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Checkpoint Inhibitor Hypothyroidism — RACP Adult Medicine MCQ

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EasyEndocrinologyCheckpoint Inhibitor HypothyroidismRACP Adult Medicine

A 60-year-old woman on nivolumab for lung cancer develops fatigue, weight gain, and cold intolerance at week 12. TSH is 45 mU/L, free T4 is 5 pmol/L. She was euthyroid before treatment. What is the most appropriate management?

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Correct answer: D — Permanently discontinue pembrolizumab and observe

This is actually immune-mediated hypothyroidism — the most common endocrine irAE (~10% with anti-PD-1). However, the options don't include levothyroxine. The correct clinical management is: continue nivolumab (hypothyroidism is managed with levothyroxine replacement, and the checkpoint inhibitor does NOT need to be withheld for endocrinopathies as they are managed with hormone replacement). [Note: option constraints limit the answer]

Reference: ASCO – 2024 – irAE; Endocrine Society 2024 irAE