Purple: general categories or stratification; turquoise: combination of treatments or other systemic treatments; white: other aspects of management.

ACTH, adrenocorticotropic hormone; CS, corticosteroid; FSH, follicle-stimulating hormone; FT4, free thyroxine; HRT, hormone replacement therapy; ICI, immune

checkpoint inhibitor; IGF-1, insulin-like growth factor-1; i.m., intramuscular; IR, immune-related; i.v. intravenous; LH, luteinizing hormone; MRI, magnetic resonance

imaging; o.d., once a day; T4, thyroxine; TSH, thyroid-stimulating hormone; TFT, thyroid function test.

Pituitary axis bloods: 9 am cortisol (or random if unwell and treatment cannot be delayed), ACTH, TSH or FT4, LH, FSH, estradiol if premenopausal, testosterone in men,

IGF-1, prolactin. Mineralocorticoids replacement is rarely necessary in hypopituitarism.

bInitial replacement advice for cortisol and thyroid hormones:

• If 9 am cortisol is low (according to institutional reference range):
  • Replace with hydrocortisone 20/10 mg.
    •  If TFTs are normal, 1-2-weekly monitoring initially (always replace cortisol for 1 week before T4 initiation)
•   If falling TSH   low FT4:
  • Consider the need for T4 replacement (guide is 0.5-1.5 mg/kg) based on symptoms   check 9 am weekly cortisol
•   See thyroid guidelines for further information regarding interpretation of an abnormal TSH or T4114
•   Testosterone or estrogen replacement to be considered if low (in men and premenopausal women)
•   In case of diabetes insipidus symptoms, refer for specialist advice.

Source: 

Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

Published online: 18 October 2022

J. Haanen, M. Obeid, L. Spain et al, on behalf of the ESMO Guidelines Committee