients the HPA axis is suppressed by the chronic exposure to excess glucocor-ticoids and fails to function for several months after the removal of normal corticotroph inhibition, such as an ACTH-secreting pituitary adenoma (128). Hydrocortisone should be replaced at a rate of 12 to 15 mg/m2/d by mouth, with appropriate increases in minor stress (two-fold) and major stress (up to 10-fold) for appropriate lengths of time. The recovery of the suppressed HPA axis can be monitored with a short ACTH test every 3 mo. When the 30-min plasma cortisol exceeds 18 ^g/dl, hydrocortisone can be discontinued. After a bilateral adrenalectomy, corticosteroid replacement will be necessary for life and includes both glucocorticoids and mineralocorticoids.
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