Hypopituitarism due to immune checkpoint inhibitors: American Society of Clinical Oncology guideline
| Situation | Action |
|---|---|
| Screening and workup | Routine thyroid function tests as outlined in Table 2 If central hypothyroidism is suspected, evaluate morning adrenocorticotropic hormone (ACTH) and cortisol as well as electrolytes ACTH stimulation testing can be falsely negative early in hypophysitis, as adrenal reserve declines slowly after pituitary stimulation is lost |
| Asymptomatic or mild symptoms (grade 1) | Consider holding immune checkpoint inhibitor until patient is stabilized on hormone replacement Endocrine consultation Initiate hormonal replacement for affected axis Adrenal insufficiency: corticosteroid replacement (hydrocortisone 15–20 mg in divided doses) No adrenal insufficiency: consider lower steroid dosing (average daily dosing over 2 months < 7.5 mg) due to report of reduced survival on higher dosing Initiate other hormone replacement after steroid initiation and only after adrenal insufficiency is corrected, to avoid crisis |
| Moderate symptoms (grade 2) | Consider holding immune checkpoint inhibitor until the patient is stabilized on hormone replacement Endocrine consultation Consider oral pulse-dose steroid therapy in patients with magnetic resonance imaging evidence of swelling or threatened optic chiasm compression; taper over 1 to 2 weeks, then maintenance steroid therapy Other hormonal replacement therapy as above |
| Severe symptoms (grade 3 or 4) | Hold immune checkpoint inhibitor until patient is stabilized on hormone replacement Endocrine consultation Hospitalize or refer to emergency department for normal saline (at least 2 L) and monitored free water replacement if the patient has diabetes insipidus Intravenous stress steroids (initial dosing: hydrocortisone 50–100 mg every 6 hours), then oral pulse-dose therapy tapered over 1–2 weeks in patients with magnetic resonance imaging evidence of significant swelling, optic chiasm compression, severe headache, or visual changes Taper stress-dose steroids to oral maintenance dose over 5–7 days Other maintenance therapy as above 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 |
Adapted from reference 49.