A clinical case of treatment of a patient with acute adrenal insufficiency after combined immunotherapy (nivolumab + ipilimumab). Prospects for a return to immunotherapy after severe complications of immunotherapy

Abstract

Checkpoint inhibitors, as well as their combinations, are increasingly included in the daily practice of the oncologist. However, given the mechanism of action, its use may be associated with immune side effects that can complicate the clinical course and prognosis of patients. As the number of reported indications for the administration of PD-1, PD-L1, CTLA-4 inhibitors increases, the rate of reports of rare complications associated with immunotherapy increases. Among the complications, it is worth highlighting the group of autoimmune endocrinopathies. Such complications of immunotherapy as hypophysitis, hypo- and hyperthyroidism are quite common, are relatively easy to correct and usually do not lead to discontinuation of therapy. The mechanisms underlying immune damage to target organs remain poorly understood. Primary adrenal insufficiency is a rare and potentially life-threatening complication that, due to non-specific symptoms, may be recognized too late. The development of adrenal insufficiency was noted in only 0.7% of patients in randomized clinical trials. To date, there is no single tactic for identifying and treating this complication. The management of such patients is possible only by a multidisciplinary team that includes an endocrinologist. We present a clinical case of the development of adrenal insufficiency on the background of combined chemo-immunotherapy and the results of the patient’s treatment after its resolution.

Keywords

• adrenal insufficiency
• endocrinopathies
• immune-checkpoint inhibitors
• immune-related adverse events
• nivolumab
• combined immunotherapy