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72-hour fast interpretation — SCE Endocrinology MCQ

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HardEndocrine emergencies/dynamic tests72-hour fast interpretationSCE Endocrinology

A patient receiving ipilimumab plus nivolumab develops headache, profound fatigue, nausea and postural hypotension. Sodium is 128 mmol/L, 09:00 cortisol 45 nmol/L, ACTH is low, free T4 is low and TSH is inappropriately normal. What is the most important immediate treatment?

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Correct answer: B — Start glucocorticoid replacement before thyroid-hormone replacement

The pattern indicates immune-checkpoint-inhibitor-associated hypophysitis with secondary adrenal insufficiency and central hypothyroidism. Glucocorticoids must be given before levothyroxine because thyroid-hormone replacement can increase cortisol demand and precipitate adrenal crisis. Mineralocorticoid replacement is generally unnecessary in secondary adrenal insufficiency because aldosterone secretion is preserved.

Reference: https://www.nice.org.uk/guidance/conditions-and-diseases/diabetes-and-other-endocrinal-nutritional-and-metabolic-conditions