Adrenal dysfunction due to immune checkpoint inhibitors: American Society of Clinical Oncology guideline
| Situation | Action |
|---|---|
| Screening and workup | No screening recommended Workup for suspected adrenal insufficiency includes morning adrenocorticotropic hormone (> 2 times the upper limit of normal), cortisol (< 3 μg/dL), basic metabolic panel, renin, and aldosterone Adrenocorticotropic hormone testing can be considered for indeterminate results Rule out other causes such as infection or metastatic disease |
| Asymptomatic or mild symptoms (grade 1) | Consider holding the immune checkpoint inhibitor until the patient is stabilized on hormone replacement Endocrine consultation Start hydrocortisone treatment (15–20 mg in divided doses) and titrate to maximum 30 mg/day for residual adrenal insufficiency Most primary adrenal insufficiency cases will also require fludrocortisone (starting dose 0.1–0.5 mg/day) Patients should have a medical alert device as well as education on stress-dosing for sick days, when to seek medical attention for impending adrenal crisis, and use of emergency steroid injectables |
| Moderate symptoms (grade 2) | Consider holding immune checkpoint inhibitor until the patient is stabilized on hormonal replacement Endocrine consultation Initiate outpatient corticosteroid treatment 2–3 times the maintenance dose (hydrocortisone 30–50 mg/day; prednisone 20 mg/day) to manage acute symptoms and decrease stress dosing after 2 days Initiate fludrocortisone as above Patient education as above |
| Severe symptoms (grade 3 or 4) | Hold the immune checkpoint inhibitor until the patient is stabilized on hormonal replacement Endocrine consultation For inpatient management, normal saline (at least 2 L) with intravenous stress-dose steroids (initial dosing: hydrocortisone 50–100 mg every 6 hours), then taper to oral maintenance doses over 5–7 days Maintenance therapy as above Patient education as above |
Adapted from reference 49.