Table 2. Anti-PD-1: immune-related thyroiditis management guidance.

Thyroiditis	Grade 1	Grade 2	Grade 3	Grade 4
Hypothyroidism	Frequently monitor thyroid function and hormone levels	Frequently monitor thyroid function and hormone levels Consider consultation with endocrinologist Continue anti-PD-1 therapy while treating thyroid disorder Treat with thyroid hormone and/or steroid replacement therapy	Withhold anti-PD-1Treat with IV methylprednisolone followed by oral prednisone Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month Replacement of appropriate hormones may be required as the steroid dose is tapered	Discontinue anti-PD-1Consider endocrine consultation Rule out infection and sepsis with culture assay and imaging Treat with IV methylprednisolone followed by oral prednisone Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month Replacement of appropriate hormones may be required as the steroid dose is tapered
Hyperthyroidism	For symptomatic hyperthyroidism, prescribe beta-blockers	Administer corticosteroids Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month	Withhold anti-PD-1Administer corticosteroids Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month Permanently discontinue anti-PD-1 for any adverse reaction that recurs	Discontinue anti-PD-1Administer corticosteroids Upon improvement to grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month

Over hypothyroidism: start levothyroxine replacement (I) if patient has both adrenal insufficiency and hypothyroidism, replace with hydrocortisone for 2–3 days before initiating levothyroxine (II) elderly patients or patients with heart diseases, start low and increase low.