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Immune-related Adverse Events from Immune Checkpoint Inhibitor Therapy

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33 Table 4. Endocrine Toxicities 4.3 Pituitary — Hypophysitis Workup/Evaluation: • Evaluate ACTH (AM), cortisol (AM), TSH, free T4, electrolytes. • Consider standard dose ACTH stimulation testing for indeterminate results (AM cortisol >3 ug/dL and <15 ug/dL). • Consider evaluating LH and testosterone in males, FSH, and estrogen in premenopausal females with fatigue, loss of libido and mood changes, or oligomenorrhea. • Consider magnetic resonance imaging (MRI) brain w/wo contrast with pituitary/ sellar cuts in all patients with new hormonal deficiencies and particularly those with multiple endocrine abnormalities +/- new severe headaches or complaints of vision changes. • Perform MRI brain w/wo contrast with pituitary/sellar cuts for all patients presenting with diabetes insipidus (DI is most commonly from metastatic disease). Grading Management All Grades • Referral to endocrinolog y • Education on steroid stress dosing, emergency injections, and a medical alert bracelet/necklace, accessory, or system. G1: Asymptomatic or mild symptoms • Consider holding ICPi until patient is stabilized on replacement hormones. • Endocrine consultation. • Corticosteroid replacement for adrenal insufficiency with preference for hydrocortisone (15–20 mg in divided doses — see additional considerations section 4.2). • Initiate other hormone replacement only after any needed adrenal replacement to avoid precipitating adrenal crisis. ▶ Thyroid hormone replacement if needed using dosing as above for primary hypothyroidism, with a goal FT4 in the upper half of the reference range (TSH is not accurate in central hypothyroidism). ▶ Testosterone or estrogen therapy if needed in those without contraindications (e.g., prostate cancer, breast cancer, or history of deep vein thrombosis (DVT)). • Recommend education on stress dosing, emergency injectable, and a medical alert /necklace accessory or system. (cont'd)

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