Emergency management of immune‐related hypophysitis: Collaboration between specialists is essential to achieve optimal outcomes

Abstract

We read with interest the report by Faje et al 1 demonstrating that patients with checkpoint inhibitor (CPI)induced hypophysitis have clinical outcomes superior to those of patients who do not develop this toxicity. Furthermore, that survival is better for patients treated with physiological replacement doses of glucocorticoids versus higher doses has clear implications for acute care physicians and nononcologists, who are increasingly likely to be the first point of contact for patients presenting acutely with this potentially fatal complication of CPI therapy.The Society for Endocrinology recently published consensus guidelines from oncologists, endocrinologists, and acute care physicians to raise awareness and assist frontline staff in the management of the various endocrine complications of CPI therapy. 2 These guidelines advocate for physiological doses, rather than pharmacological doses, of glucocorticoids for hypophysitis-induced adrenocorticotropic hormone deficiency. These guidelines also encourage continuation of CPI therapy, an issue not addressed by Faje et al. 1 We would appreciate insight into the proportions of patients in the study cohort continuing CPI therapy after developing hypophysitis and the implications for the development of other immune-mediated complications of CPI therapy and survival.The confirmation that patients treated with lower doses of glucocorticoids for CPI-induced hypophysitis have superior survival rates reinforces the importance of ensuring that patients are managed optimally. The critical first step in the management of all immune-related toxicities of CPIs is recognition. This is particularly pertinent in CPI-induced hypophysitis, where even in life-threatening cases, the presentation can be vague and nonspecific. 3 The significant variation in the settings where emergency oncology is delivered, 4 the potential for CPI-induced hypophysitis to present many months after the completion of therapy, 5 the expanding indications for CPIs, and the opportunity for early re-initiation of CPIs after hypophysitis necessitate awareness and collaboration across oncology, endocrinology, and acute care providers. FUNDING SUPPORTNo specific funding was disclosed.

Supportive Care: An Indispensable Component of Modern Oncology

“…As the prognosis for adult brain tumour survivors improves, similar issues may arise [ 70 ]. More recently, endocrine toxicities, such as hypophysitis and insulin-deficient diabetes caused by immunotherapy treatments, are also keeping endocrinologists busy [ 63 ] in collaboration with acute oncology [ 71 ]. This will be become an even more complex issue as immunotherapy moves into the adjuvant arena, with expert input into decision making algorithms crucial [ 72 ].…”

Multinational Association of Supportive Care in Cancer (MASCC) 2020 clinical practice recommendations for the management of immune checkpoint inhibitor endocrinopathies and the role of advanced practice providers in the management of immune-mediated toxicities

“…In contrast to other immune-related toxicities, hypophysitis tends to be self-limiting and can be safely treated with physiological rather than pharmacological doses of steroids. This necessitates education of emergency care physicians, other health care professionals and the patient, as early intervention can reduce the duration and severity of the complications [15]. This is particularly pertinent in immune-related hypophysitis, where even in life-threatening cases, the presentation can be vague and non-specific.…”