Endocrine Abstracts

Background: Immune related adverse events (iRAEs) of the endocrine system are commonly recognised in Checkpoint Inhibitor (CTLA-4 and PD-1 inhibitors) Therapy. Clinically, endocrinopathies can present with symptoms of hormone deficiency, hormone excess or both (in the same or different glands).

Aim: Audit of Incidence and Management (detection, investigation, referral and management) practices of Endocrinopathies due to Immunotherapy in Oncology department for the duration of six months January-June 2019. We aimed to improve management of endocrinopathies through peer led education and new locally adapted guidelines.

Methods: A retrospective anonymised audit of all patients receiving immunotherapy was done. Data sources included outpatient clinic letters, electronic prescriptions, biochemistry results and multidisciplinary team meeting summaries. Analysis of quantitative data was in percentages and proportions. The detection, investigation, referral and management was assessed on a two point criteria stating adequate or inadequate /appropriate or inappropriate taking UK Oncology Nursing Society (UKONS) Endocrinopathies with Immune Check Point Inhibitors (ICPi) Guidelines as standard. Thereafter with multidisciplinary input from Endocrinology team, a locally adapted new guidelines were written and implemented. The process was re-audited and using the two point assessment and the results will be available for presentation at the conference. The knowledge attitude and practice of doctors in oncology was also assessed with a 10 question questionnaire.

Results: Total number of patients receiving immunotherapy, ipilumab, nivolumab, atezolizumab and pembrolizumab alone or in combination were 101. Total number of patients with endocrinopathies either single or multiple were 37. Total number of endocrinopathies detected(symptomatic/asymptomatic) were 50. Total Incidence of endocrinopathies was found to be 36.6%. Thyroid disorders detected were 16/50(32%), hypoglycemia-2/50(4%), diabetes mellitus(DKA)-1/50(2%).) Hypocortisolism(Biochemical asymptomatic + symptomatic) was 6/50(12%). Symptomatic hypocortisolism was 5/50(10%) and low testosterone was found in 2/50(4%). Endocrinopathies were detected in first line therapy in 17/37(45%) and in second line therapy in 20/37(54%). The endocrinopathies were distributed amongst cancer sites as lung -29, melanoma-2, colon-2, renal-2, hypopharynx-1, Transitional cell carcinoma-1. The maximum number of endocrine aberrations were found between 3weeks-3months-29/37(78%). The process was re-audited after educational sessions and measurable improvement was achieved in clinical practise.

Conclusions: Total Incidence of endocrinopathies was found to be 36.6%. Most of the management was by individual teams and there was knowledge gap and co ordination identified amongst doctors managing these patients since immunotherapy a new and developing area of practice. KAP questionnaire was used to assess the knowledge gap amongst staff members. Shared learning and multidisciplinary approach can go a long way in management of endocrine side-effects of these novel therapies.