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irAEs — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyirAEsSCE Medical Oncology

A patient on nivolumab reports profound fatigue and headache. Sodium is 125 mmol/L, 09:00 cortisol 42 nmol/L, ACTH is low, free T4 is low and TSH is inappropriately normal. What is the safest immediate endocrine sequence?

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Correct answer: B — Withhold nivolumab and establish glucocorticoid replacement before introducing levothyroxine

The pattern indicates hypophysitis with secondary adrenal insufficiency and central hypothyroidism. Cortisol replacement must precede levothyroxine to avoid precipitating adrenal crisis. OPDIVO should be withheld for symptomatic grade 2/3 hypophysitis until stabilisation; endocrine toxicity is generally managed with replacement rather than automatic permanent discontinuation.

Reference: OPDIVO UK summary of product characteristics (Current UK SmPC, accessed August 2026): https://www.medicines.org.uk/emc/product/6888/smpc