Early onset of nivolumab-induced central adrenal insufficiency in gastric adenocarcinoma

ABSTRACT

Secondary adrenal insufficiency (AI) due to nivolumab, an immune checkpoint inhibitor, is a common occurrence. The mechanism underlying this phenomenon was believed to be the destruction of endocrine cells triggered by immune activation from the medication. A woman in her 60s developed symptoms of adrenal insufficiency (AI) complicating her sepsis a few days after her first administration of nivolumab for gastric adenocarcinoma treatment. Low morning cortisol, low ACTH and the ACTH stimulation test confirmed the diagnosis of AI. An MRI of the pituitary was normal. It is believed that by the time symptoms develop, a significant portion of the cells may have already been destroyed irreversibly. Life-long hormonal therapy is indicated based on the underlying endocrine disorder. Gastric adenocarcinoma is a serious neoplastic disease. Nivolumab should be continued if necessary for oncologic reasons, with concurrent treatment for adrenal insufficiency as indicated.

Keywords: Nivolumab, Immune checkpoint inhibitor, Central adrenal insufficiency, Secondary adrenal insufficiency, Gastric cancer