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Primary adrenal insufficiency: case report A case series described 3 men, aged 60-76 years, who developed primary adrenal insufficiency (PAI) during treatment with nivolumab and ipilimumab (1 patient), nivolumab and cabozantinib (1 patient) or nivolumab (1 patient) for metastatic renal cell carcinoma (mRCC) [routes not stated; duration of treatments to reactions onset not clearly stated] The 60-year-old man, who had mRCC, started receiving nivolumab 3 mg/kg and ipilimumab 1 mg/kg every 2 weeks for the first 4 cycles. Thereafter, a single-drug nivolumab 3 mg/kg every 2 weeks was continued. Following 10 cycles, he developed hyponatraemia and severe asthaenia, which resulted in interruption of the therapy. Bloodwork revealed a sodium concentration of 117 mg/dL and a decreased level of morning cortisol. Adrenocorticotropic hormone (ACTH) stimulation was found to be reduced. Based on these findings and clinical symptoms, a diagnosis of PAI associated with nivolumab and ipilimumab was confirmed. He received steroid replacement therapy with hydrocortisone, and exhibited an excellent clinical response with complete remission of symptoms. A clinical decision was made to restart immunotherapy once a stable dose of steroids was attained and no symptoms related to PAI were observed. The 65-year-old man, who was mRCC, started receiving nivolumab 3 mg/ kg every 2 weeks plus cabozantinib 40mg per day. Following 13 cycles, he developed hyponatraemia, which was improved with the treatment interruption. However, after restarting the treatment, he redeveloped hyponatraemia with a sodium level of 112 mg/dL. He was hospitalised. A decreased level of morning cortisol was observed, and decreased ACTH stimulation test confirmed PAI associated with nivolumab and cabozantinib. He received steroid replacement therapy with hydrocortisone, and exhibited an excellent clinical response with complete remission of symptoms. A clinical decision was made to restart immunotherapy once a stable dose of steroids was attained and no symptoms related to PAI were observed. The 76-year-old man, who had mRCC, started receiving nivolumab 480mg once per month. Following 4 cycles, he presented with hyponatraemia and mild fatigue. The nivolumab was continued. Following 5 cycles, the symptoms had progressed to orthostatic hypotension and severe fatigue. Decreased level of morning cortisol was noted. Also ACTH stimulation test confirmed PAI. He received steroid replacement therapy with hydrocortisone, and exhibited an excellent clinical response with complete remission of symptoms. A clinical decision was made to restart immunotherapy once a stable dose of steroids was attained and no symptoms related to PAI were observed. Salinas C, et al. Primary Adrenal Insufficiency during Immune Checkpoint Inhibitor Treatment: Case Reports and Review of the Literature. Case Reports in Oncology 13: 803520056 621-626, No. 2, Jan 2020. Available from: URL: http://doi.org/10.1159/000507652

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