Adrenal insufficiency and checkpoint inhibitors for cancer

Editor – Simpson et al provide a welcome overview of the importance of the recognition and treatment of adrenal insufficiency.¹ However, there is no mention of checkpoint inhibitors for cancer, which have emerged as an important and common cause of secondary adrenal insufficiency, and rarely primary adrenal insufficiency.² The importance and challenge of prompt recognition has been recognised.³ Checkpoint inhibitors are approved globally for the treatment of multiple different cancer types, including non-small-cell lung carcinoma, melanoma, bladder, kidney, and head and neck cancers. Given that around 10% of patients treated with ipilimumab, and 1–2% of patients treated with PD-1/PD-l1 inhibitors develop adrenocorticotropic hormone (ACTH) deficiency, we propose that all patients with current or recent checkpoint inhibitor use should be included in those considered at risk of an adrenal crisis.

In addition, a third of patients receiving a checkpoint inhibitors will require high does corticosteroids for management of one or more immune related adverse events and it is vital that oncological practice takes on the need to issue these patients with the new steroid card and appropriate education.^4,5