32
Treatment
Table 4. Endocrine Toxicities
G2: Moderate symptoms, able
to perform ADL
• Consider holding ICPi until patient is stabilized on
replacement hormone.
• Endocrine consultation.
• See in clinic to assess need for hydration, supportive
care, and hospitalization.
• Initiate outpatient corticosteroid treatment at 2–3
times maintenance (e.g., hydrocortisone 30–50 mg
totally dose or prednisone 20 mg daily) to manage
acute symptoms.
• Initiate fludrocortisone (0.5–0.1 mg/day).
• Decrease stress dose corticosteroids down to
maintenance doses after 2 days.
• Maintenance therapy as in G1.
G3–4: Severe symptoms,
medically significant or life-
threatening consequences,
unable to perform ADL
• Hold ICPi until patient is stabilized on replacement
hormone.
• Endocrine consultation.
• Inpatient management may be needed to provide:
▶ Normal saline (at least 2L).
▶ IV Stress dose steroids: Hydrocortisone 50–100
mg q6–8h initial dosing.
• Taper stress dose corticosteroids down to oral
maintenance doses over 5–7 days.
• Maintenance therapy as in G1.
Additional considerations:
• Primary and secondary adrenal insufficiency can be distinguished by the relationship
between ACTH and cortisol. If the ACTH is low with low cortisol, then
management is as per hypophysitis in section 4.3 for secondary (central) adrenal
insufficiency.
• Using hydrocortisone allows for re-creation of the diurnal rhythm of cortisol.
Typically, 2/3 of the dose is given in the morning and 1/3 in the early afternoon.
Long-acting steroids such as prednisone, rather than short-acting hydrocortisone,
carries risk of over replacement but can be used in special circumstances, for example,
if a patient is not able to adhere to a short-acting steroid regimen. Hydrocortisone 20
mg is equivalent to prednisone 5 mg.
• DHEA replacement is controversial but deficiency can be tested and replacement
considered in women with low libido and/or energ y who are judged to be otherwise
well replaced.
• All patients need education on stress dosing for sick days, use of emergency
injectables, when to seek medical attention for impending adrenal crisis, and a
medical alert bracelet/necklace for adrenal insufficiency to trigger stress dose
corticosteroids by emergency medical personnel. Therefore, early endocrinolog y
consultation is appropriate.
• Endocrine consultation should be part of planning prior to surgery or high-stress
treatments such as cytotoxic chemotherapy at any time during a patient's care.
(cont'd)
