[Table, Guidance for Hypothyroidism IrAE]. - Practical Approaches to Managing Advanced Kidney Cancer

Diagnostic Work-up
Thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels every 4–6 weeks (routine clinical monitoring on therapy or case detection in symptomatic patients)
Grading	Management
Grade 1: TSH <10 mIU/L and asymptomatic	Continue immunotherapy with close follow-up and monitoring of TSH, free T4
Grade 2: Moderate symptoms; able to perform ADL; TSH persistently <10 mIU/L	Hold immunotherapy until symptoms resolve to baseline Consider endocrine consultation Prescribe hormone supplementation in symptomatic patients with any degree of TSH elevation or in asymptomatic patients with TSH levels that persist > 10 mIU/L (measured 4 weeks apart) Monitor TSH every 6–8 weeks while titrating hormone replacement to normal TSH Free T4 can be used in the short term (2 weeks) to ensure adequacy of therapy in those with frank hypothyroidism where the free T4 was initially low Once adequately treated, monitor thyroid function every 6 weeks while on active immunotherapy or as needed for symptoms Repeat testing annually or as indicated by symptoms once stable
Grade 3–4: Severe symptoms, medically significant or life-threatening consequences, unable to perform ADL	Hold immunotherapy until symptoms resolve to baseline with appropriate supplementation Endocrine consultation Admit for IV therapy if signs of myxedema (bradycardia, hypothermia) Thyroid supplementation and reassessment as in grade 2
Additional considerations: For patients without risk factors, full replacement can be estimated with an ideal body weight-based dose of approximately 1.6 μg/kg/day Extreme elevations of TSH can be seen in the recovery phase of thyroiditis – Watch in asymptomatic patients to determine whether there is recovery to normal within 3–4 weeks Under endocrinologist guidance, consider tapering hormone replacement and retesting in patients with a history of thyroiditis Adrenal dysfunction, if present, must always be replaced before thyroid hormone therapy is initiated

Diagnostic Work-up

Thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels every 4–6 weeks (routine clinical monitoring on therapy or case detection in symptomatic patients)

Grading

Management

Grade 1: TSH <10 mIU/L and asymptomatic

Continue immunotherapy with close follow-up and monitoring of TSH, free T4

Grade 2: Moderate symptoms; able to perform ADL; TSH persistently <10 mIU/L

Hold immunotherapy until symptoms resolve to baseline
Consider endocrine consultation
Prescribe hormone supplementation in symptomatic patients with any degree of TSH elevation or in asymptomatic patients with TSH levels that persist > 10 mIU/L (measured 4 weeks apart)
Monitor TSH every 6–8 weeks while titrating hormone replacement to normal TSH
Free T4 can be used in the short term (2 weeks) to ensure adequacy of therapy in those with frank hypothyroidism where the free T4 was initially low
Once adequately treated, monitor thyroid function every 6 weeks while on active immunotherapy or as needed for symptoms
Repeat testing annually or as indicated by symptoms once stable

Grade 3–4: Severe symptoms, medically significant or life-threatening consequences, unable to perform ADL

Hold immunotherapy until symptoms resolve to baseline with appropriate supplementation
Endocrine consultation
Admit for IV therapy if signs of myxedema (bradycardia, hypothermia)
Thyroid supplementation and reassessment as in grade 2

Additional considerations:

For patients without risk factors, full replacement can be estimated with an ideal body weight-based dose of approximately 1.6 μg/kg/day
Extreme elevations of TSH can be seen in the recovery phase of thyroiditis
- – Watch in asymptomatic patients to determine whether there is recovery to normal within 3–4 weeks
Under endocrinologist guidance, consider tapering hormone replacement and retesting in patients with a history of thyroiditis
Adrenal dysfunction, if present, must always be replaced before thyroid hormone therapy is initiated

From: Managing Toxicities

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