Immune checkpoint inhibitors have improved the outcome of patients with advanced cancer significantly over the last decade. Disadvantageous effects of these novel treatments include auto-immune toxicities, named immune-related adverse events (irAEs), that most commonly affect the skin, gastrointestinal tract, liver and endocrine glands. Immune-related endocrine toxicities that involve the pituitary gland or adrenal glands may cause adrenal insufficiency (irAI), which can be life-threatening if not early recognized and managed.
Due to the expanding number of novel immunotherapies and indications, the number of patients with irAI will increase. We report a clinically applicable algorithm, with a key role for the nurse practitioner (NP), to manage irAI and to improve safety using a system-focused approach.
A collaboration between NP, oncologists and endocrinologists, taking input and perspectives from patients into account, was used to develop consensus regarding irAI management. Based on literature, institutional experience and group consensus, a clinically applicable algorithm was created.
Team members were educated on algorithm application and to improve safety. The NP was the first point of call and coordinated collaboration between patient, medical specialists and family physician. The NP was appointed a key role for patient education and information. Patients were educated to recognize symptoms of adrenal insufficiency and react promptly by increasing the dose of the corticosteroid substitution therapy. Patients were encouraged to contact the NP in case of problems or questions about the prophylactic dose of corticosteroids for stressful events.
Due to the increased use and the long-term efficacy of immune checkpoint inhibitors in patients with cancer, the incidence and prevalence of immune-related adrenal insufficiency (irAI) will increase. The here reported algorithm provides a streamlined approach for the management of irAI that is expected to improve safety and quality of life of patients.
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Van den Eertwegh AJM.
Has not received any funding.
M. Labots: Advisory board: BMS. J. Eertwegh: Advisory boards: BMS, Merck, Roche, Novartis, Amgen; Study grant: Roche. All other authors have declared no conflicts of interest.